cancer screening in general practice€¦ · national cancer screening programs . cancer prevention...

1

Cancer Screening in General Practice

Plan Do Study Act Cycle Activity for Cervical Screening

Cancer Council WA www.cancerwa.asn.au 13 11 20

These cancer screening education activities have been developed by Cancer Council WA in collaboration with the WA Primary Health Alliance.

http://www.cancerwa.asn.au/

Contents Cancer Screening 'Plan Do Study Act' ......................................................................................................... 3

Cancer in Australia ........................................................................................................................................ 3

National Cancer Screening Programs .......................................................................................................... 3

What is a ‘Plan Do Study Act’ cycle? ............................................................................................................. 4

Activity summary .......................................................................................................................................... 4

Accreditation ................................................................................................................................................ 5

For more information .................................................................................................................................... 5

Cervical Screening 'Plan Do Study Act' (PDSA) .......................................................................................... 6

Cervical cancer in Australia ...................................................................................................................... 6

National Cervical Screening Program ...................................................................................................... 6

Cervical screening in general practice ...................................................................................................... 7

Cervical Screening PDSA............................................................................................................................ 8

Activity summary ...................................................................................................................................... 8

Learning outcomes ................................................................................................................................... 8

Checklist .................................................................................................................................................... 9

GP/Practice Registration ........................................................................................................................ 10

Practice details ........................................................................................................................................... 10

Practice software details ........................................................................................................................... 10

Participant details ...................................................................................................................................... 10

Pre-PDSA survey: About your practice ................................................................................................. 12

Pre-PDSA survey: About you .................................................................................................................. 14

Cycle 1 – Identify eligible patients ........................................................................................................ 15

Cycle 2 – Discuss and design .................................................................................................................... 18

Cycle 3 – Implement approach ................................................................................................................ 20

Cycle 4 – Review and evaluate ................................................................................................................ 23

Post-PDSA survey ..................................................................................................................................... 25

Declaration .................................................................................................................................................. 28

Appendix: Additional resources ............................................................................................................. 29

2

Cancer Screening'Plan Do Study Act'

Cancer in Australia Cancer is the leading burden of disease in Australia1. Along with cardiovascular disease, it is Australia’s leading underlying cause of death; in 2014, cancer accounted for about 3 of every 10 deaths registered2. Cancer is known to have a substantial impact on the social and economic state of individuals, families and the Australian healthcare system2.

In 2013, there were 124,465 new cases of cancer diagnosed in Australia, with this number expected to increase2. In 2014, the number of deaths from cancer in Australia was 44,1712. The risk of an individual dying from cancer was 1 in 4 for males and 1 in 6 for females. The most commonly diagnosed cancers in 2017 were breast, colorectal (bowel), prostate, melanoma and lung cancer2. These five most common cancers account for 60% of all cancer cases in Australia.

National Cancer Screening Programs Cancer prevention and early detection practices including screening, play an important role in reducing the prevalence of cancer in Australia. Cancer screening programs aim to reduce cancer causing illnesses and deaths through a public health approach of early detection of cancer and pre-cancerous abnormalities and follow-up treatment2. Australia has three cancer screening programs: National Bowel Cancer Screening Program, BreastScreen Australia, and National Cervical Screening Program, which run through partnerships between the Australian Government and state and territory governments. The programs target specific populations and age groups where evidence shows screening is most effective at reducing cancer-related morbidity and mortality2. Since their inception in Australia, they have had a major impact in early intervention and reducing cancer related deaths2.

However, despite all three national cancer screening programs being available to eligible Australians, participation for each screening program is below desirable level2. In WA, participation rates are particularly low in regional areas.

1. Australian Institute of Health and Welfare 2016. Australian Burden of Disease Study: Impact and causes of illness and death in Australia 2011. Australian Burden of Disease Study series no. 3. BOD 4. Canberra: AIHW. 2. Australian Institute of Health and Welfare 2017. Cancer in Australia 2017. Cancer series no.101. Cat. no. CAN 100. Canberra: AIHW.

3

What is a ‘Plan Do Study Act’ cycle? A ‘Plan Do Study Act’ (PDSA) Cycle uses a ‘trial and learning’ approach in which an idea, hypothesis or a suggested solution for improvement is made and then tested on a small scale before any changes are made to the whole system. It is a cyclical model because the desired improvement is not always achieved in one cycle so the process is refined and the cycle repeated. PDSA Cycles are Category 1 activities in the RACGP QI&CPD program and are inherent Quality Improvement activities.

As part of the GP Education Project, Cancer Council WA has developed education activities on bowel, breast and cervical cancer screening to support GPs in identifying and encouraging eligible patients to participate in the three National Cancer Screening Programs.

Activity summary One cycle of a PDSA activity includes four components; plan the change (P), do the change (D), study (S) and act on the results (A). Each of these three activities includes four cycles:

Cycle 1 – Identify eligible patients GPs with the assistance of practice staff are required to review their patient records using practice’s available clinical software and randomly identify twenty patients (per GP) who fit the eligibility for cancer screening. Selected patient records are audited and information is recorded on screening status, recall and reminder.

Cycle 2 – Discuss and design Practice staff are to meet and discuss the results from cycle 1 and develop a practice approach to increase cancer screening participation of identified patients through the use of recalls/reminders and promotion of the National Cancer Screening Programs. GP/practice is also required to set a target for patients that they aim to have participated in cancer screening by the end of the activity.

Cycle 3 – Implement approach With the help of staff members, implement the approach designed in cycle 2 at the practice with the identified patients to improve their participation in the National Cancer Screening programs and record the approach taken.

Cycle 4 – Review and evaluate GPs with the assistance of practice staff are required to evaluate the practice approach implemented in cycle 3. Review records of same patients and record any changes since the

4

Plan Do

Study Act

5

start of the activity, including how many of the identified patients from Cycle 1 engaged and participated in cancer screening. Results are used to determine any improvement in participation achieved against the target agreed in cycle 2.

Each of these three activities can be undertaken by an individual GP, a group of GPs or by the whole practice (with the assistance of practice manager and practice nurses). Depending on who is involved in the completion of the activity will influence the roles and responsibilities in each cycle of the PDSA. GPs and practices can choose to complete one, two or all three activities based on their patient demographic and area of interest.

These PDSA activities are expected to be completed over the course of four to six months. A minimum of six hours of work (per activity) is needed to meet the requirements of RACGP Category 1 activity.

Accreditation The Cervical Screening PDSA activity is accredited under the RACGP QI&CPD program for the 2017-19 triennium.

TOTAL POINTS: 40 (Category 1) Activity ID: 125604 Cancer Council Western Australia is an Accredited Activity Provider of the RACGP QI&CPD Program. Provider number: 217907

The Cervical Screening PDSA activity is accredited under the ACRRM Professional Development Program for the 2017-19 triennium.

