• Institute for Clinical Systems Improvement (ICSI). Initial management of abnormal cervical cytology (Pap smear) and HPV testing. Bloomington (MN): Institute for Clinical Systems Improvement (ICSI); 2008 Oct. 32 p. [63 references]

Does not apply to this measure

This measure is used to assess percentage of adult women diagnosed with initial abnormal cervical cytology of atypical squamous cells of undetermined significance (ASCUS) with high-risk human papillomavirus (HPV) type who have follow-up colposcopy within six months of abnormality identified.

The priority aim addressed by this measure is that all women who undergo cervical cytologic analysis and receive an abnormal cervical cytology result will receive appropriate clinical follow-up.

Cervical cytology; atypical squamous cells of undetermined significance (ASCUS); high-risk human papillomavirus (HPV) type; colposcopy

Number of women with an initial abnormal cervical cytology of atypical squamous cells of undetermined significance (ASCUS) with high-risk human papillomavirus (HPV) type identified by International Classification of Diseases, Ninth Revision (ICD-9) code 795.05 within reporting quarter

Number of women with follow-up colposcopy within six months (see the related "Numerator Inclusions/Exclusions" field in the Complete Summary)

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

Unspecified

Current routine use

Internal quality improvement

Physician Group Practices/Clinics

Physicians

Group Clinical Practices

Unspecified

Female (only)

Unspecified

Unspecified

Unspecified

Unspecified

Unspecified

Unspecified

Staying Healthy

Effectiveness
Timeliness

Users of care only

Women with an initial abnormal cervical cytology result of atypical squamous cells of undetermined significance (ASCUS) with high-risk human papillomavirus (HPV) type isolated

Identify women with abnormal Pap smear results of ASCUS with high-risk HPV type by International Classification of Diseases, Ninth Revision (ICD-9) code. If you are doing this measure quarterly, select a three-month target period that is six to nine months prior. For example, if this measure is to be collected in June, select a target period of October through December of the previous year.

The suggested time frame for data collection is quarterly.

Patients associated with provider

Inclusions
Number of women with an initial abnormal cervical cytology of atypical squamous cells of undetermined significance (ASCUS) with high-risk human papillomavirus (HPV) type identified by International Classification of Diseases, Ninth Revision (ICD-9) code 795.05 within reporting quarter

Exclusions
Unspecified

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

Clinical Condition

Time window is a single point in time

Inclusions
Number of women with follow-up colposcopy within six months*

*Women identified in the denominator who have had an encounter with a Current Procedure Terminology (CPT) code of 57452, 57454, 57455, 57456, 57460, 57461 within six months of initial abnormal Pap results.

Review the visit data for the women identified in the target period for clinical follow-up using the International Classification of Diseases, Ninth Revision (ICD-9) code listed. Many medical groups will have access for this data through their clinical data systems and access the CPT codes through their administrative data system.

For those women who have not received a follow-up colposcopy, a chart audit can be performed to determine if care was received from an outside provider. Documentation of follow-up in the chart will be considered meeting the criteria of the measure.

Exclusions
Unspecified

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

Fixed time period

Administrative data
Medical record

Individual Case

Unspecified

Rate

Better quality is associated with a higher score

Unspecified

Internal time comparison

Unspecified

Percentage of adult women diagnosed with initial abnormal cervical cytology of ASCUS with high-risk HPV type who have follow-up colposcopy within six months of abnormality identified.

Institute for Clinical Systems Improvement

The following Minnesota health plans provide direct financial support: Blue Cross and Blue Shield of Minnesota, HealthPartners, Medica, Metropolitan Health Plan, PreferredOne and UCare Minnesota. In-kind support is provided by the Institute for Clinical Systems Improvement's (ICSI) members.

Work Group Members: Brendon Cullinan, MD (Work Group Leader) (Hennepin County Medical Center) (Family Medicine); Jeanne M. Anderson, MD (Family HealthServices Minnesota) (Family Medicine); Amy Nelson, MD (Sanford Health) (Family Medicine); Melissa A. Geller, MD (University of MN) (Gynecology/Oncology); Dale Akkerman, MD (Park Nicollet Health Services) (Ob/Gyn); Brigitte Barrette, MD (Mayo Clinic) (Ob/Gyn); Ashley Briggs, MD (Sanford Health) (Ob/Gyn); Jeff Raines, MD (Fairview Health Services) (Ob/Gyn); Lachlan Smith, MD (Affiliated Community Medical Center) (Ob/Gyn); Jane Suska, CNP (HealthParnters Central MN Clinics) (Ob/Gyn); Corrine Esch, RN (HealthPartners Medical Group) (Nursing); R. Paul Weatherby, MD (Park Nicollet Health Services) (Pathology); Sylvia Robinson, BSN, MBA (Institute for Clinical Systems Improvement) (Measurement/Implementation Advisor); Linda Setterlund, MA, CPHQ (Institute for Clinical Systems Improvement) (Facilitator)

ICSI has adopted a policy of transparency, disclosing potential conflict and competing interests of all individuals who participate in the development, revision and approval of ICSI documents (guidelines, order sets and protocols). This applies to all work groups (guidelines, order sets and protocols) and committees (Committee on Evidence-Based Practice, Cardiovascular Steering Committee, Women's Health Steering Committee, Preventive & Health Maintenance Steering Committee and Respiratory Steering Committee).

Participants must disclose any potential conflict and competing interests they or their dependents (spouse, dependent children, or others claimed as dependents) may have with any organization with commercial, proprietary, or political interests relevant to the topics covered by ICSI documents. Such disclosures will be shared with all individuals who prepare, review and approve ICSI documents.

No work group members have potential conflicts of interest to disclose.

Measure was not adapted from another source.

2003 Apr

2008 Oct

This is the current release of the measure.

This measure updates a previous version: Institute for Clinical Systems Improvement (ICSI). Management of initial abnormal Pap smear. Bloomington (MN): Institute for Clinical Systems Improvement (ICSI); 2006 Oct. 32 p.

• Institute for Clinical Systems Improvement (ICSI). Initial management of abnormal cervical cytology (Pap smear) and HPV testing. Bloomington (MN): Institute for Clinical Systems Improvement (ICSI); 2008 Oct. 32 p. [63 references]

This NQMC summary was completed by ECRI on February 9, 2004. This summary was updated by ECRI Institute on October 11, 2004, November 16, 2005, December 11, 2006, and again on November 26, 2008.

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.