HIVQUAL-US Annual Data Report: Based on 2007 Performance Data

Transcription

1 HIVQUAL-US Annual Data Report: Based on 2007 Performance Data December 2009 Submitted to HIVQUAL-US by: JSI Research and Training Institute, Inc. 44 Farnsworth Street Boston MA

2 NEW YORK STATE DEPARTMENT OF HEALTH AIDS INSTITUTE HUMBERTO CRUZ, M.S. DIRECTOR OFFICE OF THE MEDICAL DIRECTOR HIV QUALITY OF CARE PROGRAM BRUCE D. AGINS, M.D., M.P.H. MEDICAL DIRECTOR CLEMENS M. STEINBÖCK, M.B.A. DIRECTOR OF QUALITY INITIATIVES DANIEL R. BELANGER, L.M.S.W. DIRECTOR, NYS HIV QUALITY OF CARE TRACY HATTON DIRECTOR, HIV CLINICAL GUIDELINES DANIEL E. TIETZ MANAGER FOR CONSUMER AFFAIRS HIVQUAL-US PROGRAM BRUCE D. AGINS, M.D., M.P.H. DIRECTOR JOAN MANUEL MONSERRATE, M.P.H. DEPUTY DIRECTOR MARGARET A. PALUMBO, M.P.H. DEPUTY DIRECTOR, HEALTHQUAL-INT. CLEMENS M. STEINBÖCK, M.B.A. Q.I. SPECIALIST CHRISTOPHER G. WELLS DATA ANALYST TIERNEY R. MCAFEE ADMINISTRATIVE ASSISTANT HIVQUAL-US CONSULTANT TEAM NANETTE BREY MAGNANI, ED.D. Q.I. CONSULTANT BARBARA BOSHARD, R.N., B.S.N., M.S. Q.I. CONSULTANT JOHANNA BUCK, M.A., R.N. SENIOR Q.I. CONSULTANT KATHLEEN CLANON, M.D. Q.I. CONSULTANT ONELIA CRESPO, M.D. Q.I. CONSULTANT LORI DELORENZO, M.S.N., R.N. Q.I. CONSULTANT SUSAN O. HERLONG, R.N., M.S.N., F.C.N. Q.I. CONSULTANT SHARON (SHERRY) K. MARTIN, M.ED. Q.I. CONSULTANT M. KATHERINE RELLER, R.N., M.S. Q.I. CONSULTANT BARBARA ROSA, R.N.-C., M.S. Q.I. CONSULTANT DANIEL SENDZIK Q.I. CONSULTANT JESSE T. UNGARD Q.I. CONSULTANT HUGH DAI, M.D. PROGRAMMER, ehivqual 2

3 JSI RESEARCH AND TRAINING INSTITUTE, INC. LISA HIRSCHHORN, M.D., M.P.H. PRINCIPAL INVESTIGATOR, EVALUATION KAREN SCHNEIDER, P.H.D. PROJECT DIRECTOR LAURIE KUNCHES, N.P., P.H.D. CLINICAL ADVISOR JOSEPH MUSOLINO PROGRAMMER WENDY CHOW, M.P.H. ANALYST/PROGRAMMER ALLISON POWER PROJECT COORDINATOR EUGENIE COAKLEY, M.A., M.P.H. STATISTICAL CONSULTANT ACKNOWLEDGEMENTS The HIVQUAL-US program would like to thank the Health Resources and Services Administration, HIV/AIDS Bureau for its continued support. In particular, we would like to thank Project Officer Tracy Matthews, who has seen the program grow through the years and whose leadership has proven invaluable and incredibly graceful. In addition, we would like to thank the grantees for their ongoing participation and efforts to improve the care for people living with HIV. Finally, HIVQUAL-US would like to thank the members of the National Clinical Advisory Committee for their contributions and guidance, which not only shape the HIVQUAL portfolio of indicators, but also helps direct the offerings and services available nationwide to all participant grantees. Special thanks is given to Dr. Steve Johnson. 3

4 2008 HIVQUAL-US NATIONAL CLINICAL ADVISORY COMMITTEE JUDITH ABERG, MD MARCIA ALCOULOUMRE, MD SARA ALLEN, MSN, CRNP LYDIA F. AOUN-BARAKAT, MD JEFFREY BEAL, MD ROBIN BIDWELL, MD JEFFREY BIRNBAUM, MD SKY BLUE, MD KAREN BOYD, RN, MSN, CNP ELIZABETH CABRERA, MED MARY CAFFERY, RN, MSN ELI CAMHI, MSW JONATHAN A. COHN, MD ROBERTO CORALES, DO JENNIFER DALY, MD SHIREESHA DHANIREDDY, MD LAURIE DILL, MD THOMAS DOBBS, MD TERENCE DORAN, MD, PHD JOHN FANGMAN, MD LAWRENCE FRIEDMAN, MD FERNANDO GARCIA, MD WOLFE GERECHT, MD THOMAS GIORDANO, MD, MPH IVAN GOMEZ, MD PETER GORDON, MD CHRIS GRACE, MD ANDREW HAMILTON, RN HAROLD HENDERSON, MD MARY LAWRENCE HICKS, FNP JOHN HOGAN, MD ANNA K. HUANG, MD GEORGE JOHNSON, MD STEVE JOHNSON, MD BARBARA JOHNSTON, MD KATHERINE KNAPP, MD NANCY KOUGHAN, DO, MPH ERNESTO LAMADRID, MD BEN D. LIGHTFOOT, MD NORMA LOPEZ, MD GONZALO MALDONADO SHELDA MARTIN, MD NEW YORK UNIVERSITY/HHC BELLEVUE MEDICAL CENTER U. OF CALIFORNIA, IRVINE- MEDICAL CENTER DREXEL UNIVERSITY COLLEGE OF MEDICINE WATERBURY HOSPITAL CENTER U. OF SOUTH FLORIDA/ FL HEALTH INFORMATION CENTER CHRISTIANA CARE SUNY DOWNSTATE - HEAT PROGRAM FAMILY MEDICINE RESIDENCY OF IDAHO DETROIT COMMUNITY HEALTH CONNECTION U. OF TEXAS SOUTHWESTERN MEDICAL CENTER UCSD MOTHER, CHILD AND ADOLESCENT HIV PROGRAM NEW YORK PRESBYTERIAN SYSTEM SELECT HEALTH WAYNE STATE UNIVERSITY - SCHOOL OF MEDICINE AIDS COMMUNITY HEALTH CENTER U. OF MASSACHUSETTS MEDICAL SCHOOL HARBORVIEW MEDICAL CENTER MONTGOMERY AIDS OUTREACH SOUTHEAST MISSISSIPPI RURAL HEALTH NETWORK U. OF TEXAS, HEALTH SCIENCES CENTER, SAN ANTONIO AIDS RESOURCE CENTER OF WISCONSIN U. OF MIAMI, MILLER SCHOOL OF MEDICINE VALLEY AIDS COUNCIL AIDS PROJECT OF THE OZARKS HOUSTON CENTER FOR QUALITY OF CARE UCSF FRESNO COLUMBIA PRESBYTERIAN FLETCHER ALLEN HEALTH CARE ALLIANCE CHICAGO HEALTH CARE U. OF MISSISSIPPI MEDICAL CENTER UCSF POSITIVE HEALTH PROGRAM UNITY HEALTHCARE, INC. U. OF LOUISVILLE U. OF SOUTH CAROLINA OUTPATIENT PEDIATRIC AIDS CLINIC U. OF COLORADO-SCHOOL OF MEDICINE SAINT VINCENT'S MEDICAL CENTER-MANHATTAN ST. JUDE CHILDREN'S RESEARCH HOSPITAL DEKALB COUNTY BOARD OF HEALTH BUREAU OF HIV/AIDS FLORIDA DOH BROCKTON NEIGHBORHOOD HEALTH CENTER LYNN COMMUNITY HEALTH CENTER CENTRO DE SALUD DE LARES, INC. WEST VIRGINIA UNIVERSITY 4

