| eCQM Title | Cervical Cancer Screening |
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|---|---|---|---|
| eCQM Identifier (Measure Authoring Tool) | 124 | eCQM Version Number | 9.1.000 |
| NQF Number | Not Applicable | GUID | 42e7e489-790f-427a-a1a6-d6e807f65a6d |
| Measurement Period | January 1, 20XX through December 31, 20XX | ||
| Measure Steward | National Committee for Quality Assurance | ||
| Measure Developer | National Committee for Quality Assurance | ||
| Endorsed By | None | ||
| Description |
Percentage of women 21-64 years of age who were screened for cervical cancer using either of the following criteria: * Women age 21-64 who had cervical cytology performed within the last 3 years * Women age 30-64 who had cervical human papillomavirus (HPV) testing performed within the last 5 years |
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| Copyright |
This Physician Performance Measure (Measure) and related data specifications are owned and were developed by the National Committee for Quality Assurance (NCQA). NCQA is not responsible for any use of the Measure. NCQA makes no representations, warranties, or endorsement about the quality of any organization or physician that uses or reports performance measures and NCQA has no liability to anyone who relies on such measures or specifications. NCQA holds a copyright in the Measure. The Measure can be reproduced and distributed, without modification, for noncommercial purposes (e.g., use by healthcare providers in connection with their practices) without obtaining approval from NCQA. Commercial use is defined as the sale, licensing, or distribution of the Measure for commercial gain, or incorporation of the Measure into a product or service that is sold, licensed or distributed for commercial gain. All commercial uses or requests for modification must be approved by NCQA and are subject to a license at the discretion of NCQA. (C) 2012-2019 National Committee for Quality Assurance. All Rights Reserved. Limited proprietary coding is contained in the Measure specifications for user convenience. Users of proprietary code sets should obtain all necessary licenses from the owners of the code sets. NCQA disclaims all liability for use or accuracy of any third party codes contained in the specifications. CPT(R) contained in the Measure specifications is copyright 2004-2019 American Medical Association. LOINC(R) copyright 2004-2019 Regenstrief Institute, Inc. This material contains SNOMED Clinical Terms(R) (SNOMED CT[R]) copyright 2004-2019 International Health Terminology Standards Development Organisation. ICD-10 copyright 2019 World Health Organization. All Rights Reserved. |
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| Disclaimer |
The performance Measure is not a clinical guideline and does not establish a standard of medical care, and has not been tested for all potential applications. THE MEASURE AND SPECIFICATIONS ARE PROVIDED "AS IS" WITHOUT WARRANTY OF ANY KIND. Due to technical limitations, registered trademarks are indicated by (R) or [R] and unregistered trademarks are indicated by (TM) or [TM]. |
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| Measure Scoring | Proportion | ||
| Measure Type | Process | ||
| Stratification |
None |
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| Risk Adjustment |
None |
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| Rate Aggregation |
None |
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| Rationale |
All women are at risk for cervical cancer. In 2019, an estimated 13,170 women were diagnosed with cervical cancer in the U.S., resulting in an estimated 4,250 deaths (National Cancer Institute, 2019). If pre-cancerous lesions are detected early by Pap tests and treated, the likelihood of survival is nearly 100 percent (American Cancer Society, 2019). |
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| Clinical Recommendation Statement |
US Preventive Services Task Force (USPSTF) (2018) "The USPSTF recommends screening for cervical cancer every 3 years with cervical cytology alone in women aged 21 to 29 years. For women aged 30 to 65 years, the USPSTF recommends screening every 3 years with cervical cytology alone, every 5 years with high-risk human papillomavirus (hrHPV) testing alone, or every 5 years with hrHPV testing in combination with cytology (cotesting) (A recommendation)" "The USPSTF recommends against screening for cervical cancer in women older than 65 years who have had adequate prior screening and are not otherwise at high risk for cervical cancer. (D recommendation)" "The USPSTF recommends against screening for cervical cancer in women younger than 21 years. (D recommendation)" "The USPSTF recommends against screening for cervical cancer in women who have had a hysterectomy with removal of the cervix and do not have a history of a high-grade precancerous lesion (ie, cervical intraepithelial neoplasia [CIN] grade 2 or 3) or cervical cancer. (D recommendation)" |
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| Improvement Notation |
Higher score equals better quality |
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| Reference |
American Cancer Society. (2019). Cancer Prevention & Early Detection Facts & Figures 2019-2020. Atlanta: American Cancer Society. |
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| Reference |
National Cancer Institute. (2019). SEER Cancer Statistics Review, 1975-2016. Retrieved October 17, 2019, from SEER website: https://seer.cancer.gov/csr/1975_2016/index.html |
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| Reference |
US Preventive Services Task Force, Curry, S. J., Krist, A. H., Owens, D. K., Barry, M. J., Caughey, A. B., … Wong, J. B. (2018). Screening for Cervical Cancer: US Preventive Services Task Force Recommendation Statement. JAMA, 320(7), 674–686. https://doi.org/10.1001/jama.2018.10897 |
