MDEs_STAR Draft_Attachment 12

ATTACHMENT 12

Data Surveillance Reports

Your Program
Core Program Performance Indicators from the Data Quality Indicator Guide (DQIG)
April 2005 MDE Submission, Results from July 2003 - June 2004
Refer to the DQIG Report for additional information on these and other indicators

CORE PROGRAM PERFORMANCE INDICATORS
Indicator

DQIG

Type

Item

Program Performance Indicator

CDC
Standard

Your Program

All Programs Combined

Results

Results

Percentage

Standard
Met ? *

Percentage

Standard
Met ? *

6.a.

Initial Program Pap Tests; Rarely or Never Screened

‡ 20%

20.4% (570/2,793)

YES

20.7% (38,279/185,234)

YES

19.e.

Screening Mammograms Provided to Women ‡ 50 Years of Age

‡ 75%

72.5% (4,344/5,993)

NO

71.5% (290,362/406,296)

NO

11.a.

Abnormal Screening Results with Complete Follow-Up

‡ 90%

81.7% (58/71)

NO

87.1% (4,900/5,628)

NO

16.d.

Abnormal Screening Results; Time from Screening to Diagnosis > 60 Days

† 25%

31.7% (19/60)

YES

37.6% (1,779/4,737)

NO

Treatment Started for Diagnosis of HSIL, CIN II, CIN III, CIS, Invasive

‡ 90%

90.4% (47/52)

YES

89.9% (3,714/4,130)

YES

18.d.

HSIL, CIN II, CIN III, CIS; Time from Diagnosis to Treatment > 90 Days

† 20%

14.0% (6/43)

YES

9.6% (334/3,493)

YES

Indicators

18.g.

Invasive Carcinoma; Time from Diagnosis to Treatment > 60 Days

† 20%

33.3% (1/3)

Small #

12.3% (25/204)

YES

Breast

20.a.

Abnormal Screening Results with Complete Follow-Up

‡ 90%

88.6% (1,324/1,495)

NO

88.5% (88,659/100,199)

NO

Cancer

25.d.

Abnormal Screening Results; Time from Screening to Diagnosis > 60 Days

† 25%

19.4% (258/1,327)

YES

18.9% (16,804/88,714)

YES

Diagnostic

26.

Treatment Started for Breast Cancer

‡ 90%

86.6% (58/67)

YES

89.5% (4,007/4,477)

YES

Indicators

27.d.

Breast Cancer; Time from Diagnosis to Treatment > 60 Days

† 20%

6.9% (4/58)

YES

7.0% (277/3,968)

YES

Screening
Cervical
Cancer

17.
Diagnostic

*A standard statistical (hypothesis) test was used in determining if the program's performance met the CDC standard.
"Small #" indicates that the denominator (< 10) was insufficient to make a determination.
11/14/05

Minimum Data Elements (v5.0) Edit Report for Your Program
Edit Summary Report
Date/Time Edited:
11/14/2005 07:41:02