5 MARY E. MARR AIDS ACTION COALITION JULIO MARRERO, MD CENTRO DE SALUD DE LARES, INC. CHRIS MATHEWS, MD UCSD MEDICAL CENTER OWEN CLINIC MARK MAUS, DO, MPH DEBORAH MCMAHON, MD HARRIET MONFORTI, RN SALLY NEVILLE, RN, MSN TURNER OVERTON, MD JANICE PIATT, MD JOHN POST, MD ANA PUGA, MD KATE ROLLINS, CRN MICHAEL SAAG, MD ARIF R. SARWARI, MD JENNIFER SAYLES, MD, MPH MARGO A. SMITH, MD DAVID SPACH, MD MYLES SPAR, MD DONNA SWEET, MD SHARYN THOMPSON, MD PAOLO TROIA, MD JOSE M VASQUEZ JULIA, MD AMY WILKIN, MD SOLANO COUNTY CLINICS U. OF PITTSBURGH WAKE COUNTY HUMAN SERVICES KANSAS CITY FREE HEALTH CLINIC WASHINGTON UNIVERSITY SCHOOL OF MEDICINE MARICOPA INTEGRATED HEALTH SYSTEM MARICOPA INTEGRATED HEALTH SYSTEM CHILDREN'S DIAGNOSTIC & TREATMENT CENTER WASHINGTON HOSPITAL CENTER UNIVERSITY OF ALABAMA AT BIRMINGHAM WEST VIRGINIA UNIVERSITY T.H.E. CLINIC, INC. WASHINGTON HOSPITAL CENTER UNIVERSITY OF WASHINGTON VENICE FAMILY CLINIC WICHITA KANSAS STATE UNIVERSITY MEMPHIS COORDINATED SCHOOL HEALTH CENTER FOR AIDS RESEARCH, EDUCATION AND SERVICES PUERTO RICO DEPARTMENT OF HEALTH WAKE FOREST UNIVERSITY MEDICAL CENTER S. BRUCE WILLIAMS, MD U. OF NEW MEXICO SCHOOL OF MEDICINE BARRY ZINGMAN, MD MONTEFIORE MEDICAL CENTER JOHN ZURLO, MD HERSHEY MEDICAL CENTER 5

6 TABLE OF CONTENTS Executive Summary... 8 HIVQUAL-US Program Background Methodology Sample Inclusion Criteria Data Collection/Sampling Methodology Development of Indicators and Indicator Definitions Analysis a) Definition of Clinics versus Grantees b) Core vs. Optional Indicators c) Definition of Eligible Trimesters d) Summary Statistics for Each Performance Indicator Unadjusted Analysis Description of the 2008 Data Submission for 2007 Care Description of Clinics Submitting 2007 Care Data in Ryan White Program Funding Geographic Distribution Characteristics of Patients Included in 2008 Submission of 2007 Data Gender, Age, Race/Ethnicity HIV Transmission Risk Distribution of Patients by Ryan White Funding and Geography Insurance Type Results: 2007 Performance Indicators Engagement in Care Indicator Clinical Visits (CORE) HIV Specific Indicators ARV Therapy (CORE) HIV Monitoring (CORE) ARV Therapy Management (CORE) Adherence Assessment (CORE) PCP Prophylaxis (CORE)

7 HIV Specialist Care (CORE) Viral Suppression Rates (CORE) Screening Indicators Mental Health Screening (CORE) Substance Use Screening (CORE) Tuberculosis (TB) Screening (CORE) Syphilis Screening (CORE) Hepatitis C Screening (CORE) Lipid Screening (CORE) Colonoscopy (OPTIONAL) Tobacco Use Screening (CORE) General Medical Care Indicators Dental Care (CORE) Pneumococcal Vaccination (OPTIONAL) Ophthalmologic Care (OPTIONAL) Gynecology Indicators Gynecology Care (CORE) Chlamydia Screening (CORE) Gonorrhea Screening (CORE) Mammography Screening (CORE) Patient Education Indicators Basic Patient Education (OPTIONAL) Prevention Education (CORE) Conclusions