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| Definition |
None |
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| Guidance |
To ensure the measure is only looking for a cervical cytology test only after a woman turns 21 years of age, the youngest age in the initial population is 23. Patient self-report for procedures as well as diagnostic studies should be recorded in 'Procedure, Performed' template or 'Diagnostic Study, Performed' template in QRDA-1. This eCQM is a patient-based measure. This version of the eCQM uses QDM version 5.5. Please refer to the eCQI resource center (https://ecqi.healthit.gov/qdm) for more information on the QDM. |
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| Transmission Format |
TBD |
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| Initial Population |
Women 23-64 years of age with a visit during the measurement period |
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| Denominator |
Equals Initial Population |
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| Denominator Exclusions |
Women who had a hysterectomy with no residual cervix or a congenital absence of cervix. Exclude patients whose hospice care overlaps the measurement period. |
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| Numerator |
Women with one or more screenings for cervical cancer. Appropriate screenings are defined by any one of the following criteria: * Cervical cytology performed during the measurement period or the two years prior to the measurement period for women who are at least 21 years old at the time of the test * Cervical human papillomavirus (HPV) testing performed during the measurement period or the four years prior to the measurement period for women who are 30 years or older at the time of the test |
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| Numerator Exclusions |
Not Applicable |
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| Denominator Exceptions |
None |
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| Supplemental Data Elements |
For every patient evaluated by this measure also identify payer, race, ethnicity and sex |
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exists ( ["Patient Characteristic Birthdate": "Birth date"] BirthDate
where Global."CalendarAgeInYearsAt" ( BirthDate.birthDatetime, start of "Measurement Period" ) in Interval[23, 64 )
)
and exists ( ["Patient Characteristic Sex": "Female"] )
and exists "Qualifying Encounters"
"Initial Population"
Hospice."Has Hospice" or exists "Absence of Cervix"
exists "Cervical Cytology Within 3 Years" or exists "HPV Test Within 5 Years for Women Age 30 and Older"
None
None
None
( ["Procedure, Performed": "Hysterectomy with No Residual Cervix"] NoCervixProcedure
where NoCervixProcedure.relevantPeriod ends on or before
end of "Measurement Period"
)
union ( ["Diagnosis": "Congenital absence of cervix (disorder)"] NoCervixDiagnosis
where NoCervixDiagnosis.prevalencePeriod starts on or before
end of "Measurement Period"
)
["Laboratory Test, Performed": "Pap Test"] CervicalCytology
where CervicalCytology.relevantDatetime 3 years or less on or before
end of "Measurement Period"
and CervicalCytology.result is not null
"Initial Population"
Hospice."Has Hospice" or exists "Absence of Cervix"
exists ( ["Encounter, Performed": "Encounter Inpatient"] DischargeHospice
where ( DischargeHospice.dischargeDisposition ~ "Discharge to home for hospice care (procedure)"
or DischargeHospice.dischargeDisposition ~ "Discharge to healthcare facility for hospice care (procedure)"
)
and DischargeHospice.relevantPeriod ends during "Measurement Period"
)
or exists ( ["Intervention, Order": "Hospice care ambulatory"] HospiceOrder
where HospiceOrder.authorDatetime during "Measurement Period"
)
or exists ( ["Intervention, Performed": "Hospice care ambulatory"] HospicePerformed
where HospicePerformed.relevantPeriod overlaps "Measurement Period"
)
["Laboratory Test, Performed": "HPV Test"] HPVTest
with ["Patient Characteristic Birthdate": "Birth date"] BirthDate
such that Global."CalendarAgeInYearsAt" ( BirthDate.birthDatetime, HPVTest.relevantDatetime ) >= 30
where HPVTest.relevantDatetime 5 years or less on or before
end of "Measurement Period"
and HPVTest.result is not null
exists ( ["Patient Characteristic Birthdate": "Birth date"] BirthDate
where Global."CalendarAgeInYearsAt" ( BirthDate.birthDatetime, start of "Measurement Period" ) in Interval[23, 64 )
)
and exists ( ["Patient Characteristic Sex": "Female"] )
and exists "Qualifying Encounters"
exists "Cervical Cytology Within 3 Years" or exists "HPV Test Within 5 Years for Women Age 30 and Older"
( ["Encounter, Performed": "Office Visit"] union ["Encounter, Performed": "Preventive Care Services - Established Office Visit, 18 and Up"] union ["Encounter, Performed": "Preventive Care Services-Initial Office Visit, 18 and Up"] union ["Encounter, Performed": "Home Healthcare Services"] ) ValidEncounter where ValidEncounter.relevantPeriod during "Measurement Period"
["Patient Characteristic Ethnicity": "Ethnicity"]
["Patient Characteristic Payer": "Payer"]
["Patient Characteristic Race": "Race"]
["Patient Characteristic Sex": "ONC Administrative Sex"]
years between ToDate(BirthDateTime)and ToDate(AsOf)
DateTime(year from Value, month from Value, day from Value, 0, 0, 0, 0, timezoneoffset from Value)
["Patient Characteristic Ethnicity": "Ethnicity"]
["Patient Characteristic Payer": "Payer"]
["Patient Characteristic Race": "Race"]
["Patient Characteristic Sex": "ONC Administrative Sex"]
| Measure Set |
None |
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|---|---|---|---|