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## Complete Summary

#### TITLE

Cervical cancer screening: percentage of women ages 21 years and older
in the measurement year screened in accordance with evidence-based
standards.

#### SOURCE(S)

HealthPartners. 2007 clinical indicators report: 2006/2007 results.
Minneapolis (MN): HealthPartners; 2007 Oct. 97 p.

### Measure Domain

#### PRIMARY MEASURE DOMAIN

Process

The validity of measures depends on how they are built. By examining the
key building blocks of a measure, you can assess its validity for your
purpose. For more information, visit the [Measure
Validity](http://www.qualitymeasures.ahrq.gov/resources/measure_domains.aspx)
page.

#### SECONDARY MEASURE DOMAIN

Does not apply to this measure

### Brief Abstract

#### DESCRIPTION

This measure is used to assess the percentage of women ages 21 years and
older in the measurement year screened for cervical cancer in accordance
with evidence-based standards:

-   One screening Pap test in measurement year or two years prior for
    women ages 24 to 64 and no history of hysterectomy (ages 21 + 3 year
    look back period\_.

-   No Pap test in the measurement year for women ages 65 and older, or
    women ages 24 and older with history of hysterectomy.

Not screened:

-   No screening Pap test in measurement year or two years prior for
    women ages 24 to 64 and no history of hysterectomy.

Screened more frequently:

-   Two or more screening Pap tests in measurement year or two years
    prior for women ages 24 to 64 and no history of hysterectomy.

-   One or more Pap tests in the measurement year for women ages 65 and
    older.

-   One or more Pap tests for women ages 24 and older with history of
    hysterectomy.

#### RATIONALE

Multiple studies indicate that over 50% of cervical cancers occur in
women who have never been screened. At the same time, many women are
screened for cervical cancer more frequently than is supported by the
evidence resulting in significant unnecessary health care expenditures
and patient inconvenience. Therefore, it is this population that the
guideline is intended to impact the greatest. Significant risk factors
for cervical cancer are failure to be screened on a regular basis, and a
previously abnormal Pap smear within the last five years.

-   Screening need not be performed for women who have had a
    hysterectomy for benign disease, provided they have no history of
    cervical intraepithelial neoplasia (CIN) 2 or CIN 3.

-   Women with a history of CIN 2/3 prior to but not as the indication
    for hysterectomy should be screened until three consecutive,
    technically satisfactory normal/negative vaginal cytology tests with
    no abnormal/positive cytology test within a ten-year period are
    achieved.

-   Initially all women should have annual Pap smear screening beginning
    at age 21 or at three years after the onset of sexual activity.

-   It is appropriate to resume Pap smear screening in a woman age 65
    and older who has a new sexual partner.

-   After three consecutive normal Pap smears, and no dysplasia within
    the last five years, women may have their screening performed less
    frequently at the discretion of the clinician and patient.

#### PRIMARY CLINICAL COMPONENT

Cervical cancer screening; Pap smear

#### DENOMINATOR DESCRIPTION

All women ages 21\* years and older as of December 31 of the measurement
year who were continuously enrolled for 3 years (see the related
\"Denominator Inclusions/Exclusions\" field in the Complete Summary)

\*Due to a 3 year look-back period, this measure includes all women ages
24 and older as of December 31 of the measurement year.

#### NUMERATOR DESCRIPTION

The number of women from the denominator screened in accordance with
evidence-based standards (see the related \"Numerator
Inclusions/Exclusions\" field in the Complete Summary)

### Evidence Supporting the Measure

#### EVIDENCE SUPPORTING THE CRITERION OF QUALITY

-   A clinical practice guideline or other peer-reviewed synthesis of
    the clinical evidence

### Evidence Supporting Need for the Measure

#### NEED FOR THE MEASURE

Overall poor quality for the performance measured\
Use of this measure to improve performance\
Variation in quality for the performance measured

#### EVIDENCE SUPPORTING NEED FOR THE MEASURE

HealthPartners. 2007 clinical indicators report: 2006/2007 results.
Minneapolis (MN): HealthPartners; 2007 Oct. 97 p.