Page 5

SUMMARY OF INTER-FIELD ERROR COUNTS

All Patient Section
Count
Pct
--------------------------------------------------------------------------------------------1
CBE, Screening Pap and Mam Dates All Blank.................................... 0
0.0
2
Results of CBE, Screening Pap and Mam Not Done................................ 9
0.0 #
3
Both Resident County and Zip Code Blank....................................... 0
0.0
4
Age at Date of Screening Pap Test is Out of Range............................. 0
0.0
5
Age at Date of Screening Mammogram is Out of Range............................ 0
0.0
6
Age at Date of CBE is Out of Range............................................ 0
0.0
7
Age at Current Date is Out of Range........................................... 0
0.0
8
CBE Code Invalid for MDE Version.............................................. 0
0.0
9
CBE Date Should Be Blank...................................................... 0
0.0
10
CBE Date Should be Completed.................................................. 1
0.0
11
CBE Date Out of Range......................................................... 1
0.0
12
CBE Paid Should Be Blank...................................................... 1
0.0
13
CBE Paid Should be Completed.................................................. 0
0.0
14
Previous Pap Date Should be Blank............................................. 0
0.0
15
Previous Pap Date Out of Range................................................ 0
0.0
16
Pap Test Screening Site Indicates Screening Pap Should be Completed........... 0
0.0
17
Bethesda System Used does not Match 1991/2001 Result Fields.................. 12
0.0 #
18
Specimen Adequacy Indicates Screening Pap Should be Completed................. 1
0.0
19
Specimen Adequacy Indicates Screening Pap Should be Unsatisfactory............ 0
0.0
20
Specimen Adequacy Indicates Screening Pap Should be Blank..................... 0
0.0
21
Specimen Adequacy Invalid/Blank for Bethesda System Used...................... 0
0.0
22
Specimen Type Should be Completed............................................. 1
0.0
23
Specimen Type Should be Blank................................................. 0
0.0
24
Other Screening Pap Test Results Should be Completed......................... 26
0.0 #
25
Other Screening Pap Test Results Should be Blank.............................. 0
0.0
26
Dx Workup Cerv Should be Not Yet Determined................................... 7
0.0 #
27
Dx Workup Cerv Should be coded YES............................................ 5
0.0
28
Dx Workup Cerv Should be coded NO............................................. 2
0.0
29
Dx Workup Cerv Should be coded YES or NO...................................... 2
0.0
30
Screening Pap Date Should be Blank............................................ 0
0.0
31
Screening Pap Date Should be Completed........................................ 4
0.0
32
Screening Pap Date Out of Range............................................... 0
0.0
33
Screening Pap Date Before/Equal to Previous Pap Date........................ 506
0.5 #
34
Rslts Pap Pending, Dt Scrn Pap More Than 6 Mons Before Submission Dt......... 24
0.0 #
35
Screening Pap Paid Should be Completed........................................ 3
0.0
36
Screening Pap Paid Should be Blank............................................ 0
0.0
37
Screening Pap Paid Should be NO.............................................. 44
0.0 #
38
Previous Mam Date Should be Blank............................................. 0
0.0
39
Previous Mam Date Out of Range................................................ 0
0.0
40
Mam Screening Site Indicates Screening Mam Should be Completed................ 0
0.0
41
Dx Workup Breast Should be Not Yet Determined................................. 0
0.0
42
Dx Workup Breast Should be coded No or Not Yet Determined.................... 47
0.0 #
43
Dx Workup Breast Should be coded YES.......................................... 4
0.0
44
Dx Workup Breast Should be coded NO........................................... 0
0.0
45
Dx Workup Breast Should be coded YES or NO.................................... 0
0.0
46
Screening Mam Date Should be Blank............................................ 0
0.0
47
Screening Mam Date Should be Completed........................................ 2
0.0
48
Screening Mam Date is Out of Range............................................ 0
0.0
49
Screening Mam Date Before/Equal to Previous Mam Date........................ 228
0.2 #
50
Rslts Mam Pending, Dt Scrn Mam More Than 6 Mons Before Submission Dt.......... 8
0.0 #
51
Screening Mam Paid Should be Completed........................................ 0
0.0
52
Screening Mam Paid Should be Blank............................................ 0
0.0
53
Screening Mam Paid Should be NO............................................. 173
0.2 #

07:35 Monday, November 14, 2005
12
Mammograms with Abnormal CBE s, Diagnostic Workup Planned, and Missing Diagnostic Procedur e s a n d / o r F i n a l D i a g n o s e s
I n c l u d e s r e c o r ds with negative, benign, probab ly benign or missing mammogram screening results, cases in wh i c h m a m m o g r a m s w e r e n o t p e r f o r m e d , w i t h C B E
s c r e e n i n g r esults of 'Abnormality Suspiciou s for Cancer' for version 2.2 or later CBE data only, and dia g n o s t i c w o r k u p p l a n n e d f o r b r e a s t c a n c e r

Patient ID
Number
000000000006863
000000000026937
000000000059448
000000000060848
000000000107060
000000000157666
000000000244935
000000000255755
000000000305067
000000000307677
000000000348013
000000000371543
000000000375985
000000000387532
000000000470707
000000000570065
000000000597018
000000000630107
000000000701117
000000000780024
000000000807829
000000000835001
000000000898926
000000000976662
000000000981784
000000000994128
000000001038752
000000001079699
000000001080872
000000001102185
000000001231886
000000001413092
000000001434351
000000001479574
000000001495469
000000001503212
000000001557548
000000001574088
000000001589110
000000001652046
000000001669233
000000001748995
000000001779545
000000001783242
000000001828832
000000001841087
000000001844978
000000001845640
000000001857095
000000001941345
000000002011833
000000002074769
000000002117970

Record
Enrollment Date of M ammogram
I dentifier
Site
Mammogram T est Result
000001
000001
000004
000006
000001
000001
000001
000001
000001
000001
000001
000003
000001
000001
000001
000003
000001
000008
000002
000001
000001
000006
000003
000001
000002
000001
000001
000001
000001
000005
000001
000001
000001
000001
000001
000002
000001
000004
000001
000001
000001
000001
000001
000001
000001
000003
000001
000002
000001
000001
000002
000001
000001

