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 *:

Reedsburg Area Medical Center
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=781

23
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=781

17
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=781

21
of 24
91.17%
91.17%

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=781

14
of 24
82.84%
82.84%

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=2,189

12
of 24
83.97%
83.97%

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=161

7
of 24
86.96%
86.96%
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=10,029

21
of 21

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=10,029

14
of 22
97.17%
97.17%

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=8,520

11
of 19
46.08%
46.08%