Performance Measure: Cervical Cancer Screening

National Quality Forum #: 0032

Description: Percentage of female patients with a diagnosis of HIV who were screened for cervical cancer in the last three years

Numerator: Number of patients in the denominator who were screened for cervical cancer in the last three years

Denominator: Number of female patients with a diagnosis of HIV who meet both criteria:

  • Had at least one medical visit with a provider with prescribing privileges
  • Were ≥21 years old in the measurement year1

Patient Exclusions: Patients who had a hysterectomy for non-dysplasia/non-malignant indications

Data Elements:

  1. Does the patient have a diagnosis of HIV? (Y/N)
    1. If yes, is the patient female? (Y/N)
      1. If yes, did the patient have at least one medical visit with a provider with prescribing privileges in the measurement year? (Y/N)
        1. If yes, is the patient ≥21 years old in the measurement year? (Y/N)
          1. If yes, was a cervical cytology (Pap test) performed in the measurement year or the two years prior to the measurement year?

***Greater measure specification detail, including data elements for each value set, is available on the eCQI Resource Center (funded by the Centers for Medicare and Medicaid Services or CMS) eCQM Resources website. (Measure: CMS124v10).

National goals, target, or benchmarks for comparison

The HIV Quality Measures (HIVQM) Module is a tool within the Ryan White HIV/AIDS Services Report portal. It allows recipients to enter aggregate data specific to HRSA HAB Performance Measures. The HIVQM Module allows recipients to conduct point-in-time benchmarking across Ryan White HIV/AIDS Programs that use the module.

Department of Health & Human Services Clinical Practice Guidelines

"Women with HIV Infection Aged <30 Years: The Pap test is the primary mode for cervical cancer screening for WWH <30 years of age. WWH ages 21 to 29 years should have a Pap test at the time of initial diagnosis with HIV. Provided the initial Pap test for a young (or newly diagnosed) woman with HIV is normal, the next Pap test should occur in 12 months (BII). If the results of three consecutive Pap tests are normal, follow-up Pap tests should be every 3 years (BII). Co-testing (Pap test and HPV test) is not recommended for WWH <30 years of age.

Women with HIV infection aged ≥ 30 years: Cervical cancer screening in WWH should continue throughout a woman's lifetime (and not, as in the general population, end at 65 years of age). Either Pap testing only, or Pap testing and HPV co-testing is acceptable for screening...

Women who co-test negative (i.e., a normal Pap and negative HPV test) can have their next cervical cancer screening in 3 years."2

Use in other federal programs

  • This measure is used in CMS, Medicare and Medicaid EHR Incentive Program for Eligible Professionals, eCQM Library, Measure CMS124v10.
  • This measure is linked to an exact or similar indicator(s) within Healthy People 2030.

References/notes

1 A measurement year is any consecutive 12-month period of time.

2 Panel on Opportunistic Infections in Adults and Adolescents with HIV. Guidelines for prevention and treatment of opportunistic infections in adults and adolescents with HIV: recommendations from the Centers for Disease Control and Prevention, the National Institutes of Health, and the HIV Medicine Association of the Infectious Diseases Society of America. Department of Health and Human Services. Available online. Accessed August 2022. Q-5.

Date Last Reviewed: