Wisconsin Collaborative for Quality Healthcare

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WCHQ Measures Summary Report

This report shows a health system's most current results for all WCHQ performance measures.

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* Benchmark: For those measures with multiple result categories displayed on one bar, the benchmark applies to "Good Control" for A1C Control and LDL Control measures, and to "Two or More Tests" for Blood Sugar (A1C) Testing. The default benchmark is the top performer. This can be changed by selecting a different benchmark from the drop-down.

** Rank: For those measures with multiple result categories displayed on one bar, the rank is based on "Good Control" for A1C Control and LDL Control measures, and to "Two or More Tests" for Blood Sugar (A1C) Testing.

 
Benchmark
Good Control
(or BMI Normal)
Fair to Poor
Control (or BMI
Above Normal)
Uncontrolled
(or BMI Below Normal)
Not Tested
 
Two or More Tests One Test  
 
Percentage of Patients Meeting the Measure Criteria  

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Show Benchmark *:

Holy Family Memorial
Chronic Care  
Measure Rank **

Diabetes: Blood Sugar (A1c) Testing Good glycemic control for people with diabetes is cost-effective and improves quality of life. The A1c test has become the gold standard for assessing and monitoring glycemic control. The American Diabetes Association (ADA) strongly recommends that people with diabetes have two A1c tests annually, at a minimum. This measure assesses the percentage of patients 18 to 75 years of age with a diagnosis of diabetes who had two or more A1c tests, one A1c test, or no A1c tests within the measurement year.
Q1 2016 - Q4 2016 N=1,246

8
of 24

Diabetes: Blood Sugar (A1c) Control In an effort to align with National Quality Forum (NQF) endorsed diabetes measures, and referencing the 2013 American Diabetes Association (ADA) guidelines, the following A1C Control goals for people with diabetes are measured by the WCHQ: Good Control - A1c level controlled to less than 8.0%, Fair to Poor Control - A1c greater than or equal to 8.0% and less than or equal to 9.0%, Uncontrolled - A1c greater than 9.0%, No A1c test within the measurement period
Q1 2016 - Q4 2016 N=1,246

15
of 24

Diabetes: Kidney Function Monitored Diabetes is the leading cause of kidney disease in the United States. Early detection and intervention, along with improved glycemic and blood pressure control, can help reduce the risk of the development and progression of kidney disease. The measure shows the percent of people 18 to 75 years of age with a diagnosis of diabetes who were screened and/or monitored for kidney disease in the measurement year.
Q1 2016 - Q4 2016 N=1,246

24
of 24
77.37%
77.37%

Diabetes: Blood Pressure Control Cardiovascular disease is the major cause of mortality for individuals with diabetes. It is also a major contributor to morbidity and direct and indirect costs of diabetes. Studies have shown the benefits of reducing cardiovascular risk factors in preventing or slowing cardiovascular disease. In an effort to align with the National Quality Forum (NQF) endorsed diabetes measures, and referencing the 2013 American Diabetes Association (ADA) guidelines it is recommended that people with diabetes have a blood pressure measured at every routine diabetes visit and that the systolic blood pressure is less than 140 mmHg and the diastolic blood pressure is less than 90 mmHg. This measure assesses the percentage of patients 18-75 whose most recent blood pressure reading within the measurement period is controlled to a rate of less than 140/90 mmHg.
Q1 2016 - Q4 2016 N=1,246

24
of 24
69.66%
69.66%

Diabetes: Most Recent Tobacco Status is Tobacco-Free Studies of individuals with diabetes consistently demonstrate that smokers have a higher risk of CVD, premature death, and increased rate of microvascular complications of diabetes. Smoking may have a role in the development of type 2 diabetes. The American Diabetes Association (ADA) supports the recommendation to advise all patients not to smoke or use tobacco products and to include smoking cessation counseling and other forms of treatment as a routine component of diabetes care.
Q1 2016 - Q4 2016 N=1,246

1
of 22
96.71%
96.71%

Diabetes: All-or-None Process Measure (Optimal Testing) Diabetes All-or-None Measures. The Diabetes All-or-None Measure contains two goals. Both goals within the measure must be reached by each patient in order to meet the measure. Diabetes optimal testing includes: * Two A1C tests performed during the 12 month reporting period AND * One kidney function test during the 12 month reporting period, and/or diagnosis and treatment of kidney disease. Why use an All-or-None method? This method was chosen because of the benefits it provides to both the patient and the provider. For the Patient: The American Diabetes Association recommends these two tests to prevent and reduce diabetes complications such as blindness, loss of limb and kidney disease. Both tests should be performed and the test results will help your doctor decide the best diabetes care for you. The All-or-None measure can be used to see how well diabetes care is done where you receive your care. For the Provider: This method represents a systems perspective emphasizing the importance of optimal care through a patients entire healthcare experience. In addition, this method gives a more sensitive scale for improvement. For those organizations scoring high marks on individual measures, the All-or-None measure will give room for benchmarks and additional improvements to be made.
Q1 2016 - Q4 2016 N=1,246

