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.
Q3 2016 - Q2 2017 N=865

22
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=865

22
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=865

22
of 25
91.56%
91.56%

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=865

17
of 24
83.82%
83.82%

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=2,244

16
of 24
84.76%
84.76%

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=168

7
of 24
87.50%
87.50%
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
Q3 2016 - Q2 2017 N=10,030

22
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=10,030

17
of 23
96.76%
96.76%

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=2,916

25
of 25
65.09%
65.09%

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=4,935

25
of 25
71.47%
71.47%