27
9
5
1
23
21
15
5
21
9
27
21
7
19
23
9
23
13
29
27
19
1
9
21
21
25
7
7
21
29
25
5
21
15
15
15
17
15
9
15
21
15
21
5
15
17
13
25
11
3
17
27
7

01/03/04
01/01/03
n/a
05/30/02
02/22/04
01/23/04
02/18/02
02/19/03
12/12/01
05/10/03
07/01/03
05/13/04
03/20/04
03/07/04
03/09/04
05/12/02
12/30/03
n/a
12/22/01
n/a
09/06/02
04/22/04
11/05/02
n/a
04/14/02
n/a
n/a
n/a
07/27/02
08/24/02
09/19/02
03/08/04
01/06/04
11/22/02
04/20/03
01/31/04
n/a
n/a
03/28/04
01/27/04
n/a
10/02/02
11/02/03
n/a
06/25/04
n/a
04/04/02
06/25/04
04/10/02
10/08/02
09/11/02
09/27/02
03/09/03

N egative
B enign
N eeded Not Perf
N egative
N egative
N egative
N egative
N egative
B enign
N egative
B enign
N egative
B enign
B enign
N egative
B enign
B enign
N eeded Not Perf
N egative
N ot Needed
B enign
P rob Ben
N egative
N ot Needed
B enign
N eeded Not Perf
N ot Needed
N ot Needed
N egative
P rob Ben
B enign
B enign
B enign
N egative
N egative
N egative
N ot Needed
N eeded Not Perf
N egative
N egative
N ot Needed
B enign
N egative
D one Recently Elsewhere
B enign
N eeded Not Perf
P rob Ben
B enign
N egative
N egative
B enign
N egative
N egative

Date of
CBE
04/14/04
11/11/02
06/29/02
05/30/02
11/13/03
04/26/04
10/02/02
01/07/03
12/07/01
11/23/02
09/23/03
04/10/04
12/18/03
02/07/04
04/22/04
06/07/02
03/23/04
02/18/01
11/08/01
04/30/04
05/07/02
01/03/04
07/08/02
04/05/04
05/16/02
04/05/01
09/05/02
04/02/03
08/13/02
07/27/02
10/14/02
06/10/04
03/30/04
02/10/03
10/08/02
12/03/03
08/07/03
03/21/02
10/13/03
11/12/03
04/22/04
12/06/02
08/20/03
07/31/01
02/03/04
10/28/02
05/01/02
04/26/04
01/03/02
12/09/02
08/14/02
01/08/03
02/13/03

CBE Result
Abnormal/Susp
Abnormal/Susp
Abnormal/Susp
Abnormal/Susp
Abnormal/Susp
Abnormal/Susp
Abnormal/Susp
Abnormal/Susp
Abnormal/Susp
Abnormal/Susp
Abnormal/Susp
Abnormal/Susp
Abnormal/Susp
Abnormal/Susp
Abnormal/Susp
Abnormal/Susp
Abnormal/Susp
Abnormal/Susp
Abnormal/Susp
Abnormal/Susp
Abnormal/Susp
Abnormal/Susp
Abnormal/Susp
Abnormal/Susp
Abnormal/Susp
Abnormal/Susp
Abnormal/Susp
Abnormal/Susp
Abnormal/Susp
Abnormal/Susp
Abnormal/Susp
Abnormal/Susp
Abnormal/Susp
Abnormal/Susp
Abnormal/Susp
Abnormal/Susp
Abnormal/Susp
Abnormal/Susp
Abnormal/Susp
Abnormal/Susp
Abnormal/Susp
Abnormal/Susp
Abnormal/Susp
Abnormal/Susp
Abnormal/Susp
Abnormal/Susp
Abnormal/Susp
Abnormal/Susp
Abnormal/Susp
Abnormal/Susp
Abnormal/Susp
Abnormal/Susp
Abnormal/Susp

Diagnostic
Mam
Date of
Mammogram
Workup Planned D i a g n o s t i c
Final
Final
for Breast
Procedure
Diagnosis Diagnosis
Workup
Workup
Workup
Workup
Workup
Workup
Workup
Workup
Workup
Workup
Workup
Workup
Workup
Workup
Workup
Workup
Workup
Workup
Workup
Workup
Workup
Workup
Workup
Workup
Workup
Workup
Workup
Workup
Workup
Workup
Workup
Workup
Workup
Workup
Workup
Workup
Workup
Workup
Workup
Workup
Workup
Workup
Workup
Workup
Workup
Workup
Workup
Workup
Workup
Workup
Workup
Workup
Workup