### State of Use of the Measure

#### STATE OF USE

Current routine use

#### CURRENT USE

Internal quality improvement\
National reporting\
Pay-for-performance

### Application of Measure in its Current Use

#### CARE SETTING

Physician Group Practices/Clinics

#### PROFESSIONALS RESPONSIBLE FOR HEALTH CARE

Advanced Practice Nurses\
Physician Assistants\
Physicians

#### LOWEST LEVEL OF HEALTH CARE DELIVERY ADDRESSED

Group Clinical Practices

#### TARGET POPULATION AGE

Age greater than or equal to 24 years (ages 21 + 3 year look back
period)

#### TARGET POPULATION GENDER

Female (only)

#### STRATIFICATION BY VULNERABLE POPULATIONS

Unspecified

### Characteristics of the Primary Clinical Component

#### INCIDENCE/PREVALENCE

Unspecified

#### ASSOCIATION WITH VULNERABLE POPULATIONS

Unspecified

#### BURDEN OF ILLNESS

Unspecified

#### UTILIZATION

Unspecified

#### COSTS

Unspecified

### Institute of Medicine National Healthcare Quality Report Categories

#### IOM CARE NEED

Staying Healthy

#### IOM DOMAIN

Effectiveness

### Data Collection for the Measure

#### CASE FINDING

Users of care only

#### DESCRIPTION OF CASE FINDING

All women ages 24 years and older as of December 31 of the measurement
year who were continuously enrolled for 3 years

#### DENOMINATOR SAMPLING FRAME

Patients associated with provider

#### DENOMINATOR INCLUSIONS/EXCLUSIONS

**Inclusions**\
All women ages 21\* years and older as of December 31 of the measurement
year who were continuously enrolled for 3 years

\*Due to a 3 year look-back period, this measure includes all women ages
24 and older as of December 31 of the measurement year.

**Exclusions**\
Members who have had a diagnosis of dysplasia non-specific abnormal pap
or cervical human papillomavirus (HPV) in the past five years or a
history of cervical cancer.

#### RELATIONSHIP OF DENOMINATOR TO NUMERATOR

All cases in the denominator are equally eligible to appear in the
numerator

#### DENOMINATOR (INDEX) EVENT 

Encounter

#### DENOMINATOR TIME WINDOW

Time window precedes index event

#### NUMERATOR INCLUSIONS/EXCLUSIONS

**Inclusions**\
The number of women from the denominator screened in accordance with
evidence-based standards:

-   One screening Pap test in measurement year or two years prior for
    women ages 24 to 64 and no history of hysterectomy.

-   No Pap test in the measurement year for women ages 65 and older, or
    women ages 24 and older with history of hysterectomy.

Not screened:

-   No screening Pap test in measurement year or two years prior for
    women ages 24 to 64 and no history of hysterectomy.

Screened more frequently:

-   Two or more screening Pap tests in measurement year or two years
    prior for women ages 24 to 64 and no history of hysterectomy.

-   One or more Pap tests in the measurement year for women ages 65 and
    older.

-   One or more Pap tests for women ages 24 and older with history of
    hysterectomy.

**Exclusions**\
Diagnostic pap tests are not counted. They are identified by Current
Procedure Terminology (CPT) 88142 with International Classification of
Diseases, Ninth Revision (ICD-9) 795.0.

#### MEASURE RESULTS UNDER CONTROL OF HEALTH CARE PROFESSIONALS, ORGANIZATIONS AND/OR POLICYMAKERS

The measure results are somewhat or substantially under the control of
the health care professionals, organizations and/or policymakers to whom
the measure applies.

