WCHQ Ambulatory Measures NOTE: s of Tobacco Non-Use and Daily Aspirin or Other Anticoagulant will be added to the Measure in 2014. A1C Blood Sugar A1C Blood Sugar Kidney Function Monitored Blood Pressure Inclusions/ Gestational Diabetes (code 648.8) is Two or more A1c tests within the MP. One A1C test and No A1C tests are also measured in the final result. Most recent A1c blood sugar level controlled to less than 8.0% results in Good. Fair to Poor (>=8.0% and <=9.0%), Uncontrolled (>9.0%), and Not Tested are also included in the final results. One LDL test within the MP. No LDL is also measured in the final result. Most recent LDL during the MP is less than 100 mg/dl resulting in Good. Fair to Poor, Uncontrolled, and Not Tested are also include in the final results. Patient has one of the following documented within the MP or within an active ICD-9 code based Problem List: Microalbuminuria or Positive Gross Proteinuria Test Evidence of Diagnosis or Treatment for Nephropathy A visit to a Nephrologist controlled at less than 140/90 mmhg. Test was conducted but the result for any reason, outcome = Tested, Uncontrolled. Trace or Negative Gross Proteinuria results
All or None Process Measure: Optimal All or None Outcome Measure: Optimal Uncomplicated Essential Hypertension Blood Pressure Ischemic Vascular Disease Care Ischemic Vascular Disease Care Patients with uncomplicated essential hypertension 18-85 years of age and alive as of the last day of the MP Pts with Coronary Artery Disease (CAD) or a CAD Risk- Equivalent Condition & Patients with CAD or a CAD Risk-Equivalent Condition 18-75 years of age and alive as of the last day of the MP Inclusions/ A minimum of two hypertension (HTN) coded and one At least one diagnosis of HTN must be within the year prior to the MP or within the first six months of the MP to provide opportunity to establish control. Patients with two diagnoses of Diabetes or one diagnosis of CKD/ESRD or CHF within the prior 24 months OR those with a single, active ICD-9 based Problem List diagnosis are excluded from the denominator A minimum of two CAD or CAD Risk-Equivalent Condition coded office visits OR one Acute Coronary Event (AMI, PCI, CABG) from a hospital visit and must be seen by a PCP / and one A minimum of two CAD or CAD Risk-Equivalent Condition coded office visits OR one Acute Coronary Event (AMI, PCI, CABG) from a hospital visit and must be seen by a PCP / and one Two A1C tests, One LDL test, One kidney function test and/or diagnosis and treatment of kidney disease All of the above are during the time period specified by the measure Most recent A1C is less than 8.0%, Most recent LDL is less than 100 mg/dl, Most recent BP is less than 140/90 mm Hg controlled at less than 140/90 mmhg. One LDL test within the MP. No LDL is also measured in the final result. Most recent LDL during the MP is less than 100 mg/dl resulting in Good. Fair to Poor, Uncontrolled, and Not Tested are also include in the final results. Test was conducted but the result for any reason, outcome = Tested, Uncontrolled.
Ischemic Vascular Disease Care Daily Aspirin or antiplatelet medication usage Ischemic Vascular Disease Care Blood Pressure Screening for CKD I, II and III Annnual egfr (Estimated Glomerular Filtration Rate) test I, II and III Patients with CAD or a CAD Risk-Equivalent Condition 18-75 years of age and alive as of the last day of the MP Patients with CAD or a CAD Risk-Equivalent Condition 18-75 years of age and alive as of the last day of the MP diabetes or hypertension and alive as of the last day of the MP Stages I, II or III CKD or a Chronic Kidney Disorder and Stages I, II or III CKD or a Chronic Kidney Disorder and Inclusions/ A minimum of two CAD or CAD Risk-Equivalent Condition coded office visits OR one Acute Coronary Event (AMI, PCI, CABG) from a hospital visit and must be seen by a PCP / and one A minimum of two CAD or CAD Risk-Equivalent Condition coded office visits OR one Acute Coronary Event (AMI, PCI, CABG) from a hospital visit and must be seen by a PCP / and one A minimum of two diabetes or two hypertension coded office visits and must be seen by a PCP / Endocrinologist / Cardiologist months. Patients with a diagnosis of CKD or ESRD within the prior 24 months OR those with an active ICD-9 based Problem List diagnosis are A minimum of two CKD Stage I, II or III or two Chronic Kidney Disorder coded office visits and must be seen by a PCP / months. Patients with a diagnosis of CKD Stage IV, V or ESRD within the prior 24 months OR those with an active ICD-9 based Problem List diagnosis are excluded from the denominator. A minimum of two CKD Stage I, II or III or two Chronic Kidney Disorder coded office visits and must be seen by a PCP / months. Patients with a diag, of CKD Stage IV, V or ESRD within the prior 24 months OR those with an active ICD-9 based Problem List diag. are Documentation in the medical record of daily Aspirin or antiplatelet medication usage at the end of the MP controlled at less than 140/90 mmhg. one estimated Glomerular Filtration Rate (egfr) during the MP. one estimated Glomerular Filtration Rate (egfr) during the MP. One LDL test within the MP. No LDL is also measured in the final result. egfr result is not available because it for any reason egfr result is not available because it for any reason
I, II and III I, II and III Blood Pressure Annual Calcium Level Annual Phosphorus Level Stages I, II or III CKD or a Chronic Kidney Disorder and Stages I, II or III CKD or a Chronic Kidney Disorder and Inclusions/ A minimum of two CKD Stage I, II or III or two Chronic Kidney Disorder coded office visits and must be seen by a PCP / months. Patients with a diagnosis of CKD Stage IV, V or ESRD within the prior 24 months OR those with an active ICD-9 based Problem List diagnosis are excluded from the denominator. A minimum of two CKD Stage I, II or III or two Chronic Kidney Disorder coded office visits and must be seen by a PCP / months. Patients with a diagnosis of CKD Stage IV, V or ESRD within the prior 24 months OR those with an active ICD-9 based Problem List diagnosis are excluded from the denominator. Most recent LDL during the MP is less than 100 mg/dl resulting in Good. Fair to Poor, Uncontrolled, and Not Tested are also include in the final results. controlled at less than 130/80 mmhg. one Calcium Level during the MP. one Phosphorus Level during the MP. Test was conducted but the result for any reason, outcome = Tested, Uncontrolled.
