Wisconsin Collaborative for Quality Healthcare

View Our Reports

print this page

WCHQ Measures Summary Report

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

Health System Selection:


Clinic Selection:

Legend

* 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  

Btn Export

Show Benchmark *:

Prairie Clinic
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.
Q3 2016 - Q2 2017 N=787

19
of 25

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
Q3 2016 - Q2 2017 N=787

24
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.
Q3 2016 - Q2 2017 N=787

23
of 25
89.33%
89.33%

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.
Q3 2016 - Q2 2017 N=787

2
of 24
87.93%
87.93%

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.
Q3 2016 - Q2 2017 N=49

0
of 20
-3.00%
-3.00%
The patient population is too small (N<50) for purposes of reliably predicting Physician Group performance

Diabetes: eGFR (Estimated Glomerular Filtration Rate) Test Annually Approximately 11% of U.S. adults have CKD. The condition is usually asymptomatic until its advanced stages. Most cases of CKD are associated with diabetes or hypertension. Chronic kidney disease is defined as decreased kidney function or kidney damage that persists for at least 3 months. Tests often suggested for screening that are feasible in primary care include testing the urine for protein (microalbuminuria or macroalbuminuria) and testing the blood for serum creatinine to estimate the glomerular filtration rate (eGFR).

This measure assesses the number of diabetic patients who have had an eGFR test annually.

Q3 2016 - Q2 2017 N=787

7
of 23
95.17%
95.17%

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.
Q3 2016 - Q2 2017 N=1,762

9
of 24
85.41%
85.41%

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.
Q3 2016 - Q2 2017 N=159

1
of 24
93.08%
93.08%
Preventive Care  
Measure Rank **

Adolescent Immunization Status For the general community, high childhood immunization rates prevent the resurgence of many infectious diseases, such as polio, that have been virtually eradicated from most developed countries (CDC, 1999). The general clinical consensus is that if immunization practices ceased, most infectious and contagious diseases currently prevented by vaccinations would reemerge as lethal health threats. Potential for exposure to infectious disease is even greater with the increase in international travel. By ensuring proper immunization of adolescents, organizations can help contain the transmission of these diseases and help protect the general population. This measure assesses the percentage of adolescents who had each of the following immunizations by their 13th birthday: One dose of meningococcal vaccine AND, One tetanus, diphtheria toxoids and acellular pertussis vaccine (Tdap) OR, One tetanus, diphtheria toxoids vaccine (Td)
Q3 2016 - Q2 2017 N=157

10
of 22
85.99%
85.99%

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
Q3 2016 - Q2 2017 N=10,107

19
of 22

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.

Q3 2016 - Q2 2017 N=10,107

11
of 23
98.59%
98.59%

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
Q3 2015 - Q2 2017 N=3,046

21
of 25
71.83%
71.83%

Cervical Cancer Screening There is good evidence that cervical cancer screening significantly reduces the incidence of and mortality from cervical cancer. The US Preventive Services Task Force suggests most of the benefit can be obtained by beginning screening at age 21. Recommendations include screening for women ages 21 through 64 with cytology (Pap smear) at least every 3 years and for women ages 30 through 64 who want to lengthen the screening interval, screening with a combination of cytology and human papillomavirus (HPV) testing every 5 years. An individuals specific clinical considerations, risk factors, etc. determine if testing is needed at a more frequent interval. It is recommended that women speak with their health care providers to determine the appropriate interval for their particular situation. There is limited evidence to determine the benefits of continued screening in women older than 65, due to declining incidence of high-grade cervical lesions after middle age. There is fair evidence that screening women older than 65 is associated with an increased risk for potential harm (US Preventive Services Task Force). Therefore, it is also recommended that women over age 65 speak with their health care providers to determine if continued screening is appropriate for their personal medical condition.
Q3 2014 - Q2 2017 N=4,542

16
of 25
77.63%
77.63%

Childhood Immunization Status For the general community, high childhood immunization rates prevent the resurgence of many infectious diseases, such as polio, that have been virtually eradicated from most developed countries (CDC, 1999). The general clinical consensus is that if immunization practices ceased, most infectious and contagious diseases currently prevented by vaccinations would reemerge as lethal health threats. Potential for exposure to infectious disease is even greater with the increase in international travel. By ensuring proper immunization of children by the age of two, health organizations can help contain the transmission of these diseases and help protect the general population. This measure assesses completion of the Primary Childhood Series for children age two who have had each of the following immunizations: *Four Diphtheria Tetanus and Acellular Pertussis (DTaP) *Three Polio (IPV) *One Measles, Mumps and Rubella (MMR) *Three H influenza Type B (HiB) *Three Hepatitis B (Hep B) *One Chicken Pox/Varicella (VZV) *Four Pneumococcal Conjugate (PCV)
Q3 2016 - Q2 2017 N=273

21
of 21
73.26%
73.26%

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.

Q3 2016 - Q2 2017 N=476

1
of 21
89.08%
89.08%

Colorectal Cancer Screening The United States Preventive Services Task Force (USPSTF) strongly recommends that clinicians screen men and women, at age 50 and older for colorectal cancer. The optimal interval for screening depends on the test. Annual fecal occult blood testing (FOBT)/Fecal Immunoassay Test (FIT) offers greater reductions in mortality rates than biennial screening. A 10-year interval has been recommended for colonoscopy, but a 5-year interval is recommended for flexible sigmoidoscopies because of their lower sensitivity. Fecal DNA Screening (Cologuard test) has been added as a new option for screening in 2015 (recommended interval every three years). The USPSTF concluded that the benefits from screening for colorectal cancer substantially outweigh potential harms, and that regardless of screening strategy chosen, it is likely to be cost-effective. In persons identified as being at high-risk by their health care providers, initiating screening at an earlier age is reasonable. It is recommended that all adults speak with their health care providers to determine, on an individual basis, the age at which to begin and end screenings, the best type of screening for individual circumstances, and the frequency of these screenings.
Q3 2016 - Q2 2017 N=5,983

14
of 24
76.67%
76.67%

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).

Q3 2016 - Q2 2017 N=280

6
of 21
77.14%
77.14%