8 EXECUTIVE SUMMARY The HIVQUAL-US program provides resources and support to grantees of the Ryan White HIV/AIDS Treatment Extension Act (hereafter referred to as the Ryan White Program). HIVQUAL-US works to develop the capacity of Ryan White Part C and/or D grantees to develop integrated quality management systems that include ongoing measurement and improvement activities. The overall goal of HIVQUAL-US is to build sustainable quality management programs that optimize HIV care for people living with HIV/AIDS. Grantees can opt to submit performance data to HIVQUAL-US that measures a common set of indicators using customized software. This report describes the results of data submitted that measure the quality of care delivered during calendar year A total of 168 clinics representing 93 grantees submitted data. Altogether, 10,005 patients with at least one medical visit in the first and last six months of the review period from 1/1/2007 to 12/31/2007 were included. Two-thirds of patients were between the ages of 25 and 49 (68%) and 28% were 50 years or older. Nearly one half of the patients were female (48%), and 76% were minorities. Fifty-nine percent of patients reported any heterosexual risk and 14% reported any IDU risk. Most patients (85%) received care at clinics that received Part C funding; 12% of patients received care at clinics that received both Part C and Part D funds. Clinics in the sample represented a broad geographic distribution which is similar to that of all clinics funded through Parts C and D of the Ryan White Program. Overall, quality of HIV care provided by participating grantees met expected standards of clinical care based on US guidelines. Eighty-two percent of patients had a clinical visit at least every four months; 88% of patients received viral load and CD4 tests during the same period. Among patients who were clinically eligible for antiretroviral therapy (ART), 85% were prescribed ART in every eligible trimester. Over 90% of patients with CD4 <200 cells/mm 3 were ever on HAART. Receipt of PCP prophylaxis among eligible patients was also high at 87%. Only 47% of patients on ART had adherence measured in each trimester that they visited the clinic. Screening and prevention indicators were also measured. Rates were high for most screening indicators, including substance use (79%), syphilis (79%), hepatitis C (90%), tobacco use (82%), and lipids (83% of patients on ART). Rates of mental health screening varied, with the majority of patients screened for depression (73%), anxiety (64%), appetite (67%), cognitive function (65%), and sleep (61%). Two-thirds (67%) of patients had a PPD planted and read during the past 24 months. Of those tested, 2.5% were positive. Among female patients, about two-thirds had both a pelvic exam and Pap smear, with similar screening rates for chlamydia (58%) and gonorrhea (58%). 8

9 High rates of viral suppression were seen, representing success in this critical treatment outcome among participating Part C/D funded clinics. Fifty-eight percent of patients always maintained viral load suppression 1 throughout the year, with 75% of patients ever on ART achieving viral load suppression. Other relevant findings including trends and regional analyses are explained through the following pages. The HIVQUAL performance indicators analyzed were developed under advisement of the HIVQUAL-US National Clinical Advisory Committee. Every two years, these indicators are reviewed and adjusted to reflect the latest advances and developments in HIV care. The data are collected from grantees committed to measuring and improving the quality of services that each provides and voluntarily submitting data to contribute to the national benchmarking report. Although average scores have already been shared through the HIVQUAL-US Benchmarking Report, this publication is intended to add perspective and put into context the scores for the reader. By adding demographic analyses, as well as regional trends, the program aims to assist grantees to better target quality improvement efforts. Additionally, regional trends can also help shape not only individual QI efforts but also coordinated efforts that can ultimately help improve care in each clinic, city, state and as a result, overall HIV care for Ryan White Program patients across the nation. 1 Viral loads 400 copies/ml. 9

10 HIVQUAL-US PROGRAM BACKGROUND HIVQUAL-US (HQ-US) has been funded by the Health Resources and Services Administration s HIV/AIDS Bureau (HRSA/HAB) since 1995 to provide resources and support to Ryan White (RW) Program Part C and or Part D grantees to develop integrated quality management (QM) programs and implement ongoing performance measurement so that they can carry out quality improvement (QI) activities. The goals of HIVQUAL (HQ) are to enhance grantees capacity for adopting and sustaining quality management systems, enhance capability to monitor and measure performance, and to improve quality of care for all people living with HIV/AIDS (PLWHA). Spearheaded by the New York State Department of Health (NYSDOH) AIDS Institute, HIVQUAL-US has developed a variety of program materials, tools, and activities to support these quality improvement goals. This technical assistance is provided by a team of consultants experienced in improvement methodologies who provide each grantee with coaching, technical support and assistance, and expertise tailored to the grantee s QI goals and stage of quality improvement. Additional components of the HIVQUAL-US program that benefit grantees include the HIVQUAL software for performance measurement, online resources, and training materials. Other activities, such as regional peer learning groups and a national clinical advisory committee, facilitate communication and dissemination of information among grantees, HAB, and HIVQUAL-US. The ultimate goal of HIVQUAL-US is to support the development of sustainable grantee-based and regional quality management programs that promote chronic disease management for HIV care. Among the 450 grantees funded by Part C/D in 2007/2008, 62.2% (280) participated in HIVQUAL-US through at least one of its various services. This high rate reflects the success of HIVQUAL-US in engaging grantees in quality management of HIV care in the Ryan White Program. 10

11 Sample Inclusion Criteria METHODOLOGY In 2007, patients receiving care in all Ryan White Part C and/or Part D funded grantees participating in HIVQUAL-US who had at least one clinical visit in the first and last six months of the review period from 1/1/2007 to 12/31/2007 were eligible for inclusion in the final sample. All patients who were 14 or older were included in the analysis. Randomized samples were automatically generated using the randomizer tool in the HIVQUAL software or a web-based random number generator. The randomized samples consist of the minimum number of patients needed based on the total eligible population at the clinic to achieve 90% confidence interval for each indicator of +/- 10%. Clinics with the ability to review larger samples were encouraged to do so. Data Collection/Sampling Methodology Participation in HIVQUAL-US data submission is voluntary and is not a condition for access to or use of HIVQUAL-US quality improvement resources and services. Facilities utilizing HIVQUAL-US software are able to immediately generate data reports to monitor the progress of existing quality management projects and to identify potential areas for improvement. Development of Indicators and Indicator Definitions Indicators for the measurement of quality of care provided by HIV ambulatory care services were developed and refined by the National Project Clinical Advisory Committee, which consists of HIV providers from clinics across the United States. Initially, indicators were developed by formal group decision-making methods, beginning with a nominal group technique (NGT) process. A modified Delphi process was conducted to refine the indicators and specify review criteria. The Advisory Committee is routinely convened to review and revise selected indicators based on changes in clinical guidelines and experience in the field concerning the validity of the measures and their relevance to care. Members were recruited among HIVQUAL-US program participants to reflect the geographic distribution of clinical providers. The indicator subcommittee was chaired by Dr. Steven Johnson from the University of Colorado. 11

