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  • Measure Summary
  • NQMC:009981
  • Sep 2014

Preventive services for adults: percentage of women ages 65 to 70 who are screened for cervical cancer and have undergone appropriate screening 10 years prior.

Institute for Clinical Systems Improvement (ICSI). Quality improvement support: preventive services for adults. Bloomington (MN): Institute for Clinical Systems Improvement (ICSI); 2014 Sep. 21 p.

View the original measure documentation External Web Site Policy

This is the current release of the measure.

The measure developer reaffirmed the currency of this measure in January 2017.

Primary Measure Domain

Clinical Quality Measures: Process

Secondary Measure Domain

Does not apply to this measure

Description

This measure is used to assess the percentage of women ages 65 to 70 years who are screened for cervical cancer and have undergone appropriate screening 10 years prior.

Rationale

The priority aim addressed by this measure is to decrease the rate of patients who undergo unnecessary screenings.

The U.S. Preventive Services Task Force (USPSTF) recommendations are fully endorsed by the Institute for Clinical Systems Improvement (ICSI) Preventive Services work group:

  1. "Screening for cervical cancer in women ages 21 to 65 years with cytology (Pap smear) every 3 years or, for women ages 30 to 65 years who want to lengthen the screening interval, screening with a combination of cytology and human papillomavirus (HPV) testing every 5 years. See the Clinical Considerations for discussion of cytology method, HPV testing and screening interval."
  2. "Against screening for cervical cancer in women younger than age 21 years."
  3. "Against screening for cervical cancer in women older than age 65 years who have had adequate prior screening and are not otherwise at high risk for cervical cancer. See the Clinical Considerations for discussion of adequacy of prior screening and risk factors."
  4. "Against screening for cervical cancer in women who have had a hysterectomy with removal of the cervix and who do not have a history of a high-grade precancerous lesion (e.g., cervical intraepithelial neoplasia [CIN] grade 2 or 3) or cervical cancer."
  5. "Against screening for cervical cancer with HPV testing, alone or in combination with cytology, in women younger than age 30 years."

(USPSTF, 2012)

Evidence for Rationale

Institute for Clinical Systems Improvement (ICSI). Preventive services for adults. Recommendation table. Bloomington (MN): Institute for Clinical Systems Improvement (ICSI); 36 p.

Institute for Clinical Systems Improvement (ICSI). Quality improvement support: preventive services for adults. Bloomington (MN): Institute for Clinical Systems Improvement (ICSI); 2014 Sep. 21 p.

U.S. Preventive Services Task Force (USPSTF). Recommendation summary: cervical cancer: screening. [internet]. Rockville (MD): U.S. Preventive Services Task Force (USPSTF); 2012 Mar [accessed 2015 Feb 11].

Primary Health Components

Cervical cancer screening; elderly

Denominator Description

Number of female patients ages 65 to 70 years (see the related "Denominator Inclusions/Exclusions" field)

Numerator Description

Number of female patients ages 65 to 70 years who were screened for cervical cancer and have undergone appropriate screening 10 years prior

Type of Evidence Supporting the Criterion of Quality for the Measure

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

Additional Information Supporting Need for the Measure

Unspecified

Extent of Measure Testing

Unspecified

State of Use

Current routine use

Current Use

Internal quality improvement

Measurement Setting

Ambulatory/Office-based Care

Professionals Involved in Delivery of Health Services

Advanced Practice Nurses

Midwife

Nurses

Physician Assistants

Physicians

Least Aggregated Level of Services Delivery Addressed

Clinical Practice or Public Health Sites

Statement of Acceptable Minimum Sample Size

Specified

Target Population Age

Age 65 to 70 years

Target Population Gender

Female (only)

National Quality Strategy Aim

Better Care

National Quality Strategy Priority

Health and Well-being of Communities
Prevention and Treatment of Leading Causes of Mortality

IOM Care Need

Staying Healthy

IOM Domain

Effectiveness

Case Finding Period

The time frame pertaining to data collection is annually.

