Distinct patterns of cervical cytological abnormalities in public tertiary and private outpatient care: a comparative study from Romania.

OBJECTIVE: To compare cervical cytological profiles between two distinct real-world screening pathways represented by public tertiary and private outpatient services in Romania and to examine age-adjusted associations between screening pathway and prespecified cytological outcomes. STUDY DESIGN: This retrospective comparative cohort study included 1,441 consecutive women undergoing routine cervical cancer screening in two Romanian healthcare settings. The public cohort comprised 726 conventional Papanicolaou smears obtained at a tertiary referral hospital, whereas the private cohort included 715 ThinPrep® liquid-based cytology examinations performed within a private outpatient network. Additionally, hrHPV testing was available for a clinically selected subgroup of 68 women from the private outpatient pathway and was performed according to routine clinical indications. Cytological findings were classified according to the 2014 Bethesda System. Between-group differences were evaluated using Pearson's chi-square test with post-hoc analysis of adjusted standardized residuals. Age-adjusted logistic regression was used to examine associations between screening pathway and prespecified cytological outcomes. RESULTS: A total of 1,441 women were included (public, n = 726; private, n = 715). Age distributions were comparable between healthcare settings (39.4 ± 13.4 vs. 38.3 ± 12.9 years; p = 0.120). The overall prevalence of abnormal cytology was comparable between the public and private pathways (7.4 % vs. 9.5 %; age-adjusted OR [aOR] for public vs. private, 0.77; 95 % CI 0.53-1.12; p = 0.168), whereas the distribution of Bethesda diagnostic categories differed significantly (χ2 = 21.70; p < 0.001). LSIL was more frequent in the private outpatient pathway, while ASC-H and the prespecified ASC-H/HSIL/AGC cytological composite were more frequent in the public tertiary pathway in age-adjusted analyses. Estimates for outcomes with small event counts, particularly ASC-H, were imprecise and should be interpreted cautiously. In the clinically selected private subgroup undergoing hrHPV testing, hrHPV positivity was associated with abnormal cytology (OR 6.91, 95 % CI 2.16-22.10; p = 0.001). CONCLUSIONS: Two distinct real-world cervical screening pathways showed comparable overall rates of abnormal cytology but different distributions of selected Bethesda categories. These differences remained apparent in age-adjusted analyses; however, healthcare setting was structurally aligned with cytological preparation method, and several potentially relevant patient-level determinants were unavailable. The findings should therefore be interpreted as associations between distinct screening pathways rather than as independent or causal effects of public versus private healthcare. The higher frequency of ASC-H in the public tertiary pathway, without a corresponding statistically significant difference in HSIL, should not be interpreted as evidence of a greater burden of confirmed high-grade disease.