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9.
As it relates to the HPV vaccine,
how often does your practice –
Mark (X) only ONE for each row.
a. Use the number of sexual partners to
determine who should get the HPV
vaccine?
FORM NAMCS-CCS
(10-8-2009)
Rarely or
never
Sometimes
Usually
Always or almost
always
2
3
4
5
b. Perform a Pap test to determine who
should get the HPV vaccine?
1
2
3
4
5
c. Recommend the HPV vaccine to
females with a history of an abnormal
Pap test result (ASC-US or higher)?
1
2
3
4
5
d. Recommend the HPV vaccine to
females with a positive HPV test?
1
2
3
4
5
11. How will your practice determine when to start routine
cervical cancer screening for fully HPV vaccinated
females?
1
2
1
Mark (X) all that apply.
U.S. CENSUS BUREAU
ACTING AS DATA COLLECTION AGENT FOR THE
U.S. Department of Health and Human Services
Centers for Disease Control and Prevention
National Center for Health Statistics
NATIONAL AMBULATORY MEDICAL CARE SURVEY
2010 CERVICAL CANCER SCREENING SUPPLEMENT
NOTICE – Public reporting burden of this collection of information is estimated to average 20 minutes per response, including the time for reviewing
instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency
may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number.
Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to:
CDC/ATSDR Information Collection Review Office, 1600 Clifton Road, MS D-74, Atlanta, GA 30333, ATTN: PRA(0920-0234).
Assurance of Confidentiality – All information which would permit identification of any individual, a practice, or an establishment will be held confidential,
will be used for statistical purposes only by NCHS staff, contractors, and agents only when required and with necessary controls, and will not be disclosed or
released to other persons without the consent of the individual or the establishment in accordance with section 308(d) of the Public Health Service Act (42 USC
242m) and the Confidential Information Protection and Statistical Efficiency Act (PL-107-347).
Yes
No – SKIP to item 14
By age
1
At same age as non-HPV
vaccinated females –
Specify age
BACKGROUND INFORMATION
1
3
4
12. How often will your practice routinely screen for cervical
cancer among females that have been fully vaccinated
with the HPV vaccine? Mark (X) one.
1
2
3
4
5
6
13. Will your practice be using the HPV DNA test for
managing abnormal cytology for females that have
been fully vaccinated with the HPV vaccine?
1
2
At a later age –
Specify age
By onset of sexual activity –
How many year(s) since
onset of sexual activity?
Will not be screening fully HPV vaccinated females
Unknown
b. There will be fewer referrals for colposcopy among
vaccinated females.
INTRODUCTION
1.
Yes
No
Agree
Disagree
Unsure
1
2
3
1
2
3
15. The Centers for Disease Control and Prevention (CDC) funds state health departments to provide breast and cervical
cancer screening services to low income women through the National Breast and Cervical Cancer Early Detection
Program (Title XV). The state health departments contract out the screening services to physicians and other health
care providers. Is this practice currently participating in this state or national screening program?
1
Yes 2 No 3 Unknown
2
Internal
Medicine
3
OB/
GYN
4
CHC Mid–level
Provider
Does your practice use any of the following methods to screen for
cervical cancer?
Mark (X) all that apply.
Annually Every 2 Every 3
years
years
More
than 3
years
No
routine
interval
recommended
3
4
5
b. Liquid-based cytology (Definition – Specimen suspended in liquid solution)
Yes – How often does your practice routinely screen
1
women using this method?
2
No
Continue with item 1c
3
Unknown
1
2
3
4
5
1
2
3
4
5
}
}
c. Other – Specify
1
2
3
Yes – How often does your practice routinely screen women using
this method?
No
Unknown
Does your practice perform colposcopy?
2
FORM NAMCS-CCS (10-8-2009)
Mark (X) one interval for routine screening.
2
1
Thank you for completing this special survey. We appreciate your time and cooperation.
The Centers for Disease Control and Prevention is conducting a special survey on cervical cancer
screening performed in community health centers and private office settings. Please answer the
following questions. We appreciate your time on this important public health concern.
1
2.
CLOSING STATEMENT
Area code Number
D. Census
contact
telephone
a. Conventional Pap test (Definition – Smear spread on glass slide and fixed)
1
Yes – How often does your practice routinely screen women
using this method?
2
No
Continue with item 1b
3
Unknown
16. For purposes of this survey, which of the following categories describe your profession? – Mark (X) only ONE.
Physician assistant/
3
Registered nurse
4
Other office staff
1
Physician
2
Nurse practitioner/ Nurse midwife
Page 4
General/Family
Practice
C. Provider’s serial number
Annually
Every 2–3 years
Every 4–5 years
Greater than every 5 years
Will not be screening fully HPV vaccinated females
Unknown
14. Please indicate to what extent you agree, disagree, or are unsure
with each statement. Please respond to both a and b.
a. There will be fewer numbers of abnormal Pap tests
among vaccinated females.
B. Census contact name
A. Provider’s specialty (Mark (X) only ONE.)
2
2
Economics and Statistics Administration
Unknown/Not
applicable/
Do not ask
1
10. Will your practice’s cervical cancer screening and
management procedures change for females who have
been fully vaccinated with the HPV vaccine?
U.S. DEPARTMENT OF COMMERCE
3
Yes
No
Unknown
USCENSUSBUREAU
3a. Does your practice ever order or collect the Human
Papillomavirus (HPV) DNA test?
Yes – Go to item 3b
No – SKIP to item 3c
Not aware of HPV DNA test
Unknown
1
2
3
4
}
SKIP to item 9
on page 4
b. Which of the following HPV DNA tests are ordered or
collected in your practice? Mark (X) all that apply.