Annual ipth Level Inclusions/ one ipth Level during the MP. Annual Lipid Profile one Lipid Profile during the MP. Annual egfr (Estimated Glomerular Filtration Rate) test one estimated Glomerular Filtration Rate (egfr) during the MP. egfr result is not available because it for any reason Annual Hemoglobin Test one hemoglobin test during the MP.
Blood Pressure Adults with Pneumococcal Vaccinations Screening for Osteoporosis Adult Tobacco Use Screening for Tobacco Use Adult Tobacco Use Tobacco User Receiving Cessation Advice Breast Cancer Screening Cervical Cancer Screening Patients greater than or equal to 65 years of age-alive as of the Female patients 65-85 years of age & years of age and alive as of the last day of the MP years of age, alive as of the last day of the MP and identified as a Tobacco User any time during the MP. 24 months Female patients 50-74 years of age 36 months Female patients 21-64 years of age Inclusions/ and one office visit in 24 months with a PCP regardless of diagnosis. and one office visit in 24 months with a PCP / OB-GYN regardless of diagnosis Patients with two office visits in 24 months and one office visit in with a PCP regardless of diagnosis Patients with two office visits in 24 months and one office visit in with a PCP regardless of diagnosis and one office visit in 24 months with a PCP / OB-GYN regardless of diagnosis. Patients with a history of unilateral or bilateral mastectomy or trans gender status prior to the end of the MP are and one office visit in 24 months with a PCP / OB-GYN regardless of diagnosis. Patients with a history of partial or total hysterectomy or trans gender status prior to the end of the MP are controlled at less than 140/90 mmhg. Patients who have received a pneumococcal vaccination prior to the end of the MP. Women who have had a bone densitometry test performed at age 60 or above or who have a diagnosis of osteoporosis or osteopenia prior to the end of the MP. Patients who had their tobacco status documented at a minimum of one encounter with any provider during the MP. Patients who received tobacco cessation intervention advice a minimum of one time with any provider during the MP, includes documentation of readiness to quit, cessation counseling offered, or pharmacologic therapy. Women who have had a mammogram or breast MRI performed during the MP. Women who have had a minimum of one cervical cancer screening (cytology) performed during the MP or for those ages 30-64 who want to lengthen the screening interval a combination of a cytology test and an HPV test. Non-Tobacco Users Breast Ultrasounds as a stand-alone test. Results with date of doc. only. Year or date of test must be present. Results with date of documentation only. Year or date of test must be present.
Colorectal Cancer Screening Patients age 50-75 years of age and alive as of the last day of the MP Inclusions/ and one office visit in 24 months with a PCP regardless of diagnosis. Patients with a history of total colectomy prior to the end of the MP are one colorectal cancer screening performed within the following timelines: FOBT = (MP) Flexible Sigmoidoscopy = 5 years CT Colonography = 5 years Colonoscopy = 10 years Results with date of documentation only. Year or date of test must be present. Screenings defined as a single specimen, such as that collected from a digital rectal exam. WCHQ Hospital Measures CABG Deep Sternal Wound Infection Society for Thoracic Surgeons (STS) Measure Period (MP) A deep sternal wound infection involves muscle, bone, and/or mediastinum. A patient must have all of the following conditions: 1. A wound that is opened with excision of tissue (I&D) 2. A positive culture 3. Treatment with antibiotics CABG Operative Mortality Society for Thoracic Surgeons (STS) Measure Operative mortality includes: 1. All deaths occurring during the hospitalization in which the operation was performed, even if after 30 days and 2. Deaths occurring after discharge from the hospital, but within 30 days of the procedure. CABG Post-Operative Permanent Stroke A post-operative permanent stroke is a central neurologic deficit that persists for more than 24 hours. Society for Thoracic Surgeons (STS) Measure
PCI In-Hospital Risk Adjusted Mortality Period (MP) This measure represents the percentage of patients that had a cardiac catheterization procedure who died for any reason while in the hospital. American College of Cardiology (ACC) PCI Registry Measure STEMI with PCI within 90 Minutes American College of Cardiology (ACC) PCI Registry Measure This measure reflects the percent of patients, who are having a heart attack, who undergo the procedure to open the blocked artery causing the heart attack, within 90 minutes of arriving at the hospital. WCHQ Patient Experience Measures Able to Get Appointments and Care When Needed Period (MP) 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. Helpful and Courteous Office Staff Patients were asked if office staff were helpful and if they were courteous and respectful. Effective Doctor-Patient Communication Received Test Results From the Doctor s Office 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. Patients were asked if someone from the doctor s office followed up to give them the results of a blood test, x- ray, or other test when it was ordered by the doctor. Rating the Doctor as a 9 or 10 Patients were asked to rate their doctors on a scale of 0-10, with 0 being the worst possible doctor and 10 being the best possible doctor. Willing to Recommend the Doctor to Other People Patients were asked if they would recommend the doctor s office to their family and friends.