Cervical Cancer Screening Performance Measure

WCHQ Ambulatory Measure Specification

Cervical Cancer Screening Performance Measure

Measurement Period 01/01/12 - 12/31/14

Submission Period: 03/02/2015 - 03/13/2015

Measure Description

The percentage of women age 21 through 64 who had a minimum of one cervical cancer screening test during the three year measurement period or women ages 30 through 64 who had a minimum of one cervical cancer screening test and a human papillomavirus (HPV) test within the three year measurement period or prior two years (within the last 5 years). (Refer to Tables PAP-3 and PAP-4 for qualifying tests and timeframes).

Disclaimer: Measures reported by WCHQ healthcare organizations represent a specific aspect of care in relation to an evidence-based standard, but are not clinical guidelines and do not establish standards of care. All providers should have an individual care plan established with their patient.

General Information/Rationale

There is good evidence that cervical cancer screening significantly reduces the incidence of and mortality from cervical cancer. The U.S. Preventive Services Task Force (USPSTF) suggests most of the benefit can be obtained by beginning screening at age 21. Recommendations include screening for women ages 21 through 64 with cytology (Pap smear) at least every 3 years and for women ages 30 through 64 who want to lengthen the screening interval, screening with a combination of cytology and human papillomavirus (HPV) testing every 5 years1. An individual’s specific clinical considerations, risk factors, etc. determine if testing is needed at a more frequent interval. It is recommended that women speak with their health care providers to determine the appropriate interval for their particular situation. There is limited evidence to determine the benefits of continued screening in women older than 65, due to declining incidence of high-grade cervical lesions after middle age. There is fair evidence that screening women older than 65 is associated with an increased risk for potential harm1. Therefore, it is also recommended that women over age 65 speak with their health care providers to determine if continued screening is appropriate for their personal medical condition.

Reference: The Guide to Clinical Preventive Service Recommendations and rationale (updated March 2012): Screening For Cervical Cancer U.S. Preventive Services Task Force (USPSTF). Retrieved November 2012 from http://www.uspreventiveservicestaskforce.org/uspstf/uspscerv.htm

Definitions

36 Months: Measurement Period

24 Months: Most recent 2 years of Measurement Period

Primary Care Office Visit: Office visit in an outpatient, non-urgent care setting

PCP: For WCHQ measure purposes, a primary care provider is defined as any General Practice, Internal Medicine, Family Practice, Pediatrics provider with the following degree types (MD, DO, PA, NP) and any other practitioners identified by the healthcare system as primary care practitioners. The rationale for the additional practitioner(s) must be documented and must be applied consistently across all measures by the organization.

Measure Specific Specialist: As part of the denominator population for this measure visits to an OB-GYN qualify as office visits for the denominator population.

Age Range 21-64: Patients born between 01/01/1950 and 01/01/1991

Age Range 30-64: Patients born between 01/01/1950 and 01/01/1982

Denominator Description

Women whose age at the beginning of the three year measurement period is at least 21 and whose age at the end of the three year measurement period is less than 65 and who are alive as of the last day of the measurement period. Expired patients for whom a specific date of expiration cannot be found are excluded from the denominator population.

The rationale for the denominator population is built from the following criteria:

[Question 1] – Is this a patient whose care is managed within the physician group?

[Question 2] – Is this a patient currently managed in our system?

[Question 3] – Is this a patient that is eligible for cervical cancer screening?

MINIMUM POPULATION SIZE

Organization Level Reporting:

For every WCHQ Ambulatory Measure, each organization must calculate total denominator population for this measure, not a sample (see Encounter Data section). If the Denominator for any given measure is less than 50 patients, the organization does not have to report the Numerator for the measure to WCHQ. To allow for appropriate comparisons of performance across organizations, a minimum population of 50 patients ensures a maximum of a 2% incremental scale on proportional measures.

Publication on the Website: If the Denominator is less than 50, only the Physician Group Name, Population Size (N), and the following statement will display on www.wchq.org:

· The patient population is too small (N<50) for purposes of reliably predicting Physician Group performance.

Historical Trend for Low Population Sizes: The historical trend display of Physician Group performance will not include measurement periods with population sizes less than 50. For each measurement period with insufficient data, there will be no display for that period.

Site Level Reporting:

Denominator Minimum: For site level reporting there must be a minimum of 100 patients per clinic in the denominator for each measure. If the clinic denominator for any given measure is less than 100 patients the organization does not publicly report the results for the measure. The results will still be included in the organization level data.

Provider Minimum per Clinic: For site level reporting there are two options as follows:

o A minimum of 3 providers per clinic who have patients in the measure denominator. There could be a provider or providers in a given clinic who do not get counted because they have no patients in the measure denominator.

o If an organization desires, they can report site level data for a clinic with fewer than 3 providers as long as the clinic meets the 100 patient threshold. If your organization is planning to report results publicly for clinics with less than 3 providers, all clinics that meet this criteria will need to be reported.

Publication on the Website: Clinics who do not have enough providers or patients to be publicly reported for a given measure or measures will still display on the website by name but without results and with a caveat indicating that data was reported but did not meet the minimum provider or population size.

Provider and /or Clinic Attrition Recommendation:

1. If a provider or clinic has left the organization prior to the end of the measurement period and if the organization can track the provider termination date, the provider will not be included in the site level reporting results. The provider or clinic is still included in the group level results.

2. If a clinic closes or is no longer affiliated with a health care system after the end of the measurement period and prior to next year’s data being published a termination date and verbiage will be added next to that clinic’s name on the website. This will require website updating throughout the year.

Assignment of Provider to Clinic:

Organizations can use their current internal site level reporting methodology to assign a provider to a clinic. A provider must be assigned to a “home” clinic. Organizations who are not already doing internal site level reporting can work with WCHQ for assistance.

Assignment of Patient to Provider:

For purposes of WCHQ site level reporting a patient must be attributed to one provider. Organizations can use their own internal algorithm to assign a patient to a provider. Those who are not already doing this can work with WCHQ for assistance.

ENCOUNTER DATA

Patients eligible for inclusion in the denominator include: (See Figure CEC-1)

[Question 1] – Is this a patient whose care is managed within the physician group?

Patients who had at least two Primary Care office visits (Table PAP-1), regardless of diagnosis code, on different dates of service, to a PCP and/or OB-GYN provider in the past 36 months (Measurement Period). If OB-GYN is not considered a PCP, at least one of the two office visits must be to a PCP.

[Question 2] – Is this a patient currently managed in our system?

Patients who had at least one Primary Care office visit (Table PAP-1) regardless of diagnosis code, with a PCP and/or OB-GYN provider in the most recent 24 months of the Measurement Period.

[Question 3] – Is this a patient that is eligible for Cervical Cancer Screening?

Exclude from the eligible population patients who have had a partial or total hysterectomy and/or transgender status identified in Table PAP-2. The organizations may look for exclusions as far back as possible in the patient’s history, through administrative data and/or medical record review. The exclusion can be identified through an ICD-9 diagnosis-based problem list. The problem must be ACTIVE. There is no limit on the look back date, but the date of documentation or onset date must occur prior to the end of the measurement period.

NUMERATOR DESCRIPTION

The number of eligible women who had one of the following cervical cancer screenings:

1. Women Ages 21-64: One or more Pap tests during the 3 year measurement period from Table PAP-3

2. Women ages 30-64:

a. One or more Pap tests during the 3 year measurement period from Table PAP-3

b. A Pap and Human Papillomavirus (HPV) co-test during the 3 year measurement period or the prior two years (within the last 5 years) from Tables PAP-3 and PAP-4. The co-test must occur on the same date of service.