TOTAL POINTS: 30 Activity ID: 12388

For more information If you would like more information or have any questions regarding this activity, please contact the GP Education Project: e: [email protected] p: (08) 9382 9331

mailto:[email protected]

Cervical Screening 'Plan Do Study Act' (PDSA)

Cervical cancer in Australia Cervical cancer is one of the most preventable cancers. Cervical cancer incidence for women of all ages remains at an historical low of 7 new cases per 100,000 women, and deaths are also low, historically and by international standards, at 2 deaths per 100,000 women1. Human papillomavirus (HPV), which leads to cell changes in the cervix, is the cause of nearly all cervical cancer cases. The virus can be detected through a simple Cervical Screening Test. Women who have never been screened or are under screened are at an increased risk of cervical cancer2.

National Cervical Screening Program Recent changes to the National Cervical Screening Program (NCSP) in Australia have resulted in the two-yearly Pap smear being replaced with a more accurate f i v e - y e a r l y Cervical Screening Test. Women aged 25-74 are eligible to participate. The new Cervical Screening Test looks for HPV, with partial genotyping. If HPV is detected the laboratory will automatically conduct a cytology test (reflex cytology) on the same sample. To assist in increasing cervical screening participation amongst never screened and under screened women, in early 2018 eligible women can be offered the option of a self-collected vaginal sample for HPV3.

These changes to screening are expected to protect up to 30 per cent more women from cervical cancer4. This ensures women in Australia have access to a cervical screening program that is safe, effective, efficient and based on current evidence4. For eligible women, the first Cervical Screening Test is usually due two years after their last Pap smear and then, if they receive a negative HPV result, every five years after that. Pap smears are no longer available on the Medicare Benefits Schedule (MBS) and have been replaced by the new Cervical Screening Test. For more information on the new pathology MBS items for cervical screening, view the MBS NCSP factsheet available in the appendix.

The new National Cancer Screening Register (NCSR) has been established to support the renewed clinical pathway. The NCSR provides a safety net for women reminding them and the healthcare providers when a woman is overdue for screening or a follow up test. It is important for general practitioners (GPs) to continue to provide a recall and reminder service for women in their practice. As a confidential database of all cervical screening

6

tests taken in Australia, the NCSR can be used to support GPs through the provision of women’s cervical screening histories to assist in clinical management. Until the NCSR is fully operational, the WA Cervical Screening Registry is available to support GPs.

Cervical screening in general practice As the first point of contact for health issues for many women in Australia, GPs play a key role in ensuring the success of the NCSP. Since the introduction of the NCSP in 1991, the incidence and mortality of cervical cancer has more than halved1. Despite this significant impact, in 2014–2015, only 57 per cent of the target population participated in the NCSP at a two-yearly interval as recommended in the Pap smear based screening guidelines2.

GPs play a critical role in educating women on the benefits of participating in routine cervical screening5. Due to the changes in cervical cancer screening, GPs need to know who is currently eligible to screen. In addition, implementation of key strategies in general practice, such as, GP endorsement, recall and reminder systems, auditing of patients eligible for screening, practice endorsement through display of brochures and opportunistic screening will ensure GPs continue to contribute to the success of the NCSP.

The renewed NCSP invites women aged 25–74 years to have a Cervical Screening Test every five years, in line with the new policy and guidelines.

For more information about the NCSP, visit www.cancerscreening.gov.au/cervical.

1. Australian Institute of Health and Welfare 2017. Cervical screening in Australia 2014–2015. Cancer series no. 105. Cat. no. CAN 104. Canberra: AIHW.

2. Australian Institute of Health and Welfare 2017. Cancer in Australia 2017. Cancer series no.101. Cat. no. CAN 100. Canberra: AIHW.

3. For self-collection eligibility criteria refer to the National Cervical Screening Program website. Prior to offering self-collection, please contact your pathology provider to confirm its availability.

4. Commonwealth Government, National Cervical Screening Program Renewal: Evidence review, November 2013. Available here: http://www.cancerscreening.gov.au/internet/screening/publishing.nsf/Content/E6A211A6FFC29E2CCA257CED007FB678/$File/Review%20of%20Evidence%20notated%2013.06.14.pdf

5. Munro A, Pavicic H, Leung Y, Westoby V, Steel N, Semmens J et al. The role of general practitioners in the continued success of the National Cervical Screening Program. Aust Fam Physician. 2014;43(5):293-296.

7

http://www.cancerscreening.gov.au/cervicalhttp://www.cancerscreening.gov.au/internet/screening/publishing.nsf/Content/healthcare-providers

Cervical Screening PDSA Activity summary As part of the GP Education Project, Cancer Council WA has developed an RACGP and ACRRM accredited education activity to support GPs in identifying and encouraging eligible patients to participate in cervical screening through the NCSP.

The goal of the activity is To increase participation in NCSP of under screened and never screened women in your practice by engaging with women, increasing awareness of the NCSP and encouraging informed participation. Under screened: women two or more years overdue for screening (i.e. four years or more since last Pap test or seven or more years since last Cervical Screening Test). Never screened: women aged 30 to 74 years who have no Pap smear or Cervical Screening Test result.

What changes will you make to result in an improvement? Patients who are identified as under screened or never screened will be contacted by the GP/ practice and encouraged to make an appointment to participate in cervical screening. Should a patient who has been identified to be under screened or never screened present to the practice, cervical screening will be offered at this time or an appointment made for screening.

How will you know that the change is an improvement? An improvement will be observed if women who had previously not participated in regular cervical screening, start to participate. GP/Practice can set a target. For example, if 100 women in their practice are identified to be under screened or never screened, a goal may be for 50 of these women to have a Cervical Screening Test in the next four to six months.

Learning outcomes At the end of the activity GPs/Practice staff should be able to:

1. Analyse the practice’s current recall and reminder procedures/systems for cervicalscreening participation of eligible women who are under screened or never screened.

2. Identify women who are under screened or never screened and therefore at risk forcervical cancer.

3. Develop and implement a recall and reminder system targeting women who areunder screened or never screened.

8

4. Evaluate the effectiveness of the recall and reminder system developed as part ofthis activity.

5. Promote and contribute to the delivery of the NCSP.

Checklist Before you commence the activity: □□ Fill in your practice’s details in the GP/Practice Registration page□ Complete the Pre-PDSA Survey: About your practice□ Each GP participant to complete the Pre-PDSA Survey: About

you

Then:

□ Document and complete the four PDSA CyclesAfter completing the activity:

□ Each GP participant to complete the Post-PDSA Survey□ Complete the Declaration□ Return the completed PDSA by email, fax or mail, to Cancer Council WA.

9

Email [email protected] to register your practice


GP/Practice Registration Please fill out the registration form and complete the questions in the Pre-PDSA Survey before you commence PDSA Cycle 1. One copy to be completed by each practice.

Responses will be used to assess the benefit of the activity and to make changes to the PDSA in future trienniums. Responses will be aggregated for reporting and will remain confidential.

Follow the link to complete and submit the form online: https://www.surveymonkey.com/r/cervicalpdsa-registration-aboutyourpractice

Practice details

Practice Name

Address

Suburb

Postcode

Phone

Fax

Email

Start Date

Practice software details

Practice Management Software

Clinical Software

Participant details

Please provide details of all GPs, practices nurses and practice team.