12 Analysis a) Definition of Clinics versus Grantees Recipients of Ryan White Part C/D funds are designated as grantees. Some HRSA/HAB grantees may have multiple clinics that provide HIV care. In the HIVQUAL-US performance data, some clinics under the same grantee may submit data separately, while in other cases, a grantee is only a single clinic. In this report, data were analyzed at the clinic level. The 168 clinics included in this report represented a total of 93 HRSA/HAB grantees. b) Core vs. Optional Indicators Participating grantees were required to submit patient data for the review period (1/1/ /31/2007) for all core indicators defined by the advisory group. All core performance indicators were measured as a categorical response Yes/No. Patients with missing information were counted as not having received that service ( No ). Since grantees were also required to report on new pilot indicators, these pilot indicators were scored in the same manner as core indicators, with missing data scored as a No. HIVQUAL-US also includes some indicators that are designated as optional. Only patients receiving care from grantees that explicitly chose to report on optional indicators were included in the denominator for the optional measures. c) Definition of Eligible Trimesters A number of performance indicators measure whether appropriate services were delivered to or received by the patient during specified four month periods in the review year, hereafter referred to as trimesters. Trimesters include January-April, May- August, and September-December. A trimester is deemed eligible depending on the patient eligibility status during that trimester for each particular indicator. d) Summary Statistics for Each Performance Indicator Unadjusted Analysis A description of each indicator is provided to orient the reader to the population included in the denominator and the criteria for inclusion in the numerator. The following summary statistics are reported in the Findings sections: (1) Overall population mean = percentage of all eligible patients who received the indicated service 12

13 (2) Overall clinic level statistics: i. Clinic mean = the average of all clinic performance scores ii. Clinic median = the performance level which separates the top and bottom 50% of clinics iii. & 1. level = value above which only 10% of clinics performed (n=17 clinics) 2. level = value below which only 10% of clinics performed (n=17 clinics) 13

14 RYAN WHITE PROGRAM PART C/D GRANTEE PARTICIPATION IN HIVQUAL-US The geographic distribution of all HIVQUAL-US participating grantees 2 was compared to the overall distribution of all Part C/D funded grantees. Figure 1 shows a map of state participation rates, defined as the total number of Part C/D clinics participating in HIVQUAL in each state, divided by the total number of Part C/D clinics in that state. Rates of HIVQUAL-US participation were highest in California, Puerto Rico, the Great Lakes region, and Southeastern US. At the national level, similar participation rates were observed among both Part C (62.8% of 360 grantees) and Part D (60.0% of 90 grantees) grantees overall. The distribution of HIVQUAL participating grantees compared with non-participating grantees by US Census regions 3 is shown below (Table 1). The highest numbers of participating grantees were located in the South and the Northeast, with a relatively higher percent in the Northeast and Puerto Rico compared with non-participating grantees. Table 1: Comparison of participating versus non-participating Part C/D funded grantees by Census region. HIVQUAL Participant (n=280) Non-Participant (n=170) Total RW Part C/D funded grantees (N=450) Northeast % % % West % % % Midwest % % % South % % % Puerto Rico % 0 0.0% % Virgin Islands 0 0.0% 3 1.8% 3 0.6% Total % % % 2 Includes grantees that did and did not submit data to HIVQUAL-US in Census regions: Northeast (ME, NH, VT, MA, RI, CT, NY, PA, NJ); West (WA, OR, ID, MT, WY, CO, UT, NV, CA, AZ, NM, AK, HI); Midwest (ND, SD, NE, KS, MO, IA, MN, WI, IL, IN, MI, OH); South (VA, MD, DC, DE, WV, NC, SC, GA, FL, AL, MS, TN, KY, LA, AR, OK, TX); Puerto Rico; and US Virgin Islands. 14

15 Figure 1: Geographic distribution of all Ryan White Program Part C/D supported HRSA grantees in the United States and HIVQUAL participation status, by type of Ryan White Program funding (Part C, Part D, Part C & D). State shading illustrates HIVQUAL participation rates with darker shading indicating higher state rates of participation. 4 4 State rates calculated based on number of grantees participating in HIVQUAL or submitting performance data to HIVQUAL divided by the total number of Part C/Part D funded grantees in the state 15

16 DESCRIPTION OF THE 2008 DATA SUBMISSION FOR 2007 CARE In 2008, HIVQUAL-US received year 2007 performance data submissions from 168 clinics representing 93 Ryan White Part C and/or Part D grantees. Patients age 14 and over with at least one clinical visit in the first six months and last six months of 2007 were eligible for inclusion. A total of 10,005 patients receiving care from these participating clinics were included in this report. DESCRIPTION OF CLINICS SUBMITTING 2007 CARE DATA IN 2008 Ryan White Program Funding The majority of participating clinics that submitted 2007 performance data were from grantees that received Ryan White Part C funds (88.1%), while 3.0% were from grantees that received Part D but no Part C funds, and 8.9% from grantees that received both types of funding (Table 2). The percent of clinics submitting data that received Part C funding was slightly higher than the proportion of Part C recipients among the total Part C/Part D funded grantees nationally (88% versus 80% across the Ryan White Program). Table 2: Distribution of clinics who submitted data by funding type Ryan White Funding Number of Clinics Percent of Clinics that Submitted HQ-US Data RW Part C funding % RW Part D funding 5 3.0% RW Part C and D funding % Total % Geographic Distribution Using US Census regions, we categorized clinics by geographic location. New York was separated out from the rest of the Northeast region since submission of HIVQUAL performance data is mandatory for Part C/D grantees in the state. New York State constituted the largest proportion (41.7%) 5 of all submissions, followed by the West (21.4%), the South (19.6%), the 5 New York (NY) State is separated out because all Part C/D funded grantees in NY submit data to the NYS Department of Health AIDS Institute using the HIVQUAL process. If NY was included in the Northeast Census region or PHS region 2, then it would artificially inflate the percent of clinics represented by these areas when making geographic comparisons. 16

17 Northeast (3.6%) and the Midwest (2.4%). Eleven percent or 19 clinics were in Puerto Rico. A similar distribution was found when analyzed by grantee (Table 3). Table 3: Distribution by US Census region of participation by clinic and by grantee submitting data to HQ-US in 2008 US Census Region Number of Participating Clinics Percent of Participating Clinics Number of Participating Grantees Percent of Participating Grantees Northeast (no NY) 6 3.6% 6 1.1% New York % % West % % Midwest 4 2.4% 4 4.3% South % % Puerto Rico % 3 3.2% Total % % Similar results were seen using the Public Health Service (PHS) regions which group states into 10 geographic regions (Table 4). Again, New York State was separated out from PHS region 2. Nearly half (41.7%) of clinics that submitted 2007 patient data in 2008 were located in New York, 6 and 11.3% were from other states in PHS region 2. One-fifth (19.6%) of clinics were from PHS region 9 and 13.7% of clinics were from PHS region 4. The PHS region with the smallest percent of data submissions was PHS region 8. There were no submissions from PHS region 7. The distribution of HAB grantees was similar to that of clinics across the PHS regions. Table 4: Distribution by PHS Region of participation by clinic and by grantee submitting data to HQ-US in 2008 PHS Region Number of Clinics Percent of Clinics Number of Grantees Percent of Grantees 1 (ME, NH, VT, MA, RI, CT) 2 1.2% 2 2.2% 2 (NJ, PR, excluding NY) % 4 4.3% New York % % 3 (PA, MD, DE, VA, WV) 8 4.8% 6 6.5% 4 (KY, TN, NC, SC, GA, FL, AL, MS) % % 5 (MN, WI, IL, IN, MI, OH) 4 2.4% 4 4.3% 6 (NM, TX, OK, AR, LA) 6 3.6% 3 3.2% 7 (NE, KS, IA, MO) (MT, ND, SD, WY, CO, UT) 1 0.6% 1 1.1% 9 (NV, CA, AZ, HI) % % 6 Since the New York state HIV quality program requires all clinics to submit performance measurement data utilizing the HQ-US submission system, all Part C/D supported clinics in New York were included in the analyses, resulting in a high proportion of participating clinics from PHS region 2. 17

18 10 (WA, OR, ID, AK) 2 1.2% 2 2.2% Total % % CHARACTERISTICS OF PATIENTS INCLUDED IN 2008 SUBMISSION Gender, Age, and Race/Ethnicity OF 2007 DATA Nearly one-half (47.5%) of patients were female, 51.9% were male and 0.5% were transgender (Table 5). Sixty-eight percent of patients were between ages 25 and 49 years, 27.9% were 50 years and older, and 4.3% were under 25 years. Nearly half of patients (44.5%) were Black non- Hispanic, 31.3% were Hispanic/Latino, and 19.9% were White non-hispanic (Table 5). Small demographic differences were observed between the patient sample represented in the 2007 HIVQUAL-US care data and patients receiving care at all RW Program Part C/Dsupported clinics nationally, as reported in the 2006 RW Program annual data summary. 7 These included a lower percent of men (HQ, 51.9% versus RW, 66%), and higher percent of minorities (HQ, 78.3% versus RW, 69%) and patients years old (HQ, 67.8% versus RW, 48%). Table 5: Demographics of patients in the 2007 HIVQUAL-US care data submitted in Characteristic Number Percent Total patients reported 10, % Gender Age Race/Ethnicity Female % Male % Transgender/Other % Age < % Age % Age % White, non Hispanic/Latino % Black, non Hispanic/Latino % Hispanic/Latino % Other* % Missing race/ethnicity % *Other includes Asian, American Indian/Alaska Native, Native Hawaiian/Other Pacific Islander, Other self-identified race. Missing includes unknown or missing. 7 Health Resources and Services Administration, HIV/AIDS Bureau. Ryan White HIV/AIDS Program: Annual Data Summary (2006). Available for order at: 18

19 HIV Transmission Risk HIV transmission risk information is also reported by clinics submitting HIVQUAL-US performance data. Table 6 shows the number and percent of patients that fall into each risk category. Fifty-four percent of patients in the 2007 care data reported only heterosexual transmission risk, 23.7% reported only men who have sex with men (MSM) risk, and 8.4% reported only injection drug use (IDU) risk. Some patients had multiple risk factors, such as MSM and IDU or heterosexual and IDU. Among all patients, 24.8% had any documented MSM risk and 13.9% had any IDU risk (Table 7). Almost 60% of patients had any documented heterosexual risk. Hemophilia coagulation disorder, perinatal transmission, and transfusion/blood product related transmissions accounted for less than 1% each of the total sample. Table 6: Risk factors for patients included in the 2008 HIVQUAL-US data submission Risk Factor Number of Patients Percent Heterosexual only % MSM only % IDU only % Unknown % Heterosexual & IDU % MSM & IDU % Other % Perinatal Transmission % Transfusion/Blood Components % Hemophilia/Coagulation Disorder % Total 10, % Table 7: Documented HIV risk* for patients included in 2008 HIVQUAL-US data submission based on any MSM, any IDU and any heterosexual risk Number of Patients Percent N=10,005 Any MSM Risk % Any IDU Risk % Any Heterosexual % *Above categories not mutually exclusive, i.e., clients may have multiple risk factors. Number of patients does not add up to the total sample, as not all patients possessed these baseline risk factors. 19

20 Distribution of Patients by Ryan White Funding and Geography Eighty-five percent of patients received care at clinics that were Part C funded, 3.1% of patients received care at Part D-funded clinics, and 11.7% of patients received care at clinics that were both Part C and D funded (Figure 2). In terms of US Census regions, 47.5% of patients reviewed were from New York State, and 4.4% were from other states in the Northeast region. Twentytwo percent of patients were from the South, 19.7% were from the West, and the remainder were from Puerto Rico and the Midwest (Figure 3). With respect to HRSA Public Health Service regions, nearly half (47.5%) of patients came from New York State, 17.3% came from PHS 9 (NV, AZ, HI, CA), and 14.1% came from PHS 4 (KY, TN, NC, SC, GA, FL, AL, MS) (Table 8). No large differences were found in the distribution of patients for whom data were submitted compared to clinics that submitted HIVQUAL performance data (Tables 2-4) in terms of RW funding or geography. Figure 2: Percentage of patients by Ryan White funding (N=10,005). Parts C and D, 11.7% Part D, 3.1% Part C, 85.2% Figure 3. Percentage of patients by US Census region (N=10,005). Midwest, 2.3% New York, 47.5% West, 19.7% South, 22.0% Northeast (no NY), 4.4% Puerto Rico, 4.1% 20

21 Table 8: Distribution of patients by HRSA PHS Region (N=10,005). PHS Region Percent of Patients 1 (ME, NH, VT, MA, RI, CT) 1.0% 2 (NJ, PR, excluding NY) 4.1% New York 47.5% 3 (PA, MD, DE, VA, WV) 6.4% 4 (KY, TN, NC, SC, GA, FL, AL, MS) 14.1% 5 (MN, WI, IL, IN, MI, OH) 3.3% 6 (NM, TX, OK, AR, LA) 4.9% 7 (NE, KS, IA, MO) 0.0% 8 (MT, ND, SD, WY, CO, UT) 0.6% 9 (NV, CA, AZ, HI) 17.3% 10 (WA, OR, ID, AK) 1.7% Total 100.0% Insurance Type Of the 10,005 patients included in the sample, 63.3% had missing or unknown payer information. Therefore, these analyses were not done. 21

22 RESULTS: 2007 PERFORMANCE INDICATORS ENGAGEMENT IN CARE INDICATOR Population: Definition: Findings: Clinical Visits (CORE) All HIV+ patients. All HIV+ patients who had a clinical visit 8 in each eligible trimester during the review year. 9 A total of 10,005 patients were included in this population. Of these, 8,242 (82.4%) had a clinical visit every four months in the review period. The average clinic rate was 82.8% (median clinic rate: 83.5%), with the lowest 10% performing clinics reporting rates of <68.7% and the highest 10% performing clinics reporting rates of 97.1%. Due to the change in eligibility criteria, only patients with at least one clinical visit in the first six and last six months of the review year were included. Thus, 100% of patients in the study population had a clinical visit every 6 months. % of patients with a clinical visit every eligible trimester 97.1% (n = 168) 68.7% 82.8% 8 A clinical visit is an encounter between a patient and a health care provider (also referred to as a medical HIV primary care visit). 9 If there is confirmation that a patient had expired, relocated, or been incarcerated in a particular trimester, then that trimester is not considered eligible. 22

23 HIV SPECIFIC INDICATORS Population: Definition: Findings: ARV Therapy (CORE) All HIV+ patients eligible for antiretroviral (ARV) therapy, where eligible is defined as having any CD4 count <350 cells/mm 3 or any viral load >100,000 copies/ml during the review year. Patients already on ARV therapy were counted as eligible. All HIV+ patients eligible for ARV who were on ARV therapy during every eligible trimester of the review period. A total of 9,173 patients were eligible for antiretroviral therapy (ART) and were included in the population for this indicator. Of these, 7,781 (84.8%) were ever on ART in every eligible trimester during the review period. The average clinic rate was 84.9% (median clinic rate: 87.5%), with the lowest 10% performing clinics reporting rates of <70.9% and the highest 10% performing clinics reporting rates of 100.0%. Among these 9,173 patients eligible for antiretroviral therapy, 92.8% (8,515) were ever on ART during the review period. Among the 2,041 patients with any CD4 <200 cells/mm 3, 95.0% were ever on ART. Among the 938 patients with any VL >100,000 copies/ml, 83.4% were ever on ART. Among these 9,173 patients eligible for antiretroviral therapy, 91.3% (8,375) were ever on highly active antiretroviral therapy (HAART) 10 during the review period. Among the 2,041 patients with any CD4 <200 cells/mm 3, 93.7% were ever on HAART. Among the 938 patients with any VL >100,000 copies/ml, 82.2% were ever on HAART. % of patients on ART in every eligible trimester during the review period (n=168) 70.9% 100.0% 84.9% 10 On HAART is defined as being on three or more antiretroviral drugs or on an equivalent combination therapy at anytime during the review year. On ART is defined as being on any antiretroviral drug during the review year. 23

24 HIV SPECIFIC INDICATORS Population: Definition: Findings: HIV Monitoring (CORE) All HIV+ patients. All HIV+ patients should receive a CD4 count in every eligible trimester. All HIV+ patients should receive a viral load test in every eligible trimester. A total of 10,005 patients were included in the population. Of these, 6,349 (63.5%) had a documented CD4 count in each eligible trimester during the review period. The average clinic rate was 63.4% (median clinic rate: 64.4%), with the lowest 10% performing clinics reporting rates of <38.5% and the highest 10% performing clinics reporting rates of 85.7%. Among the 10,005 patients, 6,314 (63.1%) had a documented viral load test in each eligible trimester during the review period. The average clinic rate was 61.7% (median clinic rate: 62.7%), with the lowest 10% performing clinics reporting rates of <38.4% and the highest 10% performing clinics reporting rates of 83.6%. Using a criteria of monitoring every six months, among the 10,005 patients: 87.8% (8,786) had both a viral load test and CD4 in every six month period. The average clinic rate was 85.6% (median clinic rate: 88.5%), with the lowest 10% of performing clinics reporting rates of 68.2% and the highest 10% of performing clinics reporting rates of 97.9%. 92.1% (9,216) had either a viral load test or a CD4 count in every six month period. The average clinic rate was 90.4% (median clinic rate: 93.0%), with the lowest 10% of performing clinics reporting rates of 79.2% and the highest 10% of performing clinics reporting rates of 100.0%. % of patients with CD4 count every eligible trimester 85.7% (n = 168) 63.4% 38.5% 24

25 % of patients with a viral load test every eligible trimester 83.6% (n = 168) 61.7% 38.4% % of patients with a CD4 count and viral load test every 6 months 97.9% (n=168) 68.2% 85.6% % of patients with a CD4 count or viral load test every 6 months 100.0% (n=168) 79.2% 90.4% 25

26 HIV SPECIFIC INDICATORS Population: Definition: Findings: ARV Therapy Management (CORE) All HIV+ patients ever on ARV therapy during the review year. All HIV+ patients ever on ARV therapy during the review year who were managed appropriately according to their clinical status in every eligible trimester. 11 A total of 8,515 patients were ever on ARV therapy during the review year and were included in the population. Of these, 4,840 (56.8%) were managed appropriately according to their clinical status in every eligible trimester. The average clinic rate was 53.9% (median clinic rate: 54.1%), with the lowest 10% performing clinics reporting rates of <28.0% and the highest 10% performing clinics reporting rates of 75.9%. Among the 5,421 patients who were clinically stable in every eligible trimester, 75.1% were appropriately managed in all those trimesters (receiving a viral load test every 4 months). The average clinic rate was 73.1% (median clinic rate: 76.3%), with the lowest 10% performing clinics reporting rates of <44.0% and the highest 10% performing clinics reporting rates of 100.0%. Among the 431 patients who were unstable in every eligible trimester, 53.6% were appropriately managed in all trimesters (change in ARV therapy and a viral load test within 8 weeks of being categorized unstable, OR written justification if there is no change in ARV therapy or discontinuation of therapy). The average clinic rate was 48.4% (median clinic rate: 50.0%), with the lowest 10% performing clinics reporting rates of 0.0% and the highest 10% performing clinics reporting rates of 100.0%. There were less than 50 patients who were clinically defined as late stage in every eligible trimester. Of these, 90.2% were appropriately managed in all those trimesters (clinical follow-up visit in every trimester). Due to small numbers, clinic rates were unstable and thus are not reported. 11 Patient clinical status is determined and confirmed by the provider. The following guidelines are used: Stable is defined as having an undetectable viral load or a VL that dropped by > 1 log since last trimester, or increased by <3x from lowest value in last 12 months and the provider deemed the patient clinically stable in the patient record. Unstable is defined has having a VL that increased by more that 1 log and >1000 in the last trimester, having a CD4 count that dropped by >50% since last trimester, having an opportunistic infection (OI) in the last trimester, and having the provider deem the patient clinically unstable in the patient record. Late stage is defined as meeting the criteria for instability, but the clinician determines that the patient has no other therapeutic options available. 26

27 % of patients on ARV managed appropriately according to their clinical stability status in all trimesters 75.9% (n=168) 53.9% 28.0% % of patients on ARV and clinically stable throughout the review period who were managed appropriately in all trimesters (n=168) 73.1% 100.0% 44.0% % of patients on ARV and clinically unstable throughout the review period who were managed appropriately in all trimesters 100.0% (n=118) 48.4% 0.0% 27

28 HIV SPECIFIC INDICATORS Population: Definition: Findings: Adherence Assessment (CORE) All HIV+ patients ever on ARV therapy in each eligible trimester during the review year. All HIV+ patients ever on ART therapy in each eligible trimester during the review year who had adherence quantitatively assessed in every eligible trimester. A total of 7,781 patients were ever on ARV therapy in every eligible trimester during the review year and were included in this population. Of these, 3,663 (47.1%) had adherence quantitatively assessed during each eligible trimester they were on ARV therapy. The average clinic rate was 47.6% (median clinic rate: 52.5%), with the lowest 10% performing clinics reporting rates of 0.0% and the highest 10% performing clinics reporting rates of 90.4%. Of those patients ever on ARV therapy during the review year (n=8,515), 22.4% (1,911) had an adherence problem identified in at least one trimester of the review period. Among patients ever on ARV therapy who had an adherence problem identified (N=1,911), 95.5% (1,824) had documentation that the adherence problem was addressed by a provider. % of patients who received ART adherence assessment in every eligible trimester on ART 90.4% (n = 168) 47.6% 0.0% 28

29 HIV SPECIFIC INDICATORS Population: Definition: Findings: PCP Prophylaxis (CORE) All HIV+ patients with lowest CD4 <200 cells/mm 3 in the review year who did not have a rebound in CD4 >200 cells/mm 3 for >6 months. All HIV+ patients with CD4 count <200 cells/mm 3 during the review year who did not have a rebound in CD4 >200 cells/mm 3 for >6 months who were on PCP prophylaxis. A total of 1,574 patients with a CD4 count <200 cells/mm 3 during the review period who did not have a rebound >200 cells/mm 3 for 6 months were included in this population. Of these, 1,362 (86.5%) received PCP prophylaxis during the review period. The average clinic rate was 86.0% (median clinic rate: 92.3%) with the lowest 10% performing clinics reporting rates of 61.3% and the top 10% performing clinics reporting rates of 100.0%. % of patients with lowest CD4<200 who received PCP prophylaxis 100.0% (n = 160) 86.0% 61.3% 29

30 HIV SPECIFIC INDICATORS Population: Definition: Findings: HIV Specialist Care (CORE) All HIV+ patients. All HIV+ patients should have a clinical visit with an HIV specialist in all eligible trimesters. A total of 10,005 patients were included in this population. Of these, 7,567 (75.6%) had a clinical visit with an HIV specialist every four months. The average clinic rate was 73.9% (median clinic rate: 80.5%) with the lowest 10% performing clinics reporting <42.9% and the top 10% performing clinics reporting 94.4%. % patients with a clinical visit with an HIV specialist every eligible trimester (n=168) 94.4% 73.9% 42.9% 30

31 HIV SPECIFIC INDICATORS Population: Definition: Findings: Viral Suppression Rates (CORE) All HIV+ patients ever on ARV therapy in year. All HIV+ patients ever on ARV therapy who always maintained viral suppression (VL 400 copies/ml) throughout the review period. All HIV+ patients ever on ARV therapy whose last viral load test result was <400 copies/ml. A total of 8,515 patients were ever on ARV therapy during the review year and were included in this population. Of these, 4,900 (57.6%) always maintained viral suppression during the year, with all viral loads 400 copies/ml. The average clinic rate was 56.2% (median clinic rate: 58.8%) with the lowest 10% performing clinics reporting rates of 33.3% and the top 10% performing clinics reporting rates of 75.0%. Because patients newly entering the clinic would be more likely to have an initial unsuppressed viral load if just initiating ARV therapy, we also looked at the subpopulation of 8,008 patients ever on ARV therapy who were not newly seen in the clinic in Of these, 4,742 (59.2%) always maintained viral suppression during the year, with all viral loads 400 copies/ml. The average clinic rate was 58.0% (median clinic rate: 60.8%) with the lowest 10% performing clinics reporting rates of 34.1% and the top 10% performing clinics reporting rates of 76.9%. Of the 8,515 patients ever on ARV therapy during the review year, 6,379 (74.9%) had their last viral load in the year 400 copies/ml. The average clinic rate was 73.2% (median clinic rate: 76.5%), with the lowest 10% performing clinics reporting rates of 51.1% and the top 10% performing clinics reporting rates of 90.0%. % of patients ever on ART who always had VL % (n=168) 56.2% 33.3% 31

32 % of patients ever on ART who always had VL 400 (excluding new patients in 2007) 76.9% (n=168) 58.0% 34.1% % of patients ever on ART who had a last VL % (n=168) 73.2% 51.1% 32

33 SCREENING INDICATORS Population: Definition: Findings: Mental Health Screening (CORE) All HIV+ patients. All HIV+ patients with documented mental health screening during the past 12 months. To meet this indicator, a patient needs to have received all specified components, including screening for cognitive function, depression, anxiety, sleeping habits, appetite, domestic violence and post traumatic stress disorder. A total of 10,005 patients were included in this population. Of these, 3,280 (32.8%) received all seven components of mental health screening during the past 12 months. The average clinic rate was 37.9% (median clinic rate: 20.9%) with the lowest 10% performing clinics reporting rates of 0.0% and the top 10% performing clinics reporting rates of 100.0%. Of the 10,005 patients, 29.1% (2,710) had a mental health need identified. Of patients with a need identified, 36.0% (975) were currently receiving mental health care, 55.7% (1,508) received a referral for mental health services, and 8.3% (227) did not receive a referral. Of the 1,508 patients who received a referral, 72.8% (1,098) kept their appointment within 30 days of receiving the referral. % of patients who received all required components of mental health screen 100.0% (n = 168) 37.9% 0.0% 33

