Data Surveillance Reports

ATTACHMENT 10
Data Surveillance Reports

Your Program
Core Program Performance Indicators from the Data Quality Indicator Guide (DQIG)
October 2008 MDE Submission, Results from January 2007 - December 2007
Refer to the DQIG Report for additional information on these and other indicators
Your Program

CORE PROGRAM PERFORMANCE INDICATORS
Indicator

DQIG

Type

Item

Program Performance Indicator

Results

CDC

Percentage

Standard

Standard
Met ? *

6.a.

Initial Program Pap Tests; Rarely or Never Screened

‡ 20%

26.0% (674/2,593)

YES

19.e.

Screening Mammograms Provided to Women ‡ 50 Years of Age

‡ 75%

85.7% (3,995/4,659)

YES

11.a.

Abnormal Screening Results with Complete Follow-Up

‡ 90%

91.6% (76/83)

YES

16.d.

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

† 25%

35.1% (26/74)

NO

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

‡ 90%

91.8% (56/61)

YES

18.d.

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

† 20%

9.3% (5/54)

YES

Indicators

18.g.

Invasive Carcinoma; Time from Diagnosis to Treatment > 60 Days

† 20%

0.0% (0/2)

YES

Breast

20.a.

Abnormal Screening Results with Complete Follow-Up

‡ 90%

93.0% (1,391/1,496)

YES

Cancer

25.d.

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

† 25%

13.1% (182/1,389)

YES

Diagnostic

26.

Treatment Started for Breast Cancer

‡ 90%

96.3% (52/54)

YES

Indicators

27.d.

Breast Cancer; Time from Diagnosis to Treatment > 60 Days

† 20%

9.6% (5/52)

YES

Screening
Cervical
Cancer

17.
Diagnostic

*For percentages with a denominator ‡ 10, a one-sided hypothesis test was used in determining if a program failed to meet a DQIG standard.
"Small #": The denominator is less than 10. The one-sided hypothesis test was not conducted.
03/20/09

Version 50.3.2 (1.1.0)

Date/Time Edited: 03/23/2009 09:42:52
5

Minimum Data Elements(v5.0) Edits
Your Program
Edit Summary Report
Summary of Inter-field Edit Counts
All Patient Section

Count

Pct

----------------------------------------------------------------------------------------1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53

CBE, Pap Test and Mammogram Dates All Blank...................................
CBE, Pap, Mammogram and Diagnostic Procedures All Coded as "Not Done".........
Both Resident County and Zip Code Blank.......................................
Age at Date of Pap Test is Out of Range.......................................
Age at Date of Mammogram is Out of Range......................................
Age at Date of CBE is Out of Range............................................
Age at Current Date is Out of Range...........................................
CBE Code Invalid for MDE Version..............................................
CBE Date Should Be Blank......................................................
CBE Date Should Be Completed..................................................
CBE Date Out of Range.........................................................
CBE Paid Should Be Blank......................................................
CBE Paid Should be Completed..................................................
Previous Pap Date Should be Blank.............................................
Previous Pap Date Out of Range................................................
Pap Test Screening Site Indicates Pap Should be Completed.....................
Bethesda System Used and 1991/2001 Result Fields are not consistent...........
Specimen Adequacy Indicates Pap Test Result Should be Completed...............
Specimen Adequacy Indicates 1991 Pap Test Result Should be Unsatisfactory.....
Specimen Adequacy Indicates 2001 Pap Test Result Should be Blank..............
Specimen Adequacy Invalid/Blank for Bethesda System Used......................
Specimen Type Should be Completed.............................................
Specimen Type Should be Blank.................................................
Other Pap Test Result Should be Completed.....................................
Other Pap Test Result Should be Blank.........................................
Dx Workup Cerv Should be Not Yet Determined...................................
Dx Workup Cerv Should be Coded YES............................................
Dx Workup Cerv Should be Coded NO.............................................
Dx Workup Cerv Should be Coded YES or NO......................................
Pap Date Should be Blank......................................................
Pap Date Should be Completed..................................................
Pap Date Out of Range.........................................................
Pap Date Before/Equal to Previous Pap Date....................................
Rslts Pap Pending, Dt Scrn Pap More Than 6 Mons Before Submission Dt..........
Pap Paid Should be Completed..................................................
Pap Paid Should be Blank......................................................
Pap Paid Should be NO.........................................................
Previous Mammogram Date Should be Blank.......................................
Previous Mammogram Date Out of Range..........................................
Mammogram Screening Site Indicates Mammogram Should be Completed..............
Dx Workup Breast Should be Not Yet Determined.................................
Dx Workup Breast Should be Coded No or Not Yet Determined.....................
Dx Workup Breast Should be Coded YES..........................................
Dx Workup Breast Should be Coded NO...........................................
Dx Workup Breast Should be Coded YES or NO....................................
Mammogram Date Should be Blank................................................
Mammogram Date Should be Completed............................................
Mammogram Date is Out of Range................................................
Mammogram Date Before/Equal to Previous Mammogram Date........................
Rslts Mam Pending, Mam Date More Than 6 Mons Before Submission Dt.............
Mammogram Paid Should be Completed............................................
Mammogram Paid Should be Blank................................................
Mammogram Paid Should be NO...................................................