Note: This PDSA activity can be undertaken by an individual GP, a group of GPs or a multidisciplinary team.

Name Occupation RACGP / ACRRM No. FTE

1

2

3

4

10

https://www.surveymonkey.com/r/cervicalpdsa-registration-aboutyourpractice

5

6

7

8

9

10

11

12

13

14

15

16

17

18

19

20

11

Pre-PDSA survey: About your practice

1. Does your practice have an online booking system?

Yes No

2. How does your practice currently send out recalls and reminders to patients?

Letter

Phone call Text/SMS

Other (please specify)

3. Does your practice have a recall and/or reminder process in place for cervical screening?

Yes No

If yes, please describe:

4. Has your practice previously implemented strategies to improve patient participation in theNCSP?

Yes No

If yes please list strategies used:

5. What barriers and challenges has your practice experienced when previouslyattempting to implement strategies to improve cervical screening participation?

12

6. What motivated you/your practice to participate in this activity? (tick all that apply)

Build on existing knowledge and/or skills in this area

This is a new area in my practice Near miss analysis

Feedback from patients Improve safety strategies for staff and patients in practice

Review of existing systems


7. How did you/your practice hear about this activity?

Cancer Council WA website

RACGP website WAPHA

Directly from PHL staff member(s) Cancer Council WA General Practice eNewsletter

Colleague Other (please specify)

13

Pre-PDSA survey: About you One copy to be completed by each GP participating in the activity.

Follow the link to complete and submit the form online: https://www.surveymonkey.com/r/cervicalpdsa-pre-survey-aboutyou

Name: RACGP QI&CPD number:

ACRRM number: Practice surgery:

Email:

On a scale of 1 – 5 (where 1 = very poor; 5 = very good) rate your understanding of: 1 2 3 4 5

Cervical cancer epidemiology in Australia

Evidence for cervical screening

Current screening policy and guidelines to prevent cervical cancer in Australia Recent changes to the National Cervical Screening Program

On a scale of 1 – 5 (where 1 = very poor; 5 = very good) rate your ability to: 1 2 3 4 5

Identify women who are under screened or never screened

Communicate the importance of regular cervical screening to eligible women Implement strategies to encourage eligible women to participate in regular cervical screening Communicate the likely benefits and possible limitations of participating in cervical screening with eligible women

On a scale of 1 – 5 (where 1 = not important at all; 5 = very important) rate the importance of the GP in: 1 2 3 4 5

Identifying women who are under screened or never screened

Promoting and contributing to the delivery of the National Cervical Screening Program

14

https://www.surveymonkey.com/r/cervicalpdsa-pre-survey-aboutyou

Cycle 1 – Identify eligible patients

Start date:

End date:

PLAN GP (or designated staff member) to audit patient records using the practice’s available data extraction clinical software and identify twenty patients (per GP) who are under screened or never screened. A CAT Recipe has been included in the appendix to assist you in identifying patients in your practice clinical software.

DO Each GP involved (with the assistance of staff member) to review their patient records and randomly identify twenty patients (per GP) who:

a) Meet the criteria for under screened or never screenedCriteria for under screened: Women aged 30 to 74 years who are two or more years overdue forscreening (i.e. last Pap smear was taken four or more years ago or last Cervical Screening Test wastaken seven or more years ago).

Criteria for never screened: Women aged 30 to 74 years who have no Pap smear or CervicalScreening Test result.

Refer to clinical guidelines (in appendix) for more information.

b) Have visited the practice in the past 12 months

Each GP involved (with the assistance of staff member) to collect information on screening status and recalls/reminders of their twenty patients and complete the table below.

GP RACGP/ ACCRM number

Recall/reminder status: How many of these 20

patients have been recalled/reminded by the

practice for cervical screening in the past 12 months?

Screening status: How many of these 20

patients have a cervical screening result recorded from the past two years*?

Any additional comments

Count: /20 Count: /20

15










Total Count: / Count: /

*A tip sheet has been included in the appendix for correctly recording cervical screening results.

IMPORTANT: Each GP/practice staff to save a list of these identified patients. You will be monitoring them for the rest of the activity.

STUDY Compare the results to your expectations and summarise what was learnt.

From looking at this data and clinical guidelines, can you identify any gaps and areas of improvement for cervical screening or specific groups of people to target?

16

ACT Act on the results

What strategies could your practice implement to address any of the identified gaps and areas of improvement for cervical screening and which specific groups of people could you target?

17

Cycle 2 – Discuss and design

Start date:

End date:

PLAN Designated staff member to host a practice team meeting OR individual GP to conduct a discussion with relevant member/s of the practice on: • the data collected from Cycle 1• a target for percentage of patients identified in Cycle 1 that the practice aims to have

screened for HPV by the end of the activity• methods to increase engagement of identified patients in the NCSP, including the use

of recalls and reminders (e.g. SMS reminders), and how each staff member may beimpacted*

• other methods to promote the NCSP at the practice (e.g. letter, flag record for a chatat the next appointment) *

• design a practice approach to increase participation of identified patients in the NCSP*• the roles and responsibilities of each person in the practice to implement the approach

*Letter, SMS templates and promotional resources have been included in the appendix to assist you indeveloping your practice approach.

DO Carry out the plan and record what was discussed.

Attendees at the discussion/meeting

GPs present (list):

Practice nurses present (list):

Other staff present (list):

18

List five points discussed at the meeting:

Set target: Out of the patients identified, I/our practice aim to screen %.

STUDY Compare the results of Cycle 1 to your expectations and summarise what was learnt.

ACT Act on the results and summarise the planned approach and the responsibility of each person within the practice.

19

Cycle 3 – Implement approach

Start date:

End date:

PLAN To increase patient participation of identified patients in cervical screening with NCSP. GP/whole practice to implement approach designed in Cycle 2 to increase participation of patients identified in the NCSP, including the use of recalls and reminders.

Identify specific action steps for the cycle.

DO With assistance from practice staff, implement the recall/reminder (or other) strategy designed in Cycle 2 to encourage identified patients to make an appointment to discuss or participate in cervical screening.

Record any practice strategies and recall/reminder actions each GP took with their identified twenty patients in the tables below.

Tick any practice strategies that were applied

Waiting room patient education resources

Opportunistic conversation with other eligible patients


20

Identified patients were reminded via (tick all that apply)


Letter from practice

Phone call from GP/

practice nurse

SMS from practice

Face-to-face conversation

with GP/ practice nurse



21

ACT Act on the results and identify how this information could change your practice.

22

Cycle 4 – Review and evaluate

Start date:

End date:

PLAN

GP (or designated staff member) to review data of same patients identified in Cycle 1 using the practice’s available data extraction clinical software, and evaluate any changes to reminder and screening status in the last four to six months.

DO Record any outcomes (with their count) of those identified patients that received a recall/reminder in the table below.

Patients outcomes (tick all that apply)


Recall/reminder status: How many of these 20

patients have been recalled/reminded by

the practice for cervical screening in the past

12 months?

How many of these 20 patients have booked an appointment for

cervical screening with the practice?

Screening status: How many of these 20 patients have a cervical screening

result recorded from the past two years*?


