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.



  WFMG TOSA FL 2 CRD

  201 N Mayfair Rd Fl 2
  Wauwatosa, WI 53226
  (414) 259-7505

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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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WFMG TOSA FL 2 CRD
Chronic Care  
Measure Rank **

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=359

269
of 344
80.22%
80.22%

Diabetes: All-or-None Outcome Measure (Optimal Control)  Diabetes All-or-None Measures. The Diabetes All-or-None Measures are two separate measures, one for process (optimal testing) and one for outcomes (optimal results). Each measure contains three goals. All three goals within a measure must be reached in order to meet that measure. The numerator of each all-or-none measure is collected from the organizations total diabetes denominator. Using the diabetes denominator optimal results includes: * Most recent A1C test result is less than than 8.0% AND * Most recent blood pressure measurement is less than 140/90 mm Hg AND * Tobacco Non-User AND * Daily Aspirin or Other Antiplatelet for Diabetes Patients with Ischemic Vascular Disease Unless Contraindicated AND * Statin Use for patients ages 40 through 75 or patients with IVD of any age. Why use an All-or-None method? This method was chosen because of the benefits it provides to both the patient and the practitioner. First, this methodology more closely reflects the interests and likely desires of the patient. With the data collected in two scores (optimal testing and optimal results), patients can easily look and see how their provider group is performing on these criteria rather than trying to make sense of multiple scores on individual measures. Second, this method represents a systems perspective emphasizing the importance of optimal care through a patients entire healthcare experience. Third, 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. Nolan T, Berwick DM. All-or-none measurement raises the bar on performance. JAMA. 2006 Mar 8;295(10):1168-70.
Q1 2016 - Q4 2016

N/A The number of patients or providers is too small for purposes of reliably reporting performance

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/A The number of patients or providers is too small for purposes of reliably reporting performance

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/A The number of patients or providers is too small for purposes of reliably reporting performance

Diabetes: Daily Aspirin or Other Antiplatelet for Diabetes Patients with Ischemic Vascular Disease (IVD) Unless Contraindicated Based on trials involving other secondary prevention therapies, the American College of Cardiology (ACC) and the American Hospital Assocation (AHA) recommends aspirin in all patients, unless contraindicated, with established coronary and other atherosclerotic vascular disease, including peripheral arterial disease, atherosclerotic aortic disease, and carotid artery disease. The ACC and AHA also recommend the use of other antiplatelet agents based on disease type and clinical conditions. The American Diabetes Association (ADA) supports this recommendation as a secondary prevention strategy for type 1 or type 2 diabetes with a history of cardiovascular disease.
Q1 2016 - Q4 2016

N/A The number of patients or providers is too small for purposes of reliably reporting performance

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/A The number of patients or providers is too small for purposes of reliably reporting performance

Diabetes: Statin Use Unless Contraindicated In November 2013, The American College of Cardiology/American Heart Association (ACC/AHA) Task Force on Practice Guidelines released updated guidance for the treatment of blood cholesterol. The new recommendations remove treatment targets for LDL-C for the primary or secondary prevention of atherosclerotic cardiovascular disease (ASCVD) and recommend high or moderate intensity statin therapy based on patient risk factors. Four major stain benefit groups were identified and diabetics age 40 to 75 years, regardless of LDL-C level and without clinical ASCVD are one of the identified groups.
Q1 2016 - Q4 2016

N/A The number of patients or providers is too small for purposes of reliably reporting performance

Ischemic Vascular Disease: All-or-None Outcome Measure (Optimal Control)  The IVD All-or-None Measure is one outcome measure (optimal control). The measure contains four goals. All four goals within a measure must be reached in order to meet that measure. The numerator for the all-or-none measure should be collected from the organization's total IVD denominator.All-or-None Outcome Measure (Optimal Control) - Using the IVD denominator optimal results include: * Most recent blood pressure measurement is less than 140/90 mm Hg -- And * Most recent tobacco status is Tobacco Free -- And * Daily Aspirin or Other Antiplatelet Unless Contraindicated -- And * Statin Use. Why use an All-or-None method? This method was chosen because of the benefits it provides to both the patient and the practitioner. First, this methodology more closely reflects the interests and likely desires of the patient. With the data collected in two scores (optimal testing and optimal results), patients can easily look and see how their provider group is performing on these criteria rather than trying to make sense of multiple scores on individual measures. Second, this method represents a systems perspective emphasizing the importance of optimal care through a patient's entire healthcare experience. Third, 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/A The number of patients or providers is too small for purposes of reliably reporting performance

