Data Surveillance Reports

ATTACHMENT 10
Data Surveillance Reports

Your Program
Core Program Performance Indicators from the Data Quality Indicator Guide (DQIG)
October 2011 MDE Submission, Results from January 2010 - December 2010
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%

28.9% (708/2,446)

YES

19.e.

Mammograms Provided to Women ‡ 50 Years of Age

‡ 75%

85.6% (4,297/5,020)

YES

11.a.

Abnormal Screening Results with Complete Follow-Up

‡ 90%

89.4% (93/104)

YES

16.d.

Abnormal Screening Results; Time from Screening to Diagnosis > 90 Days

† 25%

13.0% (10/77)

YES

Treatment Started for Diagnosis of HSIL, CIN2, CIN3, CIS, Invasive

‡ 90%

91.0% (71/78)

YES

18.d.

HSIL, CIN2, CIN3, CIS; Time from Diagnosis to Treatment > 90 Days

† 20%

5.8% (4/69)

YES

Indicators

18.g.

Invasive Carcinoma; Time from Diagnosis to Treatment > 60 Days

† 20%

50.0% (1/2)

Small #

Breast

20.a.

Abnormal Screening Results with Complete Follow-Up

‡ 90%

95.3% (1,630/1,710)

YES

Cancer

25.d.

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

† 25%

7.1% (115/1,623)

YES

Diagnostic

26.

Treatment Started for Breast Cancer

‡ 90%

100.0% (74/74)

YES

Indicators

27.d.

Breast Cancer; Time from Diagnosis to Treatment > 60 Days

† 20%

2.7% (2/74)

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.
04/04/12

Version 60.1.2 (2.0.3)

Date/Time Edited: 04/10/2012 14:03:53
6

Minimum Data Elements(v6.0) Edits
Your Program
Edit Summary Report
Summary of Inter-field Edit Counts
All Patient Section

Count

Pct

----------------------------------------------------------------------------------------1 CBE, Pap Test, HPV Test, Mammogram, 'Referral' and Final Dx Dates All Blank...
2 CBE, Pap, HPV Test, Mammogram and Diagnostic Procedures All Coded as "Not
Done"
3 Both Resident County and Zip Code Blank.......................................
4 Age at Date of Pap Test is Out of Range.......................................
5 Age at Date of Initial Mammogram is Out of Range..............................
6 Age at Date of CBE is Out of Range............................................
7 Age at Date of HPV Test is Out of Range.......................................
8 Age at Current Date is Out of Range...........................................
9 Race 3 Should be Blank........................................................
10 Race 4 Should be Blank........................................................
11 Race 5 Should be Blank........................................................
12 CBE Code Invalid for MDE Version..............................................
13 CBE Date Should Be Blank......................................................
14 CBE Date Should Be Completed..................................................
15 CBE Date Out of Range.........................................................
16 CBE Paid Should Be Blank......................................................
17 CBE Paid Should be Completed..................................................
18 Previous Pap Date Should be Blank.............................................
19 Previous Pap Date Out of Range................................................
20 Cervical Diagnostic Referral Date Should be Blank.............................
21 Cervical Diagnostic Referral Date Should be Completed.........................
22 Cervical Diagnostic Referral Date is Out of Range.............................
23 Bethesda System Used and 1991/2001 Result of Pap Test Fields are not
Consistent
24 Bethesda System Used Should be Blank..........................................
25 Bethesda System Used Should be Completed......................................
26 Specimen Adequacy Should be Blank.............................................
27 Specimen Adequacy Should be Completed.........................................
28 Specimen Adequacy Indicates Result of Pap Test Should be Completed............
29 Specimen Adequacy Indicates Result of Pap Test (1991) Should be Unsatisfactory
30 Specimen Adequacy Indicates Result of Pap Test (2001) Should be Blank.........
31 Specimen Adequacy Invalid/Blank for Bethesda System Used......................
32 Specimen Type Should be Blank.................................................
33 Specimen Type Should be Completed.............................................
34 Result of Pap Test (Bethesda 1991 System) Should be Blank.....................
35 Result of Pap Test (Bethesda 1991 System) Should be Completed.................
36 Result of Pap Test (Bethesda 2001 System) Should be Blank.....................
37 Result of Pap Test (Bethesda 2001 System) Should be Completed.................
38 Indication for Pap Test Should be "Referred Into Program".....................
39 Other Pap Test Result Should be Blank.........................................
40 Other Pap Test Result Should be Completed.....................................
41 Date of Pap Test Should be Blank..............................................
42 Date of Pap Test Should be Completed..........................................
43 Date of Pap Test Out of Range.................................................
44 Date of Pap Test Before or Equal to Date of Previous Pap Test.................
45 Rslts Pap Pending, Dt Scrn Pap More Than 6 Mons Before Submission Dt..........
46 Pap Paid Should be Blank......................................................
47 Pap Paid Should be Completed..................................................
48 Pap Paid Should be NO.........................................................
49 HPV Test Result Should be Blank...............................................
50 HPV Test Result Should be Completed...........................................
51 HPV Test Date Should be Blank.................................................
52 HPV Test Date Should be Completed.............................................
53 HPV Test Date is Out of Range.................................................
54 HPV Test Paid Should be Blank.................................................
55 HPV Test Paid Should be Completed.............................................
56 Dx Workup Cerv Should be Blank................................................