Count: /20 Count: /20 Count: /20








23



Total Count: / Count: / Outcome:

*A tip sheet has been included in the appendix for correctly recording cervical screening results.

Measure target: To measure target, divide outcome by total number of patients identified and multiply by 100.

Out of all patients identified in Cycle 1, % have been screened.

Has the target been achieved? Yes No


ACT Act on the results and identify how this information could change your practice.

24

Post-PDSA survey One copy to be completed by each GP participating in the activity.

Follow the link to complete and submit the form online: https://www.surveymonkey.com/r/cervicalpdsa-post-survey

Name: RACGP QI&CPD number:

ACRRM number: Practice surgery:

Email:

On a scale of 1 – 5 (where 1 = very poor; 5 = very good) rate your understanding of: 1 2 3 4 5

Cervical cancer epidemiology in Australia

Evidence for screening for cervical cancer

Current clinical guidelines for screening to prevent cervical cancer in Australia Recent changes to the National Cervical Screening Program

On a scale of 1 – 5 (where 1 = very poor; 5 = very good) rate your ability to: 1 2 3 4 5

Identify patients at risk of being under screened or never screened for cervical cancer Communicate the importance of regular cervical screening to patients Implement strategies to encourage patients to participate in regular cervical screening Communicate the likely benefits and possible limitations of participating in cervical screening with eligible women

On a scale of 1 – 5 (where 1 = not important at all; 5 = very important) rate the importance of the GP in: 1 2 3 4 5

Identifying patients at risk of being under screened or never screened for cervical cancer Promoting and contributing to the delivery of the National Cervical Screening Program

Would you recommend this activity to a colleague?

Yes No Unsure


25

https://www.surveymonkey.com/r/cervicalpdsa-post-survey

Rate the degree to which the learning outcomes were met and tell us how the learning outcomes were achieved through this activity.

1. Analyse the practice’s current recall and reminder procedures/systems for cervical screeningparticipation of eligible women who are under screened or never screened .

Not met Partially met Entirely met

How was this learning outcome achieved through this activity?

2. Identify women who are under screened or never screened and therefore at risk for cervicalcancer.



3. Develop and implement a recall and reminder system targeting women who are under screened or never screened.



4. Evaluate the effectiveness of the recall and reminder system developed as part ofthis activity.



5. Promote and contribute to the delivery of the NCSP.


26


Rate the degree to which your own learning needs were met.


Rate the degree to which this activity is relevant to your practice.


Quality improvement Complete this section to fulfil the QI component of the RACGP 2017-19 triennium.

CHANGES IN YOUR PRACTICE What changes did you implement in your practice as a result of this activity?

MONITORING THESE CHANGES How do you monitor these changes?

EVALUATION What evaluation process do you use to measure these changes?

CHALLENGES Were there any challenges in implementing this activity in your practice?

27

28

Declaration To be completed by any person in the practice that was involved in the completion of this activity.

I, on behalf of the practice, declare to Cancer Council WA: • The practice has completed this activity, and to the best of our knowledge it has

been conducted and completed in accordance with the relevant RACGP programrequirements, educational standards and criteria.

• The information the practice have provided in this document is accurate and correct.

• The practice understands and acknowledges that Cancer Council reserves the rightto withdraw recognition of this activity if in the opinion of Cancer Council theactivity does not meet the RACGP program requirements, educational standards andcriteria.

Signed: Date:

Completed forms Once all forms are complete, please return by email, fax or mail to the GP Education Coordinator: e: [email protected] f: (08) 9212 4334 m: Cancer Council WA, Level 1, 420 Bagot Road Subiaco WA 6008


Appendix: Additional resources

Educational resources 1. Medicare Benefits Schedule NCSP factsheet (find attached)

2. NCSP: Guidelines for the management of screen-detected abnormalities, screeningin specific populations and investigation of abnormal vaginal bleeding

3. NPS MedicineWise Online Training Modules – NCSPSeries of six modules which provide training for healthcare providers who conductcervical screening tests and follow-up management for women aged 25-74.

4. Cervical Screening Health Pathways

5. Information for healthcare providers about their role in the NCSP

Practice resources 6. Data extraction CAT recipe

Finding patients eligible for cervical screening

7. Tip sheet to correctly record mammogram results:• Best Practice Premier – Entering cervical screening results• Medical Director – Entering cervical screening results

8. Letter template (find attached)

9. SMS template (find attached)

10.NCSP promotional resourcesCan be ordered online

11. Renewed NCSP Tools and Resources (WACCPP)

12.Cancer Council WA publications and resources• Prevention and early detection publications order form• Patient Information publications order form

29

https://wiki.cancer.org.au/australia/Guidelines:Cervical_cancer/Screeninghttps://wiki.cancer.org.au/australia/Guidelines:Cervical_cancer/Screeninghttps://www.nps.org.au/cpd/activities/national-cervical-screening-program?p=GPsshttps://wa.healthpathways.org.au/index.htmhttp://www.cancerscreening.gov.au/internet/screening/publishing.nsf/Content/healthcare-providershttp://help.pencs.com.au/display/CR/Cancer+Screening+West+Australiahttp://trainitmedical.com.au/wp-content/uploads/2017/10/Bp-Summary-Sheet-Enter-Cervical-Screening-Test-CST-Result-Train-IT-Medical-V03-2017.pdfhttp://trainitmedical.com.au/wp-content/uploads/2017/10/MD-Summary-Sheet-Enter-Cervical-Screening-Test-CST-Result-Train-IT-Medical-V03-2017.pdfhttp://www.cancerscreening.gov.au/internet/screening/publishing.nsf/Content/resources-menuhttp://ww2.health.wa.gov.au/Articles/N_R/Renewed-NCSP-tools-and-resourceshttps://www.cancerwa.asn.au/resources/publications/https://www.cancerwa.asn.au/resources/2018-02-21-Publications-order-form.pdfhttps://www.cancerwa.asn.au/resources/2018-03-26-pubs-order-form.pdf

New Pathology MBS items for Cervical and Vaginal Tests

Last updated: 1/12/2017

From 1 December 2017, a new Cervical Screening Test every five years will replace the existing two yearly Pap test.

To align pathology MBS items for cervical screening will change from December 1 2017. This will have practical implications for healthcare providers, clinicians, and consumers alike.

What do the changes involve?

There will be new pathology MBS items for cervical and vaginal screening tests, to reflect changes to the National Cervical Screening Program (NCSP), aligning with clinical best practice. The previously used MBS cervical screening items will be deleted.

Pap tests will no longer be eligible for Medicare rebates, meaning that patients may be charged if this test is requested.

Pathology laboratories will assign the pathology MBS item number based on the information provided on the pathology request form.

There are new naming conventions to write on the pathology request forms these are in the last column of the Pathology Test Guide for Cervical and Vaginal Testing.

You may also need to include some additional information that supports the screening or test type written on the pathology request form this may include age, presentation and clinical history.

