Mammogram up-to-date rate
Clinical Quality & Outcomes
How this indicator is defined
Methodology version v1.0
Percentage of rostered patients eligible for breast cancer screening who have a documented mammogram within the past 2 years.
Proportion of eligible patients (percentage)
The percentage of eligible patients (the denominator) who have at least one Mammogram record within the 2-year window. Each patient is counted once.
Data inputs
- Mammogram — LOINC 24606-6
Derived from
What this indicator measures— Name, alignment, goal, rationale.
- Indicator nameField 1 — Indicator name
- Mammogram up-to-date rate
- AlignmentField 2 — Alignment
- Ontario Breast Screening Program (OBSP)
- Ontario Health MyPractice Primary Care indicator catalogue
- Strategic goalField 3 — Strategic goal
- Ensure eligible patients receive breast cancer screening at the recommended interval.
- RationaleField 5 — Rationale
- Breast cancer is the most common cancer among Canadian women. Regular mammography screening reduces mortality by detecting cancers at earlier, more treatable stages.
How it's computed— Scoring method, numerator, denominator, inclusions, exclusions.
- NumeratorField 6 — Numerator
- Active rostered patients in the denominator with at least one mammogram result documented in the EMR within 2 years of the reporting-period end date.
- DenominatorField 7 — Denominator
Active rostered patients, sex=F, age 50–74 at reporting-period end.
- Sex eligibility: F
- Age range: 50–74
- Active as of reporting-period end: yes
- ExclusionsField 9 — Exclusions
- Patients with bilateral mastectomy.
- Patients deceased before the reporting-period end date.
- Patients deactivated from the roster before the reporting-period end date.
How patients are attributed— Attribution rule and risk adjustment.
- Attribution ruleField 10 — Attribution rule
- Enrolment (rostered)
- Risk-adjustment modelField 11 — Risk-adjustment model
- None
How comparison works— Peer group, reliability threshold, peer comparator.
- Reliability thresholdField 13 — Reliability threshold
- 30
Data + reporting— Data source, reporting frequency, direction of improvement, limitations.
- Reporting frequencyField 15 — Reporting frequency
- quarterly
- Direction of improvementField 16 — Direction of improvement
- Higher is better
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.
- Methodology versionField 23 — Methodology version
- v1.0