0
16
0
0
0
0
0
0
0
0
0
2
0
0
0
0
7
1
0
0
4
2
0
25
0
24
4
1
1
0
3
3
562
48
1
0
18
0
0
0
0
4
3
1
2
0
1
0
272
0
0
0
374

0.0
< 0.1
0.0
0.0
0.0
0.0
0.0
0.0
0.0
0.0
0.0
< 0.1
0.0
0.0
0.0
0.0
< 0.1
< 0.1
0.0
0.0
< 0.1
< 0.1
0.0
< 0.1
0.0
< 0.1
< 0.1
< 0.1
< 0.1
0.0
< 0.1
< 0.1
0.4
< 0.1
< 0.1
0.0
< 0.1
0.0
0.0
0.0
0.0
< 0.1
< 0.1
< 0.1
< 0.1
0.0
< 0.1
0.0
0.2
0.0
0.0
0.0
0.3

14:52 Friday, March 20, 2009
10
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
000000000059131
000000000457653
000000000557860
000000000561885
000000000837537
000000000905631
000000000921946
000000000973590
000000000995823
000000001025606
000000001059655
000000001323951
000000001369597
000000001437971
000000001470797
000000001515754
000000001571005
000000001826166
000000001959788
000000001983712
000000002030339
000000002098619
000000002162718
000000002312745
000000002318094
000000002417759
000000002656910
000000002664078
000000002665034
000000002858720
000000002920247
000000003064981
000000003231419
000000003279624
000000003378594
000000003409442

Record
Identifier

Enrollment
Site

000001
000001
000001
000001
000001
000002
000001
000001
000001
000002
000002
000002
000002
000001
000008
000002
000001
000002
000001
000001
000001
000001
000001
000001
000001
000001
000001
000002
000001
000002
000001
000001
000004
000001
000002
000001

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

Date o f
Mammogr am

Mammogram
Test Result

Date of
CBE

06/25/0 4
n/a
n/a
05/20/0 4
09/20/0 3
04/17/0 4
07/05/0 6
08/23/0 3
n/a
n/a
n/a
04/26/0 6
n/a
02/27/0 4
10/26/0 7
07/12/0 3
07/15/0 4
03/03/0 7
06/28/0 5
01/11/0 4
12/11/0 7
n/a
01/09/0 5
07/11/0 3
12/09/0 6
n/a
n/a
05/02/0 6
09/16/0 3
12/02/0 3
08/08/0 5
06/22/0 7
05/27/0 7
n/a
n/a
04/11/0 7

Benign
Not Needed
Not Needed
Benign
Negative
Benign
Negative
Negative
Not Needed
Not Needed
Not Needed
Benign
Not Needed
Negative
Negative
Benign
Negative
Negative
Negative
Negative
Benign
Not Needed
Prob Ben
Benign
Benign
Not Needed
Not Needed
Negative
Negative
Benign
Negative
Negative
Negative
Not Needed
Not Needed
Negative