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/A The number of patients or providers is too small for purposes of reliably reporting performance

Ischemic Vascular Disease: Daily Aspirin or Other Antiplatelet Therapy Unless Contraindicated 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. Based on trials involving other secondary prevention therapies, the ACC and AHA recommends aspirin in all patients, unless contraindicated, with established coronary and other atherosclerotic vascular disease, including peripheral arterial disease, atherosclerotic aortic disease, and carotid artery disease. The ACC and AHA also recommend the use of other antiplatelet agents based on disease type and clinical conditions. This measure shows the percentage of people 18 to 75 years of age with a diagnosis coronary or other atherosclerotic vascular disease who were prescribed oral antiplatelet therapy, unless contraindicated, in the measurement year.
Q1 2016 - Q4 2016

N/A The number of patients or providers is too small for purposes of reliably reporting performance

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/A The number of patients or providers is too small for purposes of reliably reporting performance

Ischemic Vascular Disease: Statin Use Unless Contraindicated The American College of Cardiology (ACC) and the American Heart Association (AHA) recommends that high-intensity statin therapy should be initiated or continued as first-line therapy in women and men less than or equal to 75 years of age who have clinical atherosclerotic cardiovascular disease, unless contraindicated. In November 2013, the ACC and AHA Task Force on Practice Guidelines released updated guidance for the treatment of blood cholesterol. The new recommendations remove treatment targets for LDL-C for the primary or secondary prevention of atherosclerotic cardiovascular disease (ASCVD) and recommend high or moderate intensity statin therapy based on patient risk factors. Four major statin benefit groups were identified and iIndividuals with ASCVD are one of the identified groups.
Q1 2016 - Q4 2016

N/A The number of patients or providers is too small for purposes of reliably reporting performance
Preventive Care  
Measure Rank **

Adult Body Mass Index (BMI) Control The United States Preventive Services Task Force (USPSTF) Guide to Clinical Preventive Services, June 2012, recommends that clinicians screen all adult patients for obesity and offer intensive counseling and behavioral interventions to promote sustained weight loss for obese adults. In addition, the Institute for Clinical Systems Improvement (ICSI, 2011) Prevention and Management of Obesity (Mature Adolescents and Adults) provides the following guidance: *Calculate the body mass index; classify the individual based on the body mass index categories. Educate patients about their body mass index and their associated risks. *Weight management requires a team approach. Be aware of clinical and community resources. The patient needs to have an ongoing therapeutic relationship and follow-up with a health care team. *Weight control is a lifelong commitment, and the health care team can assist with setting specific goals with the patient.BMI Parameters: *Normal Parameters: 18-64 years BMI >=18.5 and <25, 65 years and older BMI >=23 and <30 *Above Normal Parameters: 18-64 years BMI >=25, 65 years and older BMI >=30 *Below Normal Parameters: 18-64 years BMI <18.5, 65 years and older BMI<23
Q1 2016 - Q4 2016

N/A
The number of patients or providers is too small for purposes of reliably reporting performance

Adult Body Mass Index (BMI) Screening Annually The United States Preventive Services Task Force (USPSTF) Guide to Clinical Preventive Services, June 2012, recommends that clinicians screen all adult patients for obesity and offer intensive counseling and behavioral interventions to promote sustained weight loss for obese adults.

In addition, the Institute for Clinical Systems Improvement (ICSI, 2011) Prevention and Management of Obesity (Mature Adolescents and Adults) provides the following guidance: *Calculate the body mass index; classify the individual based on the body mass index categories. Educate patients about their body mass index and their associated risks. *Weight management requires a team approach. Be aware of clinical and community resources. The patient needs to have an ongoing therapeutic relationship and follow-up with a health care team. *Weight control is a lifelong commitment, and the health care team can assist with setting specific goals with the patient.

This measure assesses adults ages 18 through 85 who have had a minimum of one BMI Test annually.

Q1 2016 - Q4 2016

N/A The number of patients or providers is too small for purposes of reliably reporting performance

Chlamydia Screening in Women Sexually transmitted infections (STIs) cause significant morbidity and mortality in the United States each year. The Centers for Disease Control and Prevention (CDC) estimates that 19 million new infections occur annually in the United States, almost one half of which occur in persons 15 to 24 years of age.

Chlamydia is a common STD that can infect both men and women. It can cause serious, permanent damage to a woman's reproductive system, making it difficult or impossible for her to get pregnant later on. Chlamydia can also cause a potentially fatal ectopic pregnancy (pregnancy that occurs outside the womb).

