CERVICAL CANCER SCREENING

Understanding Noncompliance

Preventive care is one of the cornerstones of managed care. But not all members get the recommended care. This plan sought to improve understanding of the characteristics of noncompliant women. By analyzing data about this important population, screening and early detection programs could be improved.

The use of the Papanicolaou (Pap) test has been proven to significantly reduce the chances of invasive cervical cancer. Pap smears can detect precancerous lesions before they require more invasive treatment. With a high percentage of its female population in the age category at risk, this plan felt the need to focus on improving its rate of cervical cancer screening.

The plan used HEDIS 2.5 methodology throughout the activity. The targeted population consisted of continuously enrolled women aged 21 to 64 years. The HEDIS performance measure used was the percentage of this population that had been screened for cervical cancer with a Pap test in the last three years. The hybrid method (a combination of chart review and administrative data) was used to calculate the rate for a representative sample.

Baseline data from 1995 indicated that 63.4% of the female members had received a Pap test in the preceding three years. The plan did not identify a benchmark for this initiative. The initial performance goal, suggested by the plan's quality improvement (QI) committee, was a Pap smear rate of 65%. Based on the Healthy People 2000 goal, the plan set a long-term goal of an 85% screening rate for the year 2000.

In order to better understand why some women failed to get Pap tests, the plan enlisted the help of a biostatistician to compare the women who had Pap tests versus those who did not.

The difference in the mean age of screened women (41.9 years) and unscreened women (43.4 years) was not significant. However, the percentage of older women was greater in the unscreened group: 37% of women in the unscreened group were 50 to 65 years, as compared with 23% of women in the screened group.

The plan also analyzed screened and unscreened women to determine if there was a difference by category in the rate of visits to their primary care physician (PCP) or OB/GYN. There appeared to be no statistically significant difference in the mean encounter rate for these two populations. Nonetheless, when women were categorized as having a high or low rate of ambulatory encounters, a pattern emerged: 55% of screened women versus 35% of unscreened women had fewer than seven visits. The plan concluded that unscreened women tended to be older and have less frequent visits to both their PCP and OB/GYN.

POPULATION ANALYSIS Understanding the differing characteristics of compliant and noncompliant patients can help identify barriers to care. Although in this case a simple examination of mean ages and encounter rates was not revealing, the plan's statistical analysis of the distribution of ages and encounter rates did disclose some differences between the two sets of women.

The initial interventions focused on member and provider education. The plan published articles in both provider and member newsletters. The plan continued these articles on an annual basis. Additionally, the plan's staff provided its physicians with feedback regarding their performance on ambulatory medical record review audits. It focused particularly on the documentation of preventive care services.

The plan identified those women who had no record of a Pap smear in 1992, 1993, or 1994, and sent them letters that included a survey to elicit why they had not had a Pap smear. As a follow-up, the plan provided the names of these members to their physicians.

The plan also sought to improve access by sending nurses to conduct cervical cancer screening tests at the sites of two of its largest employers.

Remeasurement, based on 1996 data, demonstrated a rate of cervical cancer screening of 71%. This represented a significant improvement. The plan set a new interim goal of 75% for 1997 and initiated additional interventions.

The plan has continued its interventions and implemented new actions in an effort to meet its goal for the year 2000.

It has established for its lab provider quality indicators for timeliness in Pap test reporting. It is also incorporating screening rates in its provider profile that are used for recredentialing.

The plan is looking at collaborative efforts to conduct a long-term study analyzing variations in the care as related to the outcomes of treatment for cervical cancer.