48
0

< 0.1
0.0

0
0
0
0
0
0
0
0
0
0
0
4
2
1
0
0
0
0
2
0
5

0.0
0.0
0.0
0.0
0.0
0.0
0.0
0.0
0.0
0.0
0.0
0.1
0.1
0.1
0.0
0.0
0.0
0.0
0.1
0.0
0.1

0
1
0
123
4
0
0
4
0
1
0
1
0
4
0
0
10
0
10
8
622
22
0
3
0
0
253
0
0
0
0
0
1

<
<
<

<
<

0.0
< 0.1
0.0
< 0.1
< 0.1
0.0
0.0
< 0.1
0.0
< 0.1
0.0
< 0.1
0.0
< 0.1
0.0
0.0
< 0.1
0.0
< 0.1
< 0.1
0.4
< 0.1
0.0
< 0.1
0.0
0.0
0.1
0.0
0.0
0.0
0.0
0.0
< 0.1

09:45 Tuesday, April 10, 2012
Mammograms with Abnormal CBEs, Diagnostic Workup Planned, and Missing Diagnostic Procedures and/or Final Diagnoses
Includes records with negative, benign, probably benign or missing mammogram screening results, cases in which mammograms were not performed, with CBE
screening results of 'Abnormality Suspicious for Cancer' for version 2.2 or later CBE data only, and diagnostic workup planned for breast cancer
Patient ID
Number

Record
Identifier

Enrollment
Site

Date of
Mammogram

000000000122264
000000000177929
000000000220866
000000000407666
000000000463693
000000000502575
000000000549401
000000000625457
000000000656363
000000000830864
000000000903909
000000001021232
000000001214254
000000001251862
000000001294617
000000001674481
000000001689636
000000001741581
000000001847728
000000002045129
000000002549620
000000002615081
000000002616681
000000002823333
000000002832042
000000002938858
000000002960379
000000002992475
000000003028785
000000003250086
000000003388537
000000003410821
000000003800930
000000003848386
000000003942019
000000004026433
000000004091390
000000004164986

00000001
00000006
00000001
00000001
00000005
00000005
00000001
00000003
00000001
00000001
00000005
00000001
00000004
00000001
00000005
00000001
00000002
00000001
00000003
00000001
00000004
00000004
00000001
00000001
00000002
00000002
00000001
00000001
00000001
00000002
00000005
00000002
00000001
00000001
00000002
00000002
00000002
00000002

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

11/09/06
05/28/08
11/11/10
07/22/10
09/17/10
07/17/08
08/30/07
04/09/07
11/17/08
01/13/08
n/a
n/a
01/07/09
07/31/08
n/a
07/23/06
05/23/10
07/09/07
n/a
08/12/10
06/26/09
11/22/10
04/30/07
03/10/08
07/24/08
10/01/06
n/a
09/08/07
12/17/10
04/26/07
06/11/09
08/13/10
03/02/10
03/27/10
05/18/08
03/12/09
07/10/08
02/12/08