22
of 23
65.41%
65.41%

Controlling High Blood Pressure: Blood Pressure Control Hypertension (high blood pressure) affects approximately 50 million individuals in the United States. "Essential Hypertension" is diagnosed when no specific cause for the elevated blood pressure can be found. A normal blood pressure for most adults is less than 120/80 mm Hg. High blood pressure is a leading risk factor for coronary heart disease, congestive heart failure, renal disease and stroke. Controlling one's blood pressure can help prevent these diseases. This measure assesses the percentage of patients 18-85 years of age who have a diagnosis of essential hypertension and whose blood pressure was adequately controlled based on the the eighth report of the Joint National Committee treatment goals of: *Less than 140/90 for patients less than 60 years of age or patients of any age with a diagnosis of diabetes and/or chronic kidney disease. *Less than 150/90 for patients 60 years of age and older without diabetes or chronic kidney disease.
Q1 2016 - Q4 2016 N=2,513

24
of 24
71.47%
71.47%

Ischemic Vascular Disease: Blood Pressure Control There has been important evidence from clinical trials that further supports and broadens the merits of risk-reduction therapies for patients with established coronary and other atherosclerotic vascular disease, including peripheral arterial disease, atherosclerotic aortic disease, and carotid artery disease. The American College of Cardiology (ACC) and the American Heart Association (AHA) recommends that a blood pressure is measured at every routine visit and that the systolic blood pressure is less than 140 mmHg and the diastolic blood pressure is less than 90 mmHg. This measure shows the percentage of people 18-75 years of age with a diagnosis of IVD whose most recent blood pressure reading within the measurement period is controlled to a rate of less than 140/90 mmHg.
Q1 2016 - Q4 2016 N=453

23
of 24
76.60%
76.60%

Ischemic Vascular Disease: Most Recent Tobacco Status is Tobacco-Free  The American Heart Association /American College of Cardiology (AHA/ACC) recommends secondary prevention for patients with Coronary and other Vascular Disease that includes strongly encouraging patient and family to stop smoking and to avoid secondhand smoke through the provision of counseling, pharmacological therapy and formal smoking cessation programs as appropriate. The goal is for complete smoking cessation.
Q1 2016 - Q4 2016 N=453

1
of 22
97.13%
97.13%
Preventive Care  
Measure Rank **

Breast Cancer Screening There is convincing evidence that screening with film mammography reduces breast cancer mortality, with a greater absolute reduction for women aged 50 to 74 years than for women aged 40 to 49 years. The strongest evidence for the greatest benefit is among women aged 60 to 69 years. Among women 75 years or older, evidence of benefits of mammography is lacking.Recommended intervals for mammography screening may also vary on an individual basis, but there is a general consensus that every two years is the minimum frequency. However, it is recommended that women speak with their health care providers to determine on an individual basis the age at which to begin and end mammography screening and the frequency of these screenings. For women who have had sporadic breast cancer the evidence supports regular history, physical examination, and mammography as the cornerstone of appropriate breast cancer follow-up. Women treated with breast-conserving therapy should have their first post-treatment mammogram no earlier than 6 months after definitive radiation therapy. Subsequent mammograms should be obtained every 6 to 12 months for surveillance of abnormalities. Mammography should be performed yearly if stability of mammographic findings is achieved after completion of loco regional therapy.This measure assesses the percentage of women age 50 through 74 who had a minimum of one breast cancer screening test during the two year measurement period
Q1 2015 - Q4 2016 N=4,020

23
of 23
68.18%
68.18%

Screening for Osteoporosis The USPSTF (US Preventive Services Task Force) found good evidence that the risk for osteoporosis and fracture increases with age (and other factors). They also found that bone density measurements accurately predict the risk for fractures in the short-term and that treating asymptomatic women with osteoporosis reduces their risk for fracture. The benefits of screening and treatment are of at least moderate magnitude for women at increased risk by virtue of age or the presence of other risk factors. No recommendation has been made by the USPSTF for or against screening for osteoporosis in postmenopausal women younger than 60 or in women 60-64 who are not at increased risk for an osteoporotic fracture. The National Osteoporosis Foundation recommends a bone density screening for all women at 65 years and older regardless of their risk factors.
Q1 2016 - Q4 2016 N=2,611

18
of 23
75.56%
75.56%