Because chlamydia is usually asymptomatic, screening is necessary to identify most infections. Screening programs have been demonstrated to reduce rates of adverse secondary consequences in women. CDC recommends yearly chlamydia screening of all sexually active women younger than 25.

This measure assesses women 16 through 24 years of age identified as sexually active who had at least one test for chlamydia during the 12-month measurement period.

Q1 2016 - Q4 2016

N/A The number of patients or providers is too small for purposes of reliably reporting performance

Screening For Clinical Depression Adolescent Recommendation (12-18 years)
The United States Preventive Services Task Force (USPSTF) recommends screening of adolescents (12-18 years of age) for major depressive disorder (MDD) when systems are in place to ensure accurate diagnosis, psychotherapy (cognitive-behavioral or interpersonal), and follow-up.

Adult Recommendation (18 years and older)
The USPSTF recommends screening adults for depression when staff-assisted depression care supports are in place to assure accurate diagnosis, effective treatment, and follow-up.


Q1 2016 - Q4 2016

N/A The number of patients or providers is too small for purposes of reliably reporting performance

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/A The number of patients or providers is too small for purposes of reliably reporting performance

Well Child Visit First 15 Months of Life This measure is based on the CMS and American Academy of Pediatrics guidelines for Early and Periodic Screening, Diagnostic and Treatment (EPSDT) visits which outlines the following benefits of Well-Child Visits: *Prevention. Your child gets scheduled immunizations to prevent illness. You also can ask your pediatrician about nutrition and safety in the home and at school. *Tracking growth and development. See how much your child has grown in the time since your last visit, and talk with your doctor about your childs development. You can discuss your childs milestones, social behaviors and learning. *Raising concerns. Make a list of topics you want to talk about with your childs pediatrician such as development, behavior, sleep, eating or getting along with other family members. Bring your top three to five questions or concerns with you to talk with your pediatrician at the start of the visit. *Team approach. Regular visits create strong, trustworthy relationships among pediatrician, parent and child. The AAP recommends well-child visits as a way for pediatricians and parents to serve the needs of children. This team approach helps develop optimal physical, mental and social health of a child. * It is recommended that visits in the first 15 months of life occur at the following ages: By 1 month, 2 months, 4 months, 6 months, 9 months, 12 months and 15 months.

This measure assesses the percentage of pediatric patients who turned 15 months old during the measurement period and who had six or more well-child visits with a PCP during their first 15 months of life (by their 15 month birthday).

Q1 2016 - Q4 2016

N/A The number of patients or providers is too small for purposes of reliably reporting performance
Patient Experience - Visit Results  
Measure Rank **

Getting Timely Appointments, Care, and Information Patients were asked how often they were able to get an appointment for care as soon as it was needed and received timely answers to questions when they called the office. Patients were also asked how often they saw the doctor within 15 minutes of their appointment time. The score shows how often patients answered Always to these specific questions.
2015 Patient Experience

N/A The number of surveys or providers is too small for purposes of reliably reporting performance

How Well Providers Communicate Patients were asked if their doctors explained things in a way that was easy to understand, listened carefully, gave easy to understand instructions, knew important information about their medical history, showed respect, and spent enough time with the patient. The score shows how often patients answered Yes, definitely to these specific questions.
2015 Patient Experience

N/A The number of surveys or providers is too small for purposes of reliably reporting performance

Helpful, Courteous, and Respectful Office Staff Patients were asked if office staff were helpful and if they were courteous and respectful. The score shows how often patients answered Yes, definitely to these specific questions.
2015 Patient Experience

N/A The number of surveys or providers is too small for purposes of reliably reporting performance

Follow Up on Test Results Patients were asked if someone from the doctors office followed up to give them the results of a blood test, x-ray, or other test when it was ordered by the doctor. The score shows how often patients answered Yes, definitely to this specific question.
2015 Patient Experience

N/A The number of surveys or providers is too small for purposes of reliably reporting performance

Rating the Provider a "9" or "10" on a 0-10 Scale Patients were asked to rate their doctors on a scale of 0 to 10, with 0 being the worst possible doctor and 10 being the best possible doctor. The score shows how often patients gave the doctor a 9 or 10.
2015 Patient Experience

N/A The number of surveys or providers is too small for purposes of reliably reporting performance

Willingness To Recommend Patients were asked if they would recommend the doctors office to their family and friends. The score shows how often patients answered Yes, definitely to this specific question.
2015 Patient Experience

N/A The number of surveys or providers is too small for purposes of reliably reporting performance