Table 2.

Example of health policy analysis to inform improvements in guidelines for Pap smears after total hysterectomy for benign disease through Bardach’s steps 1–8

Step	Example from Fetters et al 14
1. Define the problem.	Lack of evidence and controversial recommendations regarding Pap smear screening after total hysterectomy for benign disease.
2. Assemble evidence.	Medline review of medical literature, including case studies, using terms: hysterectomy and vaginal smears or vaginal smears and vaginal neoplasm. Review major textbooks of gynaecology. Review recommendations from major organisations with known background in screening, cancer and women’s health issues.
3. Construct alternatives.	Describe assumptions and positions justifying each policy under consideration, including existing cervical cancer guidelines of Pap smears after total hysterectomy for benign disease or cessation of the practice.
4. Select the criteria.	USPSTF criteria to measure and evaluate the practicality and sustainability of each alternative. Included consideration of the survival rate, and cost-effectiveness of the diagnosis and treatment.
5. Project the outcomes.	Quantify the magnitude of the impact of each alternative, including the cost of false positives due to low prevalence, as well as the number of missed cases of vaginal dysplasia or carcinoma due to lack of screening.
6. Confronting the trade-offs.	Weigh the relative benefit and importance of each criterion, such as the cost savings of eliminating screenings against the relative risks of missed diagnoses for each alternative.
7. Decision-making.	Insufficient evidence for Pap smears after total hysterectomy for benign disease, although patients who undergo subtotal hysterectomy should still receive regular Pap smears due to retention of the cervix.
8. Sharing the results of the process.	Presentation to USPSTF for consideration and subsequent revision of the USPSTF guidelines.

Pap smear, Papanicolaou smear; USPSTF, US Preventive Services Task Force.