Cervical cancer screening up-to-date rate

Clinical Quality & Outcomes

How this indicator is defined

Methodology version v1.0

Percentage of rostered patients eligible for cervical cancer screening (per OCSP eligibility criteria) who have a documented Pap or HPV test within the most recent OCSP-recommended screening window.

Proportion of eligible patients (percentage)

The percentage of eligible patients (the denominator) who have at least one Cervical screening record within the 3-year window. Each patient is counted once.

Data inputs

  • Cervical screening — LOINC 19765-7

Derived from

What this indicator measures— Name, alignment, goal, rationale.
Indicator nameField 1 — Indicator name
Cervical cancer screening up-to-date rate
AlignmentField 2 — Alignment
  • Ontario Health (Cancer Care Ontario) — Ontario Cervical Screening Program (OCSP)
  • Ontario Health MyPractice Primary Care indicator catalogue
  • Provincial Family Health Team Balanced Scorecard — Effectiveness — Cancer screening row
  • Accreditation Canada / HSO 34015 (voluntary) — cancer-screening domain
Strategic goalField 3 — Strategic goal
Improve population-health outcomes by ensuring the FHT's eligible rostered population is screened for cervical cancer at the recommended interval; surface practice-level variation to the Physician Lead so coaching conversations can target patients overdue for screening.
RationaleField 5 — Rationale
Cervical cancer is largely preventable through routine screening: OCSP detects pre-cancerous cellular changes (cervical intraepithelial neoplasia) before they progress to invasive disease. Practice-level variation in screening rates is one of the most actionable signals available to a Physician Lead — it surfaces gaps that respond to recall-letter campaigns, EMR prompts, and panel-management workflow changes. Process indicator (no risk adjustment per PRD §3 + claim C-045): the indicator is delivered as a crude rate with peer-group context.
How it's computed— Scoring method, numerator, denominator, inclusions, exclusions.
NumeratorField 6 — Numerator
Active rostered patients in the denominator who have at least one of the following events documented in the EMR within the screening window: a Pap test (cervical cytology) result, OR an HPV test result (where adopted by OCSP at the customer's reporting period). The screening window for the Sprint 1 fixture is 3 years from the reporting-period end date.
DenominatorField 7 — Denominator

Active rostered patients at the FHT, with sex='F' (or sex-at-birth=female), age 25–69 at reporting-period end date, active=true on the roster as of reporting-period end date.

  • Sex eligibility: F
  • Age range: 25–69
  • Active as of reporting-period end: yes
InclusionsField 8 — Inclusions
  • Pap tests AND HPV tests, regardless of which lab processed the specimen.
  • Tests imported from CCO via the Screening Activity Report (when CCO module is enabled per PRD Cap 21).
  • Tests documented in the EMR investigations table (HL7 v2 / FHIR / manual entry).
  • The most recent qualifying test per patient is the one counted (a patient screened twice in window is counted once).
ExclusionsField 9 — Exclusions
  • Patients who have had a total hysterectomy with cervix removed for non-cancer indication (cervix-absent; OCSP exits).
  • Patients deceased before the reporting-period end date.
  • Patients deactivated from the roster before the reporting-period end date.
  • Patients younger than 25 at the reporting-period end date.
  • Patients aged 70 or older at the reporting-period end date with no documented prior abnormal result.
  • NOT excluded: patients with total hysterectomy for cervical cancer or pre-cancer (still require ongoing surveillance).
How patients are attributed— Attribution rule and risk adjustment.
Attribution ruleField 10 — Attribution rule
Enrolment (rostered) — The indicator is attributed to the patient's rostered family physician as of the reporting-period end date. End-of-period rostered-physician identity (not encounter-based; not ordering-provider attribution).
Risk-adjustment modelField 11 — Risk-adjustment model
None — Not applicable (process indicator) per PRD §3 + claim C-045. Process indicator: the question is 'was the patient screened?', not 'what was the outcome?' Risk adjustment for cervical screening would only matter if differential outcomes were the indicator (e.g., cervical-cancer mortality), not whether screening was completed.
How comparison works— Peer group, reliability threshold, peer comparator.
Peer groupField 12 — Peer group

Family physicians at the same FHT (within-customer peer group).

  • Panel size bands: small (< 1000 rostered patients); medium (1000–1750); large (> 1750)
  • Panel-mix dimensions: average rostered-patient age; proportion of patients aged ≥ 65
  • Minimum cell size: 5
  • Cross-FHT peer groups: V1.x; not Sprint 1 or Sprint 2 scope
Reliability thresholdField 13 — Reliability threshold
25 — Minimum denominator: 30 eligible patients per reporting period. Below threshold, lib/measures.computeScore returns suppressed=true and the scorecard renders 'Not reportable — fewer than 30 cases this period' (S1-AC-9 + S1-AC-16). Numerator and denominator are still computed (so audit + drill-down can show what was suppressed and why), but value is null.
Peer comparatorField 17 — Peer comparator
  • Within-FHT: When peer group ≥ 5 physicians per Cap 4
  • Provincial benchmark (provincial rate): CCO Cervical-screening program-level provincial rate (verify the published rate for the customer's reporting period at first publish).
  • Organizational: Customer FHT organizational rate (rendered from the customer's own data once a real customer is connected; placeholder in the synthetic demo fixture).
  • Sprint 1 renders only the external benchmark (provincial rate, mocked from a literal in the seed) since peer aggregation is Sprint 2.
Data + reporting— Data source, reporting frequency, direction of improvement, limitations.
Data sourceField 14 — Data source
  • Synthetic fixture: Synthetic demonstration dataset of screening events (no real patient records).
  • Production: Primary: the EMR investigations record (Pap / HPV test results). Secondary, where enabled: the OCSP Screening Activity Report from Ontario Health (Cancer Care Ontario).
Reporting frequencyField 15 — Reporting frequency
quarterly — Matches a typical Family Health Team's balanced-scorecard review cadence and the OCSP recall cycle.
Direction of improvementField 16 — Direction of improvement
Higher is better — More eligible patients screened on schedule = better screening coverage.
Limitations and caveatsField 26 — Limitations and caveats
  • OCSP HPV-primary transition: Ontario is migrating from Pap-primary to HPV-primary cervical screening. The numerator counts both Pap and HPV tests so the indicator is forward-compatible; only the screening-window length changes when HPV-primary is fully adopted (every 5 years instead of 3).
  • Hysterectomy exclusions are structural in the logic, but source data may under-document hysterectomy status — screening rates can be modestly understated for panels with un-coded exclusions.
Targets + governance— Target, justification, owner, review, approval, version, notes.
TargetField 18 — Target
70.0% — the clinic's target for this indicator, set by the product owner.
Last reviewedField 25 — Last reviewed
2026-05-10 — reviewed annually
Methodology versionField 23 — Methodology version
v1.0 — Initial published definition. Every reported score is reproducible against the exact definition version in effect for its reporting period; any change to the definition is released as a new version with its own change note.
NotesField 24 — Notes
  • Privacy: the indicator definition, the score, the case list, and the audit record never contain patient names, OHIP numbers, dates of birth, addresses, or chart text. Patient references are opaque source-system identifiers.