CERVICAL CANCER SCREENING

Sticking to the Basics: Outreach and Self-Referral

Encouraging members to obtain routine preventive screenings can sometimes be difficult. Health plans have a tendency to try one novel intervention after another until they find one that seems to work. This health plan implemented tried and true interventions that had been known to work in other plans.

Cervical cancer causes 7,000 deaths a year. Through early detection and treatment, the Papanicolaou (Pap) test has been credited with reducing mortality from cervical cancer by 75%. With demographic data demonstrating the significant number of plan members for whom Pap tests were important, this plan decided to focus on basic efforts to increase screening rates.

The plan followed HEDIS 2.5 specifications throughout the activity. The target population consisted of all women members aged 21 through 64 years. The measurement selected was the percentage of this population who had received 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 of a representative sample.

Baseline data form 1993 showed a cervical cancer screening rate of 62.4%. As a benchmark, the plan chose a score of 89%, which had been achieved by a plan participating in the NCQA Report Card Pilot Project. The plan's quality improvement (QI) committee set a performance goal of 85%.

The plan began its selected interventions in a deliberate fashion. It implemented educational interventions for members and practitioners.

Articles that promoted the need for cervical cancer screening were published in both provider and member newsletters. Preventive health guidelines that included recommendations for Pap tests were mailed to all practitioners. Recognizing the importance of women's health issues, the plan already allowed self-referral to participating gynecologists for annual Pap tests. Information placed in the plan's handbook and schedule of benefits promoted this self-referral option.

SELF-REFERRAL Implementing programs of self-referral may seem simple on the surface, but issues of reimbursement and choice can make their administration challenging. This plan found that medical groups wanted to restrict access to a single group or IPA, while members wanted network-wide choice. Also complicating the picture: a state mandate for open access.

The first remeasurement, based on 1994 data, showed a screening rate of 68.2%, a statistically significant improvement.

To determine barriers to cervical cancer screening, the plan mailed a survey to all 4,511 women in the target group who did not receive a Pap test. Although only 12% responded, five top reasons for not obtaining the test emerged:

• they preferred an OB/GYN not in the plan's network
• they did not have available time
• the procedure was embarrassing
• their doctors did not remind them of the need
• the procedure was painful

BARRIER ANALYSIS Initial interventions probably could have been made more effective if the plan had conducted this survey earlier. In the rush to action, barrier analyses sometimes aren't performed until relatively late in the QI cycle. Skipping or delaying barrier analysis not only decreases the strength of interventions, it also wastes resources and makes prioritizing actions difficult.

Both the remeasurement results and the survey responses encouraged the plan to enhance its interventions. It established a dedicated QI team, tasked to further improve screening rates. The plan began sending birthday card reminders to its members between the ages of 18 and 80 years. In August 1995, it mailed primary care physicians (PCPs) their individual HEDIS scores, identifying members who had not received a Pap test in the past three years. Included in the mailing were medical record reminder stickers for the charts of women who needed a Pap test and template reminder letters that PCPs could use.

Member and provider education programs were maintained. The plan continued to promote the self-referral benefit with newsletters.

The second remeasurement, based on 1995 data, showed a statistically significant rise in the screening rates, to 74.4%. Encouraged by these results, the QI team moved forward. They maintained their interest in education, but focused on making their efforts stronger.

The plan replaced the birthday card reminders with educational materials targeted at those members who had not had a Pap test in the past 32 months. The new mailing included a reminder of the self-referral benefit and a list of participating OB/GYNs.

The plan mailed preventive health guidelines to practitioners. A special member version of the guidelines was published in the member newsletter.

The third remeasurement, using 1996 data, showed a rate of 75.2%. Although short of the desired performance goal, this represented a statistically significant improvement over the prior year.

The plan has since continued its efforts. In 1997, the plan added practitioners' individual cervical cancer screening rates to an annual PCP report card. This provided a comparison of the individual practitioner's rate to the plan-wide performance goal.

The plan also has moved to HEDIS 3.0 specifications, and now uses administrative data alone, resulting in a new baseline screening rate of 67.3%.

As it continues to pursue its performance goal of 85%, the plan may soon find that it is time to try other approaches to encourage preventive screening, particularly for women who have rarely or never been screened.