#### NUMERATOR TIME WINDOW

Encounter or point in time

#### DATA SOURCE

Administrative data

#### LEVEL OF DETERMINATION OF QUALITY

Individual Case

#### PRE-EXISTING INSTRUMENT USED

Unspecified

### Computation of the Measure

#### SCORING

Rate

#### INTERPRETATION OF SCORE

Better quality is associated with a higher score

#### ALLOWANCE FOR PATIENT FACTORS

Unspecified

#### STANDARD OF COMPARISON

External comparison at a point in time\
External comparison of time trends\
Internal time comparison\
Prescriptive standard

#### PRESCRIPTIVE STANDARD

Percent with evidence-based screening - 2007 Goal:

-   Excellent\--45%

-   Superior\--55%

#### EVIDENCE FOR PRESCRIPTIVE STANDARD

HealthPartners. 2007 clinical indicators report: 2006/2007 results.
Minneapolis (MN): HealthPartners; 2007 Oct. 97 p.

### Evaluation of Measure Properties

#### EXTENT OF MEASURE TESTING

This measure has been used to report medical group and health plan
performance for three years. Data accuracy has been verified by medical
group and health plan personnel over that period.

#### EVIDENCE FOR RELIABILITY/VALIDITY TESTING

Institute for Clinical Systems Improvement (ICSI). Cervical cancer
screening. Bloomington (MN): Institute for Clinical Systems Improvement
(ICSI); 2005 Jun. 38 p. \[41 references\]

Institute for Clinical Systems Improvement (ICSI). Preventive services
for adults. Bloomington (MN): Institute for Clinical Systems Improvement
(ICSI); 2006 Oct. 82 p. \[152 references\]

### Identifying Information

#### ORIGINAL TITLE

Evidence-based cervical cancer screening for average risk asymptomatic
women.

#### MEASURE COLLECTION

[HealthPartners Clinical
Indicators](http://www.qualitymeasures.ahrq.gov/Browse/DisplayOrganization.aspx?org_id=1376&doc=4306)

#### MEASURE SET NAME

[Cervical Cancer (Health Partners Clinical
Indicators)](http://www.qualitymeasures.ahrq.gov/Browse/DisplayOrganization.aspx?org_id=1376&doc=12282)

#### DEVELOPER

HealthPartners

#### ADAPTATION

Measure was not adapted from another source.

#### RELEASE DATE

2005 Oct

#### REVISION DATE

2007 Oct

#### MEASURE STATUS

This is the current release of the measure.

#### SOURCE(S)

HealthPartners. 2007 clinical indicators report: 2006/2007 results.
Minneapolis (MN): HealthPartners; 2007 Oct. 97 p.

#### MEASURE AVAILABILITY

The individual measure, \"Evidence-based Cervical Cancer Screening for
Average Risk Asymptomatic Women,\" is published in the \"2007 Clinical
Indicators Report: 2006/2007 Results.\"

For print copies of the 2007 Clinical Indicators Report: 2006/2007
Results, please contact HealthPartners Quality Measurement and
Improvement Department at (952) 883-5777; E-mail:
<quality@healthpartners.com>; Web site:
[www.healthpartners.com](http://www.healthpartners.com/).

#### COMPANION DOCUMENTS

The following is available:

-   Institute for Clinical Systems Improvement (ICSI). Cervical cancer
    screening. Bloomington (MN): Institute for Clinical Systems
    Improvement (ICSI); 2005 Jun. 34 p.

-   Institute for Clinical Systems Improvement (ICSI). Preventive
    services for adults. Bloomington (MN): Institute for Clinical
    Systems Improvement (ICSI); 2006 Oct. 82 p.

#### NQMC STATUS

This NQMC summary was completed by ECRI Institute on May 23, 2008. The
information was verified by the measure developer on June 20, 2008.

#### COPYRIGHT STATEMENT

This NQMC summary is based on the original measure, which is subject to
the measure developer\'s copyright restrictions.

### Disclaimer

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© 2008 National Quality Measures Clearinghouse

Date Modified: 11/3/2008