Appropriate assignment of pathology MBS numbers by pathology labs is important in ensuring that patients avoid unnecessary out-of-pocket expenses for testing. It also enables laboratories to provide the correct clinical management recommendations, and accurate and timely reports on testing rates. This will in turn support the ongoing monitoring and evaluation of the new NCSP

Healthcare providers will still perform a vaginal speculum examination and take a cervical sample, but the sample medium is liquid-based and will be tested for the presence of HPV. If HPV is detected the laboratory will automatically conduct a cytology test.

Why is the Government making this change?

The new Cervical Screening Test is expected to protect up to 30% more people from cervical cancer.

The new test is more effective because it detects the human papillomavirus (HPV). Human papillomavirus, also known as HPV, is a common virus that can cause cervical cell abnormalities that in rare cases may develop into cervical cancer.

The new Cervical Screening Test and pathway is a risk-based approach to the management of patients. Patients are managed according to their risk of developing cervical abnormalities and that is determined by their Cervical Screening Test result, namely the HPV result and reflex liquid based cytology (LBC) if indicated.

The Medicare Benefits Schedule (MBS) items for cervical and vaginal pathology testing for cervical pre-cancer and cancer have been updated to support the revised clinical management pathway and renewed National Cervical Screening Program (NCSP). There will be seven new MBS item numbers, and the currently used item numbers will be deleted.

The new Cervical Screening Test and pathway will better identify patients at risk of pre-cancerous abnormalities and cervical cancer.

What are the changes?

There are several major changes to cervical screening practice in the renewed NCSP.

Five-yearly routine Cervical Screening Tests (CSTs) are recommended for asymptomatic patients from 25 up to 74 years of age, with a previously normal screening history. Where HPV is not detected, patients aged 70–74 years are eligible to exit the program.

Testing methodology and pathology MBS item numbers have changed. This means that pathology request forms need to be filled in differently from previously, and it is important that the appropriate test name and supporting patient information is written on the request form.

The renewed NCSP will be supported by the new National Cancer Screening Register (NCSR), and there are new ‘opt out’ procedures for patients.

Self -collection will not be immediately offered with the renewed program on 1 December 2017.

What do screening providers need to do?

Healthcare service providers need to become familiar with the changes to the NCSP, and how these changes will affect their patients and practice.

For the pathology laboratory to correctly test your patient’s sample you need to provide the patient’s presentation, age and screening history on the pathology request form, as detailed in the Pathology Tests for Cervical and Vaginal Testing Quick Guide.

Self-collection will be available to encourage women who are under screened or never screened and have refused to have a healthcare provider collected sample. Women must be 30 years of age or older and overdue for cervical screening by two years or more to be eligible for an MBS funded test. A self-collect sample contains vaginal cells only (not cells from the cervix) and can be tested for HPV only.

Self-collection will not be offered with the renewal program on 1 December 2017 but it is expected that it will be offered later in 2018. More information about self-collection will be available when it becomes available at www.cancerscreening.gov.au/cervical

The Australian Government Department of Health’s National Cervical Screening Program website has a range of practical resources for clinicians and consumers regarding the new NCSP and should be consulted for further information about screening, follow-up and clinical management for cervical cancers and pre-cancerous abnormalities.

Change to item description / fees:

Following a period of extensive stakeholder consultation, the Department is pleased to provide the National Cervical Screening Program Renewal MBS item descriptors, associated fees and explanatory statement, which will come into effect from 1 December, 2017.

Item

Item descriptor

73070

A test, including partial genotyping, for oncogenic human papillomavirus that may be associated with cervical precancer or cancer:

performed on a liquid based cervical specimen; and

for an asymptomatic patient who is at least 24 years and 9 months of age

For any particular patient, once only in a 57 month period

Fee: $35.00 75%= $26.25 85%= $29.75

73071

A test, including partial genotyping, for oncogenic human papillomavirus that may be associated with cervical pre cancer or cancer:

performed on a Self-collected vaginal specimen; and

for an asymptomatic patient who is at least 30 years of age

For any particular patient, once only in a 7 year period

Fee: $35.00 75%= $26.25 85%= $29.75

73072

A test, including partial genotyping, for oncogenic human papillomavirus, performed on a liquid based cervical specimen:

for the investigation of a patient in a specific population that appears to have a higher risk of cervical pre cancer or cancer; or

for the follow up management of a patient with a previously detected oncogenic human papillomavirus infection or cervical pre cancer or cancer; or

for the investigation of a patient with symptoms suggestive of cervical cancer; or

for the follow up management of a patient after treatment of high grade squamous intraepithelial lesions or adenocarcinoma in situ of the cervix; or

for the follow up management of a patient with glandular abnormalities; or

for the follow up management of a patient exposed to diethylstilboestrol in utero

Fee: $35.00 75%= $26.25 85%= $29.75

73073

A test, including partial genotyping, for oncogenic human papillomavirus:

performed on a selfcollected vaginal specimen; and

for the followup management of a patient with oncogenic human papillomavirus infection or cervical precancer or cancer that was detected by a test to which item 73071 applies

For any particular patient, once only in a 21 month period

Fee: $35.00 75%= $26.25 85%= $29.75

73074

A test, including partial genotyping, for oncogenic human papillomavirus:

performed on a liquid based vaginal vault specimen; and

for the investigation of a patient following a total hysterectomy

Fee: $35.00 75%= $26.25 85%= $29.75

73075

A test, including partial genotyping, for oncogenic human papillomavirus, if:

the test is a repeat of a test to which item 73070, 73071, 73072, 73073, 73074 or this item applies; and

the specimen collected for the previous test is unsatisfactory

Fee: $35.00 75%= $26.25 85%= $29.75

73076

Cytology of a liquidbased cervical or vaginal vault specimen, where the stained cells are examined microscopically or by automated image analysis by or on behalf of a pathologist, if:

the cytology is associated with the detection of oncogenic human papillomavirus infection by:

a test to which item 73070, 73071, 73073, 73074 or 73075 applies; or

a test to which item 73072 applies for a patient mentioned in paragraph (a) or (b) of that item; or

the cytology is associated with a test to which item 73072 applies for a patient mentioned in paragraph (c), (d), (e) or (f) of that item; or

the cytology is associated with a test to which item 73074 applies; or

the test is a repeat of a test to which this item applies, if the specimen collected for the previous test is unsatisfactory; or

the cytology is for the followup management of a patient treated for endometrial adenocarcinoma

Fee: $46.00 Benefit: 75% = $34.50 85%= $39.10

Explanatory notes

It is the responsibility of the treating healthcare practitioner to determine if the sample is being collected as part of the routine screening program under 73070 or 73071 or represents a sample falling under 73072 or 73073 or 73074 or 73075 or 73076, and to indicate this on the request form. Unless a co-test is specifically requested, requiring the pathology laboratory to perform both a human papillomavirus (HPV) test and a liquid based cytology (LBC) test on the same specimen, the pathology laboratory will by default perform an HPV test and then only undertake reflex LBC testing if oncogenic HPV (any type) is detected. The pathology laboratory will issue the HPV test result, the LBC test result and overall screening risk rating as a combined report as prescribed by the National Pathology Accreditation Advisory Council (NPAAC) Requirements for Laboratories reporting tests for the National Cervical Screening Program (NPAAC Requirements).

