Institute for Healthcare Improvement: Percent of Female Patients/Clients with an Annual Papanicolaou (Pap) Test

Definition

Papanicolaou (Pap) tests, an important public health intervention, offer the opportunity for early identification of cervical disease and subsequent clinical intervention. Cervical cancer appears to be more aggressive in HIV-infected women than in non-infected women. Frequent and regular exams can be instrumental in detecting and treating cervical cancer in its early stages. Pap tests have been credited with reducing mortality from cervical cancer by as much as 93.5 percent when performed on an annual basis. Many organizations have adopted the recommendation that all women who are or have been sexually active, or have reached the age of 18, should have an annual Pap smear.

Formula: The number of female patients/clients with at least one HIV primary care visit in the past 12 months who have had a Pap test in the past 12 months (as documented in the HIV primary care record). Divide by the number of female patients with at least one HIV primary care visit in the past 12 months. Multiply by 100 to calculate percent.

Data Collection Plan

Analyze data monthly (or at the frequency established for your quality improvement effort). On the last day of the month, identify your sample (female patients/clients with at least one HIV primary care visit in the past 12 months). From this sample, count the number of female patients/clients with a documented Pap test in the last 12 months. Divide by the total number in your sample of female HIV patients/clients who had at least one HIV primary care visit during the past 12 months. Multiply by 100 to calculate percent.

The National HIVQUAL Project’s Minimum Sample Table will help you determine the number of records to include in your sample. The Research Randomizer can generate a random number series to help you select which records to review.