High risk (HR) HPV DNA test
Low risk (LR) HPV DNA test
Not aware there was a high risk or
low risk HPV DNA test
Type-specific HPV DNA test
Unknown
1
2
3
4
5
}
2
3
1
2
3
SKIP to
item 4a
c. Why is the HPV DNA test not ordered or collected in
your practice? – Mark (X) all that apply.
1
4a. If a patient’s Pap test result is borderline or abnormal,
does your practice routinely order an HPV DNA test
to be performed on that sample (commonly called
reflex HPV DNA testing)? (An HPV DNA test may be
run on the same liquid-based medium as the Pap test
or an HPV DNA test specimen may be collected at
the same time as the conventional Pap test.)
My practice does not see the types of patients for
whom the HPV DNA test is indicated.
My practice uses other tests, procedures, or
examination methods to manage patients for whom
the HPV DNA test is indicated.
The patients in my practice have timely access to
colposcopy.
5
2
6
The health plans or health systems affiliated with
my practice do not recommend the HPV DNA test.
4
7
The HPV DNA test is not a reimbursed or covered
service for most patients in my practice.
Notifying or counseling patients about positive HPV
DNA test results would take too much time.
1
3
11
Notifying or counseling patients about positive HPV
DNA test results might make clinicians in my
practice feel uncomfortable.
Notifying or counseling patients about positive HPV
DNA test results might make patients in my
practice feel uncomfortable, angry, or upset.
SKIP to item 7 on page 3.
1
3
2
4
5
6
7.
1
Women under 21 years old
Women 21 years old to 29 years old
Women 30 years old and over
Other – Specify
Yes – Go to item 5b
No
SKIP to item 6a on page 3
Unknown
}
2
4
5
ASC-US (atypical squamous cells of
undetermined significance)
ASC-H (atypical squamous cells of undetermined
significance – cannot exclude high-grade
intraepithelial lesion)
LSIL (low-grade squamous intraepithelial lesion,
encompassing mild dysplasia/CIN1)
HSIL (high-grade squamous intraepithelial lesion,
moderate dysplasia/CIN2, severe dysplasia/CIN3,
and carcinoma in situ)
AGC (atypical glandular cells)
FORM NAMCS-CCS (10-8-2009)
Given the following screening histories, when would your practice recommend that a woman between 30 and
60 years of age return for her next Pap test?
Prior Pap test results
in past 5 years
(excluding current
normal results)
b. For which abnormal or borderline Pap test result would
your practice recall a patient for an HPV DNA test?
Mark (X) all that apply.
3
Page 2
Women under 21 years old
Women 21 years old to 29 years old
Women 30 years old and over
Women who request the test for cervical cancer screening
Women who request the test to check their HPV infection status
Other – Specify
1
5a. Does your practice routinely recall patients to come back
for a second sample collection for an HPV DNA test if
their Pap test is abnormal or borderline (recall testing)?
2
10
3
}
c. For which patients does your practice usually order reflex
HPV DNA testing? – Mark (X) all that apply.
The labs affiliated with my practice do not offer the
HPV DNA test.
9
}
2
3
Assessing patients’ HPV infection status is not a
priority at my practice.
Discussing cervical cancer screening in the context
of an STD is avoided in my practice.
Yes – Go to item 6b
No
SKIP to item 7
Unknown
1
b. For which patients does your practice routinely order or collect an HPV DNA test along with the Pap test (commonly called
adjunct HPV testing or cotesting)? Mark (X) all that apply.
Yes – Go to item 4b
No
SKIP to item 5a
Unknown
b. For which borderline or abnormal Pap test result would
your practice order or collect a reflex HPV DNA test?
Mark (X) all that apply.
1
ASC-US (atypical squamous cells of undetermined
significance)
2
ASC-H (atypical squamous cells of undetermined
significance – cannot exclude high-grade
intraepithelial lesion)
3
LSIL (low-grade squamous intraepithelial lesion,
encompassing mild dysplasia/CIN1)
4
HSIL (high-grade squamous intraepithelial lesion,
moderate dysplasia/CIN2, severe dysplasia/CIN3,
and carcinoma in situ)
5
AGC (atypical glandular cells)
4
8
6a. Does your practice routinely order or collect an HPV DNA test at the same time as the Pap test as part of routine
cervical cancer screening (commonly called adjunct HPV testing or cotesting)?
For each of the following scenarios, mark (X) only ONE for each row.
Have no
Current
Current
experience
HPV
No
6 months
3
1
2
with this
DNA test Pap test follow-up Less than
to less
years
year
years
6
months
type of
result
results
needed
than 1 year
or more
patient or
test
(a) Two consecutive
normal Pap tests
Has not
had test
Normal
1
2
3
4
5
6
7
(b) Two consecutive
normal Pap tests
Negative
Normal
1
2
3
4
5
6
7
(c) Two consecutive
normal Pap tests
Positive
Normal
1
2
3
4
5
6
7
(d) Has not had a Pap
Negative
test
Normal
1
2
3
4
5
6
7
(e) Has not had a Pap
test
Positive
Normal
1
2
3
4
5
6
7
(f) Abnormal Pap test Negative
Normal
1
2
3
4
5
6
7
(g) Abnormal Pap test
Normal
1
2
3
4
5
6
7
Positive
QUESTIONS 8–14 ASK ABOUT THE HPV VACCINE
8.
How often does your practice use an HPV test to determine who should get the HPV vaccine? Mark (X) only one.
1
2
3
4
5
Rarely or never
Sometimes
Usually
Always or almost always
Do not recommend the HPV vaccine –SKIP to item 10.
FORM NAMCS-CCS (10-8-2009)
Page 3
| File Type | application/pdf |
| File Title | namcsccsp1_4.g |
| File Modified | 2009-11-05 |
| File Created | 2009-11-05 |