The test used for detecting oncogenic HPV must allow partial HPV genotyping to identify HPV16, HPV18 with or without HPV45 as well as meet the criteria for a population based screening test as prescribed by the NPAAC Requirements.

When used together, the self-collection device and the HPV test must meet the NPAAC Requirements, including the HPV test must be a polymerase chain reaction (PCR) test.

73070 applies to an HPV test on a cervical specimen for primary screening purposes and collected by a healthcare practitioner (or an accredited test provider under the supervision of a healthcare practitioner) from an asymptomatic patient as part of routine five yearly screening recommended by the National Cervical Screening Program. The Health Insurance Act 1973 excludes payment of Medicare Benefits for health screening services except where Ministerial directions have been issued to enable benefits to be paid, this includes HPV testing that is performed in accordance with the policy of the National Cervical Screening Program (available at www.cancerscreening.gov.au). This policy provides for a screening interval of five years for an asymptomatic patient commencing at 24 years and 9 months of age and for a patient aged between 70 to 74 years of age to cease cervical screening if the last test result is normal (i.e. low risk). A patient aged 75 years of age or older who has never had a cervical screening test or has not had one in the previous five years, may request a cervical screening test and be screened.

In accordance with the national policy for the National Cervical Screening Program, where oncogenic HPV (any type) is detected, the pathology laboratory will conduct reflex LBC automatically under 73076 (a) without requiring an additional request by the treating healthcare professional.

73071 only applies to HPV tests for primary screening purposes requested by a healthcare practitioner on a self-collected vaginal specimen if a specimen collected by a healthcare practitioner has been declined.

HPV testing on self collected vaginal specimens carried out under 73071 should be in accordance with the agreed National Cervical Screening Program Self Collection Policy. The Policy allows self collection where a patient is ≥ 30 years of age and has either never screened or is under screened (i.e. overdue for cervical screening by at least two years, being greater than 7 years since the patient’s last HPV screening test). A patient aged 75 years of age or older who has never had a cervical screening test or has not had one in the previous seven years, may request a Self- collected vaginal sample and be screened.

During the early years of the transition, this may include a patient who is overdue since the patient’s last conventional Pap test (i.e. greater than four years since last conventional Pap).

It is the intention of the National Cervical Screening Program where oncogenic HPV has previously been detected under this Item, the healthcare practitioner collected liquid based sample from the cervix that follows, can be claimed under 73076 (a) with a further request by the treating healthcare practitioner.

73072 applies to HPV tests where the specimen has been collected in accordance with the National Cervical Screening Program: Guidelines for the Management of Screen Detected Abnormalities, Screening in Specific Populations and Investigation of Abnormal Vaginal Bleeding (2016 Guidelines) which provides for:

(a)an HPV test (and reflex LBC) performed on a patient within a specific population suggestive of a higher risk of pre-cancerous or cancerous cervical changes. HPV tests carried out in specific populations under Item C should be in accordance with the 2016 Guidelines including:

(i)screening with an HPV test (and reflex LBC) every 3 years for an immune-deficient patient; or

(ii)a single HPV test between 20 and 24 years of age could be considered by healthcare practitioners on a case by case basis for a patient who experienced first sexual activity at a young age (less than 14 years of age) and who has not received the HPV vaccine before sexual debut; or

(b)an HPV test (and reflex LBC) performed for the follow up management of previously detected oncogenic HPV infection with a negative or possible/low grade squamous intraepithelial lesion (LSIL) cytology result; or

(c)a co-test (HPV+LBC) for the investigation of symptoms of cervical cancer, most commonly abnormal vaginal bleeding; or

(d)a co-test (HPV+LBC) for the management of a patient following treatment of high grade squamous intraepithelial lesions (HSIL) of the cervix as part of a ‘test of cure’ process performed at 12 months after treatment and annually thereafter, until receiving a negative co-test on two separate consecutive occasions, then the patient can return to routine five yearly screening. In accordance with the 2016 Guidelines this also applies to a patient undergoing follow up or post-treatment for a glandular abnormality as part of annual surveillance performed indefinitely; or

(e)a co-test (HPV+LBC) for the follow up management of glandular abnormalities; or

(f)a co-test (HPV+LBC) for screening a patient exposed to diethylstilboestrol (DES) in utero and daughters of patients exposed to DES in utero, if requested.

A co-test requires both HPV and LBC tests to be performed irrespective of the HPV test result. A reflex LBC is only required if oncogenic HPV (any type) is detected; where oncogenic HPV (any type) has been detected in a liquid based sample from the cervix by a healthcare professional, the pathology laboratory will conduct LBC automatically without requiring an additional request. It is the intention of the National Cervical Screening Program where a co-test is requested or oncogenic HPV has previously been detected under this Item, the LBC can be claimed under 73076 without requiring an additional request by the treating healthcare professional.

73073 applies to the management of a patient with previously detected oncogenic HPV (any type) infection on a Self-collected vaginal sample if a specimen collected by a healthcare practitioner has been declined. It may only be claimed when the test is performed within in a 21 month period following detection of oncogenic HPV (any type) associated with 73071.

It is expected that most patients who are undergoing follow up, after detection of oncogenic HPV (any type) on a Self-collected vaginal sample, will agree to have a clinician collected cervical sample at the follow up visit. Some patients may decline and this Item applies to this group of patients.

It is the intention of the National Cervical Screening Program where oncogenic HPV has previously been detected under this Item, the healthcare practitioner collected liquid based sample from the cervix that follows, can be claimed under 73076 (a) with a further request by the treating healthcare practitioner.

73074 applies to an HPV test on a vaginal vault specimen collected by a healthcare practitioner (or an accredited test provider under the supervision of a healthcare practitioner) from a patient with past history of total hysterectomy, in accordance with the 2016 Guidelines which provides for:

(a)an HPV test for a patient who has no evidence of cervical pathology and the patient’s screening history is not available, performed at 12 months following a total hysterectomy and annually thereafter until a patient has two negative HPV tests (i.e. oncogenic HPV detected) on two separate consecutive occasions and can be advised that no further testing is required; or

(b)a co-test (HPV+LBC) for a patient who has had a total hysterectomy, performed at 12 months following a total hysterectomy and annually thereafter until two consecutive co-tests are negative:

(i)if unexpected LSIL or HSIL is identified in the cervix at the time of total hysterectomy after completed ‘test of cure’ process; or

(ii)if the total hysterectomy was for treatment of high-grade cervical intraepithelial neoplasia in the presence of benign gynaecological disease; or

(iii)if the total hysterectomy was after histologically confirmed HSIL without Test of Cure and there is no cervical pathology; or

(c)indefinite co-testing (HPV+LBC) for a patient who has had a total hysterectomy, performed at 12 months after treatment and annually thereafter if the total hysterectomy was after adenocarcinoma in situ (AIS).

73075 applies to HPV tests repeated due to an unsatisfactory HPV test under 73070 or 73071 or 73072 or 73073 or 73074 or this item.