Planned
Planned
Planned
Planned
Planned
Planned
Planned
Planned
Planned
Planned
Planned
Planned
Planned
Planned
Planned
Planned
Planned
Planned
Planned
Planned
Planned
Planned
Planned
Planned
Planned
Planned
Planned
Planned
Planned
Planned
Planned
Planned
Planned
Planned
Planned
Planned
Planned
Planned
Planned
Planned
Planned
Planned
Planned
Planned
Planned
Planned
Planned
Planned
Planned
Planned
Planned
Planned
Planned

Standard Audit Report Feedback 9 - Your Program
April 2005 MDE Submission
MDE data from January 1, 2000 through June 30, 2004
For information or questions call your Technical Consultant at IM S
The National Breast and Cervical Cancer Early Detection Program
Division of Cancer Prevention and Control

Yes
No
No
No
No
No
No
No
No
No
No
No
No
No
Yes
No
No
No
No
Yes
No
No
No
Yes
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No

n/a
01/09/03
n/a
n/a
n/a
n/a
n/a
n/a
n/a
05/12/03
n/a
n/a
n/a
11/07/04
n/a
n/a
n/a
n/a
n/a
n/a
n/a
08/22/04
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a

Pending
Not Diagnosed
Pending
Pending
Pending
Pending
Pending
Blank
Pending
Not Diagnosed
Pending
Pending
Pending
Not Diagnosed
Pending
Pending
Pending
Pending
Pending
Pending
Pending
Not Diagnosed
Pending
Pending
Pending
Pending
Pending
Pending
Pending
Pending
Pending
Pending
Pending
Pending
Pending
Pending
Pending
Pending
Pending
Pending
Pending
Pending
Pending
Pending
Pending
Pending
Pending
Blank
Pending
Pending
Pending
Pending
Pending

Mam Status
of Final
Diagnosis
Pending
Complete
Pending
Pending
Pending
Pending
Pending
Blank
Pending
Complete
Pending
Pending
Pending
Complete
Pending
Pending
Pending
Pending
Pending
Pending
Pending
Complete
Pending
Pending
Pending
Pending
Pending
Pending
Pending
Pending
Pending
Pending
Pending
Pending
Pending
Pending
Pending
Pending
Pending
Pending
Pending
Pending
Pending
Pending
Pending
Pending
Pending
Blank
Pending
Pending
Pending
Pending
Pending

MDE Data Quality Indicator Guide - Your Program
April 2005 MDE Submission

November 14, 2005

Mammogram Data
Variable
20.

Completeness of follow-up
for screenings performed
prior to the diagnostic
cut-off date with abnormal
initial screening results or
Diagnostic Workup is
Planned

Attribute

Total number of screenings performed prior to
the cut-off date with an abnormal screening
result or diagnostic workup is planned

01/00 - 06/03

3,419

07/03 - 06/04

1,495

07/04 - 12/04 Notes

N/A

This total includes Mammogram results of suspicious of
abnormality, highly suggestive of malignancy, assessment is
incomplete, and "result unknown, presumed abnormal, Mam
from a non-program funded source", abnormal CBE results,
or diagnostic workup planned for breast cancer.

N/A

Complete is defined by having a diagnostic procedure and a
final diagnosis recorded.
‡ 90%

N/A

An indication in the Status of Final Diagnosis of Lost to
Follow-up
† 3%

20.a.*
Percentage with complete follow-up

91.0

88.6

20.b.*
Percentage lost to follow-up

2.4

2.6

20.c.*

20.d.*

20.e.*

20.f.*

Percentage refused

3.6

2.4

N/A

An indication in the Status of Final Diagnosis of Refused
† 2%

Percentage with incomplete follow-up due to no
final diagnosis and no diagnostic procedures
recorded

2.8

5.1

N/A

The final diagnosis is blank and no diagnostic procedures
are recorded as being done.

Percentage with incomplete follow-up due to a
diagnostic procedure recorded, but no final
diagnosis recorded

0.1

0.9

N/A

The final diagnosis is blank, but there is a diagnostic
procedure recorded.

Percentage with incomplete follow-up due to a
final diagnosis recorded, but no diagnostic
procedure recorded

0.1

0.5

N/A

There are no diagnostic procedures recorded, but a final
diagnosis is recorded.

*Note: 20.d., 20.e., and 20.f. are mutually exclusive categories of incompleteness and their sum should be † 5%. The sum of 20.a. through 20.f. must be 100%.
Vers. 5.0

13

Mam