Mammogram
Test Result
Negative
Benign
Benign
Benign
Benign
Negative
Benign
Benign
Negative
Benign
Blank
Blank
Negative
Negative
Blank
Prob Ben
Benign
Benign
Blank
Benign
Benign
Prob Ben
Benign
Negative
Benign
Benign
Blank
Negative
Benign
Prob Ben
Negative
Benign
Prob Ben
Negative
Negative
Negative
Benign
Negative

Date of
CBE
11/01/06
03/25/08
10/21/10
06/30/10
09/07/10
06/22/08
08/22/07
02/21/07
11/17/08
01/13/08
10/04/07
08/08/06
11/15/08
07/31/08
11/02/06
07/03/06
05/17/10
06/17/07
12/09/10
07/30/10
06/16/09
11/22/10
04/21/07
02/07/08
07/10/08
08/21/06
10/18/06
09/08/07
10/27/10
04/26/07
04/23/09
08/10/10
02/27/10
02/14/10
04/29/08
03/12/09
05/10/08
02/04/08

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

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
Workup
Workup

Mam
Diagnostic
Procedure

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

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

N = 38

Standard Audit Report Feedback 9 - Your Program
October 2011 MDE Submission
MDE data from July 1, 2006 through December 31, 2010
For information or questions call your Technical Consultant at IMS
The National Breast and Cervical Cancer Early Detection Program
Division of Cancer Prevention and Control

Date of
Final
Diagnosis

Mammogram
Final
Diagnosis

n/a
05/28/08
n/a
n/a
n/a
n/a
n/a
04/09/07
n/a
n/a
10/10/07
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
08/12/10
n/a
n/a
n/a
n/a
n/a
n/a
10/18/06
09/08/07
n/a
n/a
n/a
n/a
03/02/10
03/27/10
05/26/08
n/a
n/a
n/a

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

Mam Status
of Final
Diagnosis

9

Pending
Complete
Pending
Pending
Pending
Pending
Pending
Complete
Pending
Pending
Complete
Pending
Pending
Pending
Pending
Pending
Pending
Pending
Pending
Complete
Blank
Blank
Pending
Pending
Pending
Pending
Lost
Complete
Pending
Pending
Pending
Blank
Complete
Complete
Complete
Pending
Pending
Pending

Your Program
MDE Data Quality Indicator Guide
October 2011 MDE Submission
Data from July 1, 2006 to June 30, 2011
Date Began Screening:
Submission Cut-off Date:
Diagnostic Cut-off Date:
Note:

April 04, 2012

April 1991
June 30, 2011
December 31, 2010

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
07/06 - 12/09

01/10 - 12/10

01/11 - 06/11

Total Pap Tests

18,495

4,842

1,877

Total initial mammograms

21,621

6,614

2,785

07/06 - 12/09

01/10 - 12/10

01/11 - 06/11

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 / 39,370)

(0 / 11,371)

(0 / 4,677)

0.0

0.0

0.0

Percentage missing

(0 / 39,370)

(0 / 11,371)

(0 / 4,677)

0.0

0.0

0.0

Percentage missing

(0 / 39,370)

(0 / 11,371)

(0 / 4,677)

County/Zip of Residence
Birth Year
Race/Ethnicity

1.6

1.3

1.3

Percentage missing/unknown

(612 / 39,370)

(150 / 11,371)

(61 / 4,677)

0.5

0.6

0.5

Percentage multiracial

(199 / 39,370)

(68 / 11,371)

(25 / 4,677)

2.1

1.8

1.6

Percentage unknown

(844 / 39,370)

(203 / 11,371)

(75 / 4,677)

Hispanic Origin

Percentage missing
Vers. 6.0

< 0.1

< 0.1

0.0

(1 / 39,370)

(2 / 11,371)

(0 / 4,677)

1

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

unknown and missing combined should be < 5%
Demography