73076 applies to a LBC test on a cervical or vaginal vault specimen:

(a)as part of a reflex test following detection of oncogenic HPV (any type) described in the national policy and 2016 Guidelines associated with:

(i)items 73070 or 73071 or or 73073 or 73074 or 73075; or

(ii)item 73072 for a patient mentioned in paragraph (a) or (b);

(b)as part of a co-test (i.e. HPV+LBC) described in the national policy and 2016 Guidelines under 73072 for a patient mentioned in paragraph (c) or (d) or (e) of (f); or

(c)associated with a test to which item 73074 applies;

(d)if the test is a repeat of a test to which this item applies, if the specimen collected for the previous test is unsatisfactory; or

(d)for the follow up management of a patient with a past history of total hysterectomy for endometrial adenocarcinoma.

Medicare Benefits Schedule Fact Sheet: New Pathology MBS items for Cervical and Vaginal TestsPage 2 of 8MBSOnline

Cancer Council WAFile AttachmentNCSP MBS factsheet

[Reminder letter template]

[Practice Letter Head]

National Cervical Screening Program - please book an appointment for a cervical screening test

Dear [Patients Name],

We are {or I am} writing to remind you are overdue to have your next cervical screening test.

Please call xxxx xxxx or visit us online to book an appointment for cervical screening at our clinic as soon as possible.

Recent changes to the National Cervical Screening Program in Australia have resulted in the two-yearly Pap smear being replaced with a more accurate five yearly Cervical Screening Test. The renewed Program invites women aged 25-74 years to have a cervical screening test every five years, to detect for Human papillomavirus, which is the cause of nearly all cervical cancer cases. Earlier detection means a greater chance of successful treatment. Women who have never been screened or are under screened are at an increased risk of cervical cancer.

We {or I} strongly recommend you undergo five yearly cervical screening - even if you don’t have any symptoms or family history for cervical cancer.

More information about Program is available at www.cancerscreening.gov.au/cervical. And of course, you can also always visit your GP {or me} to discuss further about cervical cancer and screening.

Yours sincerely

Cancer Council WAFile AttachmentNCSP reminder letter template

[SMS reminder template]

Hi {{patient-first-name}}, this is a reminder from your GP to book an appointment for cervical screening. Call xxxx xxxx or visit online to book your appointment at our clinic today.

Cancer Council WAFile AttachmentNCSP SMS reminder template

Cancer Screening 'Plan Do Study Act'Cancer in AustraliaNational Cancer Screening ProgramsWhat is a ‘Plan Do Study Act’ cycle?As part of the GP Education Project, Cancer Council WA has developed education activities on bowel, breast and cervical cancer screening to support GPs in identifying and encouraging eligible patients to participate in the three National Cancer Screen...

Activity summaryOne cycle of a PDSA activity includes four components; plan the change (P), do the change (D), study (S) and act on the results (A). Each of these three activities includes four cycles:Cycle 1 – Identify eligible patientsCycle 2 – Discuss and designCycle 3 – Implement approachCycle 4 – Review and evaluateEach of these three activities can be undertaken by an individual GP, a group of GPs or by the whole practice (with the assistance of practice manager and practice nurses). Depending on who is involved in the completion of the activity will influence ...These PDSA activities are expected to be completed over the course of four to six months. A minimum of six hours of work (per activity) is needed to meet the requirements of RACGP Category 1 activity.

AccreditationFor more information

Cervical Screening 'Plan Do Study Act' (PDSA)Cervical cancer in AustraliaNational Cervical Screening ProgramCervical screening in general practiceThe renewed NCSP invites women aged 25–74 years to have a Cervical Screening Test every five years, in line with the new policy and guidelines.Cervical Screening PDSAActivity summaryAs part of the GP Education Project, Cancer Council WA has developed an RACGP and ACRRM accredited education activity to support GPs in identifying and encouraging eligible patients to participate in cervical screening through the NCSP.The goal of the activity isWhat changes will you make to result in an improvement?How will you know that the change is an improvement?

Learning outcomesChecklistBefore you commence the activity:

GP/Practice RegistrationPractice detailsPractice software detailsParticipant detailsPre-PDSA survey: About your practicePre-PDSA survey: About youCycle 1 – Identify eligible patientsDOEach GP involved (with the assistance of staff member) to review their patient records and randomly identify twenty patients (per GP) who:a) Meet the criteria for under screened or never screenedCriteria for under screened: Women aged 30 to 74 years who are two or more years overdue for screening (i.e. last Pap smear was taken four or more years ago or last Cervical Screening Test was taken seven or more years ago).Criteria for never screened: Women aged 30 to 74 years who have no Pap smear or Cervical Screening Test result.Refer to clinical guidelines (in appendix) for more information.b) Have visited the practice in the past 12 monthsEach GP involved (with the assistance of staff member) to collect information on screening status and recalls/reminders of their twenty patients and complete the table below.ACT

Cycle 2 – Discuss and designPLANDesignated staff member to host a practice team meeting OR individual GP to conduct a discussion with relevant member/s of the practice on:DOACT

