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. This is a process indicator reported without risk adjustment: the rate is delivered as a crude rate with peer-group context.
How it's computed— Scoring method, numerator, denominator, inclusions, exclusions, exceptions.
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 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 Cancer Care Ontario via the Screening Activity Report, where that data feed is enabled.
  • 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). 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-organization peer groups: Planned for a future release; peer comparisons today are within the FHT.
Reliability thresholdField 13 — Reliability threshold
26 — Minimum denominator: 30 eligible patients per reporting period. Below this threshold the rate is suppressed and the scorecard shows 'Not reportable — fewer than 30 cases this period'. The numerator and denominator are still computed — so audit and drill-down can show what was suppressed and why — but no rate is reported.
Peer comparatorField 17 — Peer comparator
  • Within-organization: Shown when the peer group has at least 5 physicians.
  • 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: The FHT's own organizational rate, rendered from the customer's data once a real customer is connected; shown with demonstration data until then.
  • The provincial benchmark is a published program-level reference rate; it is not recalculated from this team's data.
Data + reporting— Data source, reporting frequency, direction of improvement, limitations.
Data sourceField 14 — Data source
  • Demonstration data: 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
82.0% — 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.