Numerator compliance can be demonstrated by any of the following:

· Administrative data, which can include:

o Table PAP-3 (for #1 above) and Table PAP-3 and Table PAP-4 (for #2 above)

o Internal, external and/or patient reported screenings extracted electronically from an Electronic Medical Record (EMR), requiring one of the following:

ü Year test was performed

ü Date range test was performed, providing the entire range is within the measurement period.

NOTE: This does not include results with a date of documentation only; the actual year or date range of the test must be present and be within the numerator description timeframes for inclusion in the numerator.

· Medical Record Review (Refer to Medical Record Review for Numerator Inclusion/Denominator Exclusion section)

Cervical Cancer Screening Annual Review –Draft Final 2014

This specification is updated annually; refer to previous versions for coding and other changes

WCHQ Ambulatory Measure Specification

Cervical Cancer Screening Performance Measure

Measurement Period 01/01/12 - 12/31/14

Submission Period: 03/02/2015 - 03/13/2015

Cervical Cancer Screening Annual Review –Draft Final 2014

This specification is updated annually; refer to previous versions for coding and other changes

WCHQ Ambulatory Measure Specification

Cervical Cancer Screening Performance Measure

Measurement Period 01/01/11 - 12/31/13

Submission Period: 03/03/2014 - 03/14/2014

sampling methodology

Organizations unable to collect numerator data by electronic means can do so by using the following criteria for chart review;

The Sample size for chart review is determined based in the following criteria:

· c = 95% Confidence Interval

· E = 5% Margin of Error

· N = Total number of patients in the denominator pool

· Use the “Sample Size Generator” at the Wisconsin Collaborative for Healthcare Quality website http://www.wchq.org/calculator/index.php, and enter values to generate the sample size appropriate for your organization

· A 10% over sample is recommended beyond the generated sample size.

Internally Developed Codes – Data Translation/Mapping Requirements

If a medical group utilizes internally generated codes to identify specific services or events required for a given WCHQ performance measure, the group may translate or map the information to the WCHQ performance measurement specifications. The medical group must assure that the internally generated code matches the clinical specificity of the standard (ICD-9, CPT) codes included in the WCHQ performance measurement specifications.

In order to use internally developed codes for WCHQ performance measure reporting, the medical group needs to document the translation/mapping to the codes in the specifications. This documentation should include the internally generated code, a description of the internally developed code, any additional clinical information for the internally developed code, and the equivalent standard code with description from the WCHQ performance measurement specifications. Once the translation/ mapping documentation is established, the medical group’s WCHQ performance measurement team must review the mapping on a yearly basis and document that internally developed codes have not changed and are being used in the manner described in the translation/ mapping document.

The medical group must have documented processes in place for adding codes to the medical group’s administrative data system and procedures to implement the internally developed codes.

Medical Record Review for Numerator Inclusion/Denominator Exclusion

If appropriate, and/or when necessary, every organization may complement their electronic capture of patient medical history with electronic or manual record review. The following criteria apply only to data captured/reviewed during medical record review.

Numerator Inclusion

For WCHQ Preventive Screening Measures, which can include, internal, external, and/or patient reported test results, proof of numerator compliance requires one of the following:

ü Year test was performed

ü Date range test was performed, providing it is within the measurement period.

Denominator Exclusion

For all WCHQ Measures, proof of Denominator exclusion requires:

ü Existence of exclusion criteria.

These data may be retrieved, in whole or in part, from any of the following:

· Notation in Progress Note

· Notation in Medical History or Surgical History

· Flag/Field in Electronic Medical Record

· Documentation in patient chart

NOTE: The organization may not count biopsies for this measure because they are used for diagnostic and therapeutic purposes only and are not valid for primary cancer screening.

REQUIRED DATA SUBMISSION FIELDS

Fields required for data submission for this measure depend upon the methodology used. The fields are as follows:

Organization Level Reporting:

TOTAL POPULATION METHODOLOGY:

· Population Denominator (N) (Patients Eligible for Cervical Cancer Screening)