Cycle 3 – Implement approachPLANDOACT

Cycle 4 – Review and evaluateDOACT

Post-PDSA surveyDeclarationAppendix: Additional resourcesPractice resources

Practice Name: Address: Suburb: Postcode: Phone: Fax: Email: Start Date: Practice Management Software: Clinical Software: Name1: FTE1: Name2: RACGP ACRRM No2: FTE2: Name3: Occupation3: RACGP ACRRM No3: FTE3: Name4: 5: 6: 7: 8: 9: 10: 11: 12: 13: 14: 15: 16: 17: 18: 19: 20: If yes please describe: If yes please list strategies used: 5 What barriers and challenges has your practice experienced when previously attemptingto implement strategies to improve cervical screening participationRow1: Name: RACGP QICPD number: ACRRM number: Practice surgery: Email_2: Start date: End date: 20_2: 20_3: Any additional commentsCount 20: 20_4: 20_5: Count 20: 20_6: 20_7: Count 20_2: 20_8: 20_9: Count 20_3: 20_10: 20_11: Count 20_4: 20_12: 20_13: Count 20_5: 20_14: 20_15: Count 20_6: 20_16: 20_17: Count 20_7: 20_18: 20_19: Count 20_8: 20_21: Count 20_9: improvement for cervical screening or specific groups of people to target: What strategies could your practice implement to address any of the identified gaps and areas of improvement for cervical screening and which specific groups of people could you target: Start date_2: End date_2: GPs present list: Practice nurses present list: Other staff present list: undefined_52: Start date_3: End date_3: Other please specify_4: GP RACGP ACCRM numberRow1_2: Other please specify_5: Other please specify_6: Other please specify_7: Other please specify_8: Other please specify_9: Other please specify_10: Other please specify_11: Other please specify_12: Other please specify_13: Other please specify_14: Start date_4: End date_4: GP RACGP ACCRM numberRow1_3: 20_22: 20_23: 20_24: Other please specifyCount 20: GP RACGP ACCRM numberRow2_2: 20_25: 20_26: 20_27: Other please specifyCount 20_2: GP RACGP ACCRM numberRow3_2: 20_28: 20_29: 20_30: Other please specifyCount 20_3: GP RACGP ACCRM numberRow4_2: 20_31: 20_32: 20_33: Other please specifyCount 20_4: GP RACGP ACCRM numberRow5_2: 20_34: 20_35: 20_36: Other please specifyCount 20_5: GP RACGP ACCRM numberRow6_2: 20_37: 20_38: 20_39: Other please specifyCount 20_6: GP RACGP ACCRM numberRow7_2: 20_40: 20_41: 20_42: Other please specifyCount 20_7: GP RACGP ACCRM numberRow8_2: 20_43: 20_44: 20_45: Other please specifyCount 20_8: 20_46: 20_47: 20_48: Count 20_10: 20_50: 20_51: Count 20_11: have been screened: Name_2: RACGP QICPD number_2: ACRRM number_2: Practice surgery_2: Email_3: Any additional comments: How was this learning outcome achieved through this activity: How was this learning outcome achieved through this activity_2: How was this learning outcome achieved through this activity_3: How was this learning outcome achieved through this activity_4: How was this learning outcome achieved through this activity_5: What changes did you implement in your practice as a result of thisactivityRow1: How do you monitor these changesRow1: What evaluation process do you use to measure these changesRow1: Were there any challenges in implementing this activity in your practiceRow1: Signed: Date: Occupation4: RACGP ACRRM No4: FTE4: Occupation1: RACGP ACRRM No1: Occupation2: Check Box42: OffCheck Box43: OffCheck Box44: OffCheck Box45: OffCheck Box46: OffCheck Box47: OffCheck Box48: OffCheck Box49: OffGP RACGP ACCRM numberRow1: GP RACGP ACCRM numberRow2: GP RACGP ACCRM numberRow3: GP RACGP ACCRM numberRow4: GP RACGP ACCRM numberRow5: GP RACGP ACCRM numberRow6: GP RACGP ACCRM numberRow7: GP RACGP ACCRM numberRow8: GP RACGP ACCRM numberRow9: GP RACGP ACCRM numberRow10: Count: 20_20: Text24: Text25: Text26: Text27: Check Box33: OffCheck Box34: OffText28: Text29: Outcome: 20_49: Check Box50: OffCheck Box51: OffText52: Text53: Check Box21: OffCheck Box22: OffCheck Box23: OffCheck Box18: OffCheck Box19: OffCheck Box20: OffText204: Text205: Text206: Text207: Text208: Text209: Text210: Text211: Text212: Text213: Text214: Text215: Text216: Text217: Text218: Text219: Text220: Text221: Text222: Text223: Text224: Text225: Text226: Text227: Text228: Text229: Text230: Text231: Text232: Text233: Text234: Text235: Text236: Text237: Text238: Text239: Text240: Text241: Text242: Text243: Text244: Text245: Text246: Text247: Text248: Text249: Text250: Text251: Check Box252: OffCheck Box253: OffCheck Box40: OffCheck Box41: OffCheck Box39: OffCheck Box38: OffCheck Box37: OffCheck Box36: OffCheck Box35: OffCheck Box11: OffCheck Box12: OffCheck Box13: OffCheck Box16: OffCheck Box17: OffCheck Box52: OffCheck Box53: OffCheck Box54: OffCheck Box55: OffCheck Box56: OffCheck Box57: OffCheck Box58: OffCheck Box59: OffCheck Box60: OffCheck Box61: OffCheck Box62: OffCheck Box63: OffCheck Box64: OffCheck Box65: OffCheck Box66: OffCheck Box67: OffCheck Box68: OffCheck Box69: OffCheck Box70: OffCheck Box71: OffCheck Box72: OffCheck Box73: OffCheck Box74: OffCheck Box75: OffCheck Box76: OffCheck Box77: OffCheck Box78: OffCheck Box79: OffCheck Box80: OffCheck Box81: OffCheck Box82: OffCheck Box83: OffCheck Box84: OffCheck Box85: OffCheck Box86: OffCheck Box87: OffCheck Box88: OffCheck Box89: OffCheck Box90: OffCheck Box91: OffText92: Text93: Text94: Text95: Check Box96: OffCheck Box97: OffCheck Box98: OffCheck Box99: OffCheck Box100: OffCheck Box101: OffCheck Box102: OffCheck Box103: OffCheck Box104: OffCheck Box105: OffCheck Box106: OffCheck Box107: OffCheck Box108: OffCheck Box109: OffCheck Box110: OffCheck Box111: OffCheck Box112: OffCheck Box113: OffCheck Box114: OffCheck Box115: OffCheck Box116: OffCheck Box117: OffCheck Box118: OffCheck Box119: OffCheck Box120: OffCheck Box121: OffCheck Box122: OffCheck Box123: OffCheck Box124: OffCheck Box125: OffCheck Box126: OffCheck Box127: OffCheck Box128: OffCheck Box129: OffCheck Box130: OffCheck Box131: OffCheck Box132: OffCheck Box133: OffCheck Box134: OffCheck Box135: OffText136: Text137: Text138: Text139: Text140: Check Box24: OffCheck Box25: OffCheck Box26: OffCheck Box27: OffCheck Box28: OffCheck Box141: OffCheck Box142: OffCheck Box143: OffCheck Box144: OffCheck Box145: OffCheck Box146: OffCheck Box147: OffCheck Box148: OffCheck Box149: OffCheck Box150: OffCheck Box151: OffCheck Box152: OffCheck Box153: OffCheck Box154: OffCheck Box155: OffCheck Box156: OffCheck Box157: OffCheck Box158: OffCheck Box159: OffCheck Box160: OffCheck Box161: OffCheck Box162: OffCheck Box163: OffCheck Box164: OffCheck Box165: OffCheck Box166: OffCheck Box167: OffCheck Box168: OffCheck Box169: OffCheck Box170: OffCheck Box171: OffCheck Box172: OffCheck Box173: OffCheck Box174: OffCheck Box175: OffCheck Box176: OffCheck Box177: OffCheck Box178: OffCheck Box179: OffCheck Box180: OffCheck Box181: OffCheck Box182: OffCheck Box183: OffCheck Box184: OffCheck Box185: OffCheck Box186: OffCheck Box187: OffCheck Box188: OffCheck Box189: OffCheck Box190: OffCheck Box191: OffCheck Box192: OffCheck Box193: OffCheck Box194: OffCheck Box197: OffCheck Box196: OffCheck Box195: OffCheck Box198: OffCheck Box199: OffCheck Box200: OffCheck Box201: OffCheck Box202: OffCheck Box203: OffCheck Box8: OffCheck Box9: OffCheck Box10: OffCheck Box14: OffCheck Box15: OffCheck Box29: OffCheck Box30: OffCheck Box260: OffCheck Box261: OffCheck Box262: OffCheck Box263: OffCheck Box264: OffText265: Text266: Check Box31: OffCheck Box92: OffCheck Box93: OffCheck Box94: OffCheck Box136: OffCheck Box95: OffCheck Box7: OffCheck Box5: Off

cancer screening in general practice€¦ · national cancer screening programs . cancer prevention...

Documents