Denominator Sampling Frame

Patients associated with provider

Denominator (Index) Event or Characteristic

Encounter

Patient/Individual (Consumer) Characteristic

Denominator Time Window

Does not apply to this measure

Denominator Inclusions/Exclusions

Inclusions
Number of female patients ages 65 to 70 years

Data Collection: From electronic medical records (EMR), review medical records for patients who fit the denominator criteria with an office visit with primary care provider within the last 12 months.

Exclusion
Unspecified

Exclusions/Exceptions

Unspecified

Numerator Inclusions/Exclusions

Inclusions
Number of female patients ages 65 to 70 years who were screened for cervical cancer and have undergone appropriate screening 10 years prior

Exclusions
Unspecified

Numerator Search Strategy

Fixed time period or point in time

Data Source

Electronic health/medical record

Type of Health State

Does not apply to this measure

Instruments Used and/or Associated with the Measure

Unspecified

Measure Specifies Disaggregation

Does not apply to this measure

Scoring

Rate/Proportion

Interpretation of Score

Desired value is a lower score

Allowance for Patient or Population Factors

Unspecified

Standard of Comparison

Internal time comparison

Original Title

Percentage of women ages 65-70 who are screened and have undergone appropriate screening 10 years prior.

Measure Collection Name

Preventive Services for Adults

Submitter

Institute for Clinical Systems Improvement - Nonprofit Organization

Developer

Institute for Clinical Systems Improvement - Nonprofit Organization

Funding Source(s)

The Institute for Clinical Systems Improvement's (ICSI's) work is funded by the annual dues of the member medical groups and five sponsoring health plans in Minnesota and Wisconsin.

Composition of the Group that Developed the Measure

Work Group Members: John Wilkinson, MD (Work Group Leader); Charles Bass, MD; Darin Brink, MD; Susan Diem, MD, MPH; Andrea Gravley, RN, MAN, CPNP; Lisa Harvey, RD, MPH; Michael Maciosek, PhD; Leslie C. Milteer, PA-C; Peter Rothe, MD, FACP; Leif Solberg, MD

Financial Disclosures/Other Potential Conflicts of Interest

The Institute for Clinical Systems Improvement (ICSI) has long had a policy of transparency in declaring potential conflicting and competing interests of all individuals who participate in the development, revision and approval of ICSI guidelines and protocols.

In 2010, the ICSI Conflict of Interest Review Committee was established by the Board of Directors to review all disclosures and make recommendations to the board when steps should be taken to mitigate potential conflicts of interest, including recommendations regarding removal of work group members. This committee has adopted the Institute of Medicine Conflict of Interest standards as outlined in the report Clinical Practice Guidelines We Can Trust (2011).

Where there are work group members with identified potential conflicts, these are disclosed and discussed at the initial work group meeting. These members are expected to recuse themselves from related discussions or authorship of related recommendations, as directed by the Conflict of Interest committee or requested by the work group.

The complete ICSI policy regarding Conflicts of Interest is available at the ICSI Web site External Web Site Policy.

Disclosure of Potential Conflicts of Interest

Charles Bass, MD (Work Group Member)
Family Clinician, HealthPartners Medical Group and Regions Hospital
National, Regional, Local Committee Affiliations: None
Guideline-Related Activities: None
Research Grants: None
Financial/Non-Financial Conflicts of Interest: None

Darin Brink, MD (Work Group Member)
Assistant Professor, University of Minnesota Physicians
National, Regional, Local Committee Affiliations: None
Guideline-Related Activities: None
Research Grants: None
Financial/Non-Financial Conflicts of Interest: None

Susan Diem, MD, MPH (Work Group Member)
Assistant Professor of Medicine and Adjunct Assistant Professor of Epidemiology, Internist, University of Minnesota Clinicians
National, Regional, Local Committee Affiliations: None
Guideline-Related Activities: None
Research Grants: Received grant money to her institution from the National Institute on Aging for testosterone replacement in older men.
Financial/Non-Financial Conflicts of Interest: None

Andrea Gravley, RN, MAN, CPNP (Work Group Member)
Pediatric Nurse Practitioner, Pediatrics, South Lake Pediatrics
National, Regional, Local Committee Affiliations: Maple Grove Hospital Lactation work group
Guideline-Related Activities: None
Research Grants: None
Financial/Non-Financial Conflicts of Interest: None