06/11/04
12/31/07
11/07/07
02/12/04
09/18/03
04/10/04
06/28/06
05/06/03
11/26/04
12/09/05
12/15/07
03/16/06
07/14/07
08/17/03
10/24/07
07/06/03
07/05/04
03/01/07
06/13/05
01/11/04
11/21/07
06/18/04
12/26/04
07/11/03
11/25/06
11/26/07
03/29/04
02/21/06
07/15/03
11/13/03
07/31/05
06/22/07
05/21/07
06/04/07
08/01/04
04/03/07

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

Diagnostic
Workup Planned
for Breast
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

Mam
Dia g n o s t i c
Pro c e d u r e

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

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

N = 36

Standard Audit Report Feedback 9 - Your Program
October 2008 MDE Submission
MDE data from July 1, 2003 through December 31, 2007
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

Date of
Final
Diagnosis

Mammogram
Final
Diagnosis

n/a
n/a
n/a
n/a
n/a
04/17/04
n/a
n/a
n/a
n/a
n/a
n/a
n/a
05/15/04
n/a
n/a
n/a
n/a
06/28/05
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
Blank
Pending
Pending
Pending
Not Diagnosed
Pending
Pending
Pending
Pending
Pending
Pending
Pending
Not Diagnosed
Pending
Pending
Pending
Pending
Not Diagnosed
Pending
Pending
Pending
Pending
Pending
Pending
Pending
Pending
Pending
Pending
Pending
Pending
Pending
Pending
Pending
Pending
Pending

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

Your Program
MDE Data Quality Indicator Guide
October 2008 MDE Submission
Data from July 1, 2003 to June 30, 2008
Date Began Screening:
Submission Cut-off Date:
Diagnostic Cut-off Date:
Note:

March 20, 2009

April 1991
June 30, 2008
December 31, 2007

Items 7-18 and 20-27 are not evaluated for screening exams performed after the diagnostic cut-off date.
All screenings that are performed prior to the diagnostic cut-off date are expected to have complete diagnostic and treatment information, as necessary.
All screening data are used. No exclusions are made on paid variables, except for items 6.a and 19.e.
Items 6.a., 11.a., 16.d., 17, 18.d., 18.g., 19.e., 20.a., 25.d., 26, and 27.d. are Core Indicators and are also evaluated using a one-sided hypothesis test.

Record Counts
07/03 - 12/06

01/07 - 12/07

01/08 - 06/08

Total Pap Tests

19,658

5,539

2,480

Total initial mammograms

23,594

6,111

2,960

07/03 - 12/06

01/07 - 12/07

01/08 - 06/08

Notes
These counts do not include pending or non-program funded
results.

Demographic Data
Variable
1.
2.
3.
4.

5.

Attribute

County of Screening

0.0

0.0

0.0

Percentage missing

(0 / 44,290)

(0 / 12,084)

(0 / 5,598)

0.0

0.0

0.0

Percentage missing

(0 / 44,290)

(0 / 12,084)

(0 / 5,598)

0.0

0.0

0.0

Percentage missing

(0 / 44,290)

(0 / 12,084)

(0 / 5,598)

County/Zip of Residence
Birth Year
Race/Ethnicity

1.8

1.9

1.8

Percentage missing/unknown

(818 / 44,290)

(224 / 12,084)

(99 / 5,598)

0.6

0.6

0.6

Percentage multiracial

(265 / 44,290)

(78 / 12,084)

(32 / 5,598)

Hispanic Origin
Percentage unknown
Percentage missing

Vers. 5.0

5.0

2.4

2.7

(2,214 / 44,290)

(286 / 12,084)

(150 / 5,598)

0.0

0.0

0.0

(0 / 44,290)

(0 / 12,084)

(0 / 5,598)

1

Notes
< 5%
< 5%
< 5%
missing/unknown should be < 5%

unknown and missing combined should be < 5%
Demography