34 % of patients who received each type of mental health screen 100% 90% 80% 70% 60% 50% 64.7% 73.2% 64.0% 60.7% 67.1% 52.9% 41.1% 40% 30% 20% 10% 0% cognitive function depression anxiety sleep appetite domestic violence PTSD 34

35 SCREENING INDICATORS Population: Definition: Findings: Substance Use Screening (CORE) All HIV+ patients, except those receiving care at drug treatment centers. All HIV+ patients who were screened for the use of illicit substances and alcohol during the past 12 months. A total of 9,817 patients were included in this population. Of these, 7,711 (78.6%) had substance use screening and discussion with a provider during the past 12 months. The average clinic rate was 79.7% (median clinic rate: 90.1%) with the lowest 10% performing clinics reporting rates of 37.7% and the top 10% performing clinics reporting rates of 100.0%. Among patients with discussion of substance use, 23.1% (1,778) were current users, 17.4% (1,339) were past users, 57.5% (4,437) never used, and 2.0% (157) did not have documentation of use status. Of the 1,778 patients who were current users, 26.7% (475) were currently in treatment. Among 1,303 current users who were not in treatment, 9.3% (121) were referred for services, 64.5% (840) had discussion but no referral documented, and 12.3% (160) received no referral. Another 14.0% (182) of patients had missing information on referrals. Of the 2,106 patients who had no documented receipt of substance use screening or discussion, 15.6% (329) were identified as having either substance use risk at baseline or had IDU transmission risk. % of patients with whom substance use was discussed 100.0% (n = 165) 79.7% 37.7% 35

36 SCREENING INDICATORS Population: Definition: Findings: Tuberculosis (TB) Screening (CORE) All HIV+ patients with no history of TB or positive PPD. All HIV+ patients with no history of TB or positive PPD who had documentation of a PPD planted and results read during the past 24 months. 12 A total of 8,723 patients had no prior history of TB or positive PPD. Of these, 5,798 (66.5%) had a PPD planted and read during the past 24 months. The average clinic PPD completion rate was 69.7% (median clinic rate: 75.1%) with the lowest 10% of performing clinics reporting rates of 33.3% and the top 10% of performing clinics reporting rates of 100.0%. Of those patients who were screened with results documented, 147 (2.5%) had a positive PPD test. % of patients with TB test completed during the past 24 months (n=168) 69.7% 100.0% 33.3% 12 Note that the timeframe changed from 12 months to 24 months in Patients without known positive PPD or who were not on TB treatment were eligible. 36

37 SCREENING INDICATORS Syphilis Screening (CORE) Population: All HIV+ patients. 13 Definition: All HIV+ patients who were screened for syphilis during the past 12 months. Findings: A total of 10,005 patients were included in this population. Of these, 7,930 (79.3%) were screened for syphilis during the review period. The average clinic screening rate was 79.5% (median clinic rate: 84.5%) with the lowest 10% performing clinics reporting rates of 50.0% and the top 10% performing clinics reporting rates of 100.0%. The results of syphilis screening were not collected in % of patients (male and female) who received serum syphilis screening 100.0% (n = 168) 79.5% 50.0% 13 Male and female patients were included in this indicator. 37

38 SCREENING INDICATORS Population: Definition: Findings: Hepatitis C Screening (CORE) All HIV+ patients. All HIV+ patients who have documentation of their hepatitis C virus (HCV) status. If a patient is HCV negative, screening should be repeated every 5 years. A total of 10,005 patients were included in this population. Of these, 8,966 (89.6%) had documentation of known HCV status. The average clinic rate was 89.6% (median clinic rate: 96.7%) with the lowest 10% performing clinics reporting rates of 64.3% and the top 10% performing clinics reporting rates of 100.0%. Of those with known HCV status, 22.2% (1,993) were positive. Of those with known HCV status, 77.8% (6,973) were negative. Of those negative, 77.9% (5,434) were tested in past 5 years. % of patients with known hepatitis C serostatus (positive or negative) (n = 168) 100.0% 89.6% 64.3% 38

39 SCREENING INDICATORS Population: Definition: Findings: Lipid Screening (CORE) All HIV+ patients on ARV therapy at any time during review period. All HIV+ patients on ARV therapy at any time during review period that have documentation of lipid screening during the past 12 months. A total of 8,515 patients were on ARV therapy at any time during the review period. Of these, 7,088 (83.2%) received a lipid screen during the review year. The average clinic screening rate was 85.3% (median clinic rate: 90.5%) with the lowest 10% performing clinics reporting rates of 62.3% and the top 10% performing clinics reporting rates of 100.0%. % of patients on ART who had lipid profile ( n = 168) 100.0% 85.3% 62.3% 39

40 SCREENING INDICATORS Population: Definition: Findings: Colonoscopy (OPTIONAL) All HIV+ patients receiving care from facilities that elected to report on this indicator. 14 All HIV+ patients 50 years of age or older who have documentation of being screened for colon cancer by colonoscopy within the past ten years. Among the 196 patients age 50 and over who received care from facilities that elected to report on this indicator, 78 (39.8%) had documentation of a colonoscopy within the past ten years. The average clinic rate was 23.6% (median clinic rate: 16.7%) with the lowest 10% performing clinics reporting rates of 0.0% and the top 10% performing clinics reporting rates of 45.5%. Of the 161 patients from clinics that elected to report on this indicator who were between the ages of 50 and 60 years old, 36.7% were screened for colon cancer. The average clinic rate was 21.3% (median clinic rate: 12.9%) with the lowest 10% of performing clinics reporting rates of 0.0% and the top 10% of performing clinics reporting rates of 42.9%. Of the 35 patients from clinics that elected to report on this indicator who were age 60 years or over, 54.3% had colon cancer screening. The average clinic rate was 33.3% (median clinic rate: 45.0%) with the lowest 10% of performing clinics reporting rates of 0.0% and the top 10% of performing clinics reporting rates of 55.6%. % of patients age 50 and over who received a colonoscopy 45.5% (n=11) 23.6% 0.0% 14 Patients with missing information were excluded from the population because this was an optional indicator. 40