Lisa Harvey, RD, MPH (Work Group Member)
Director, Health Education, Park Nicollet Health Services
National, Regional, Local Committee Affiliations: None
Guideline-Related Activities: None
Research Grants: Receives grant money to institution from the Mayo Clinic related to decision support.
Financial/Non-Financial Conflicts of Interest: None

Michael Maciosek, PhD (Work Group Member)
Research Investigator, HealthPartners Research Foundation, HealthPartners Health Plan
National, Regional, Local Committee Affiliations: None
Guideline-Related Activities: None
Research Grants: Receives grant money to his institution from Robert Wood Johnson Foundation, Centers for Disease Control and Prevention and National Institute for Health for preventive services, disease management and cancer treatment.
Financial/Non-Financial Conflicts of Interest: None

Leslie Milteer, PA-C (Work Group Member)
Clinician Assistant, Multicare Associates
National, Regional, Local Committee Affiliations: Minnesota Academy of PAs Board Member, American Academy of PAs Delegates Member
Guideline-Related Activities: None
Research Grants: None
Financial/Non-Financial Conflicts of Interest: None

Peter Rothe, MD, FACP (Work Group Member)
Internist, Geriatrics and Hospice, Health Partners Medical Group and Regions Hospital
National, Regional, Local Committee Affiliations: None
Guideline-Related Activities: None
Research Grants: None
Financial/Non-Financial Conflicts of Interest: None

Leif Solberg, MD (Work Group Member)
Director Care Improvement Research, Family Medicine, HealthPartners Research Foundation
National, Regional, Local Committee Affiliations: Board member for HealthPartners Research Foundation.
Guideline-Related Activities: None
Research Grants: Receives grant monies paid to institution from Patient-Centered Outcomes Research Institute (PCORI) for high-tech imaging, Centers for Medicare and Medicaid Services (CMS) for COMPASS (Care of Mental and Physical and Substance Use Syndromes), Agency for Healthcare Research and Quality (AHRQ) for medical homes
Financial/Non-Financial Conflicts of Interest: None

John Wilkinson, MD (Work Group Leader)
Consultant, Department of Family Medicine, Assistant Professor of Family Medicine, Mayo Clinic and Mayo Foundation
National, Regional, Local Committee Affiliations: None
Guideline-Related Activities: None
Research Grants: None
Financial/Non-Financial Conflicts of Interest: None

Adaptation

This measure was not adapted from another source.

Date of Most Current Version in NQMC

2014 Sep

Measure Maintenance

Unspecified

Date of Next Anticipated Revision

Unspecified

Measure Status

This is the current release of the measure.

The measure developer reaffirmed the currency of this measure in January 2017.

Source(s)

Institute for Clinical Systems Improvement (ICSI). Quality improvement support: preventive services for adults. Bloomington (MN): Institute for Clinical Systems Improvement (ICSI); 2014 Sep. 21 p.

Measure Availability

Source available from the Institute for Clinical Systems Improvement (ICSI) Web site External Web Site Policy.

For more information, contact ICSI at 8009 34th Avenue South, Suite 1200, Bloomington, MN 55425; Phone: 952-814-7060; Fax: 952-858-9675; Web site: www.icsi.org External Web Site Policy; E-mail: icsi.info@icsi.org.

NQMC Status

This NQMC summary was completed by ECRI Institute on April 17, 2015.

The information was reaffirmed by the measure developer on January 10, 2017.

Copyright Statement

This NQMC summary (abstracted Institute for Clinical Systems Improvement [ICSI] Measure) is based on the original measure, which is subject to the measure developer's copyright restrictions.

The abstracted ICSI Measures contained in this Web site may be downloaded by any individual or organization. If the abstracted ICSI Measures are downloaded by an individual, the individual may not distribute copies to third parties.

If the abstracted ICSI Measures are downloaded by an organization, copies may be distributed to the organization's employees but may not be distributed outside of the organization without the prior written consent of the Institute for Clinical Systems Improvement, Inc.

All other copyright rights in the abstracted ICSI Measures are reserved by the Institute for Clinical Systems Improvement, Inc. The Institute for Clinical Systems Improvement, Inc. assumes no liability for any adaptations or revisions or modifications made to the abstracts of the ICSI Measures.

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