CERVICAL CANCER SCREENING

Turning Plan Awareness Into Action

Although this plan was aware that its rate of cervical cancer screening was low, it had no idea how its performance compared with other plans in the area. When it began participating in a regional HEDIS reporting effort, it was able to compare results. The disconcerting discovery - a competing plan posted a cervical cancer screening rate more than twice as high.

The medical literature reports that the use of the Papanicolaou (Pap) test as a screening tool can reduce mortality from cervical cancer by 75%. Cervical cancer kills 7,000 Americans annually. This plan had become motivated to seek improvement in screening its membership for this deadly but treatable disease.

The plan measured its cervical cancer screening rate on an annual basis using HEDIS methodology. Hybrid methodology (using administrative data and chart review) was used to calculate rates for a random sample in 1994 and 1996. In 1995, the plan used administrative data to calculate a rate for its entire population.

DATA SOURCES Although HEDIS specifications are designed to enhance comparability between measurements based on differing data sources, plans often worry that use of administrative data alone may result in lower scores. This plan showed improvement despite a change in data source. A switch to administrative data can represent a substantial saving of resources that would otherwise be used for chart review.

The 1994 data yielded a baseline measurement of 40.5%. The Healthy People 2000 goal is to increase the population of those who received a Pap test within the preceding three years to at least 85%. The regional HEDIS reporting initiative identified a benchmark for cervical cancer screening of 83.3% from a regional plan. Based on these numbers, the quality improvement (QI) team set a performance goal of 85%.

The plan conducted focus groups to identify the barriers to improvement in the area of Pap testing. Eight groups, four consisting of members and four consisting of providers, were gathered together in 1995. Each group had six to eight participants. They determined that the chief impediment to improvement was awareness: Pap tests seemed to be a low priority for both practitioners and members.

FOCUS GROUPS The plan's early use of focus groups in barrier analysis is exceptional. The plan needed to use sufficient numbers of practitioners and members from each distinct district. Their experience shows that the use of small focus groups can enhance the understanding of information derived from surveys.

With awareness identified as the chief impediment, the plan implemented interventions directed at member and provider education. A number of internal resources were available to support the project. The plan had departments that provided survey activities and continuing medical education seminars.

Activities included:

• a member newsletter article regarding cervical cancer
• a CME program entitled "Update for PCPs - Cervical Cancer"
• the distribution of preventive health guidelines to network primary care physicians (PCPs) and specialists
• the sharing of 1994 HEDIS summary results with approximately 1,200 plan providers

While the Pap test rate improved significantly in 1995 - to 57.7% - the plan remained below its goal. The plan decided to implement stronger interventions.

The plan had obtained positive feedback from practitioners who received the summary HEDIS report. It decided to implement quarterly reports to PCPs in March 1996. The reports contained two lists (1) members who were not considered screened in 1995 and (2) members who needed screening in 1996. These lists were generated using claims data.

During the summer of 1996, the plan surveyed members who failed to have a Pap test in the preceding three years. Surveys were sent to 11% of the noncompliant members; the response rate was 36%. Members who responded indicated that knowledge (PCPs not recommending Pap tests or members not knowing the recommended frequency) was the critical barrier. Lack of convenient office hours and the discomfort and embarrassment associated with the test were also cited.

The plan reported a cervical cancer screening rate of 82.7% in 1996. Though this did not meet the plan's goal of 85%, it was significantly higher than the 1994 and 1995 rates.

The plan's efforts have doubled the rate of cervical cancer screening - from 40.5% in 1994 to 82.7% in 1996. Since then, it has continued to produce lists of members due for a Pap test. It has focused its efforts on the timely distribution of these lists to PCPs. Its educational efforts have continued as well. The plan sponsored a CME conference entitled "Evaluation of Abnormal Pap Smears." Recognizing the importance of member communications, it published an article entitled "Women's Wellness Guidelines."

While the plan sustained its improvement in 1997, its performance remains slightly below the 85% goal. In 1997, using hybrid data, the plan reported a screening rate of 81%, which was not a statistically significant change.

The plan implemented a birthday card reminder system in 1998. One of two cards was sent to each selected member. Members who had the test performed in the preceding year received a card thanking them. Those who needed a test in the upcoming year received a reminder card.

The plan has continued to develop a physician profile that contains cervical cancer screening performance information. It has been approved, implemented, and linked to an annual quality bonus for practitioners.

The plan's efforts in conducting focus groups and a member survey were important not only to the success of this effort - the experience has been invaluable in the design of additional programs and activities.