0 icc community cy 2013 chart audit september 9, 2014 audit timeframe: jan 1, 2013 – dec 31, 2013
TRANSCRIPT
2
Audit Participants CY 2013
Seton Community Health Centers
CommUnityCare
El Buen Samaritano
Lone Star Circle of CarePeople’s Community Clinic
Volunteer Healthcare Clinic
Note: Data in this report has been provided by the individual reporting clinics, and therefore the ICC cannot directly verify the accuracy of the data. Since ICC cannot know for certain if there were any variations in data collection methodology and other variables, the reader should exercise caution in attempting to draw comparisons between clinics.
3
Parameters CY 2013
• Audit Timeframe: Jan 1, 2013 – Dec 31, 2013
• ALL Denominators include the assumption that the patient is: Active (defined as >/=1 visit at organization between Jan 1-Dec 31, 2013) AND adequately Established (defined as first visit at organization prior to July 1, 2013)
• When an Age Range is included in the denominator, the patient must have been within that age range on Dec 31, 2013
• When a Diagnosis is included in the denominator and/or numerator, audit participants should ensure that the diagnosis was Active (not Resolved) in a given patient during the audit timeframe
• When a Diagnosis is included in the denominator, numerator, or exclusion list, audit participants will determine the appropriate place(s) in their medical records/databases from which to pull the diagnosis (such as Assessments from encounters, Current/Chronic Problem List, etc). See the "Dx Code Sets" sheet for ICD-9 codes that correspond to the diagnoses being measured
• When a lab result is included in a numerator, audit participants will determine the appropriate place(s) in their medical records/databases from which to pull the results. Note that Orders are codified as CPTs and Results should be codified in LOINC, although many lab vendors return results with proprietary lab codes. A list of corresponding CPT and LOINC codes is included for the measures below. For audit participants with an EMR, the date to pull should be the Result Date (not Order Date or Recorded/Entered Date), if available
• When encounters are included in a numerator or denominator, it implies a face-to-face encounter with a provider. A lab-only visit, for example, would not be considered an encounter
Note: Data in this report has been provided by the individual reporting clinics, and therefore the ICC cannot directly verify the accuracy of the data. Since ICC cannot know for certain if there were any variations in data collection methodology and other variables, the reader should exercise caution in attempting to draw comparisons between clinics.
4
Electronic vs Manual Data Pull Poll CY 2013
• Data collection 2012 vs 2013? Electronic, Manual or Combination (E/M/C)
Note: Data in this report has been provided by the individual reporting clinics, and therefore the ICC cannot directly verify the accuracy of the data. Since ICC cannot know for certain if there were any variations in data collection methodology and other variables, the reader should exercise caution in attempting to draw comparisons between clinics.
Note:
Seton Community Health Centers: Data measures from April 1 – Dec 31, 2013.Only included in the denominator patients with current diagnosis of IVD because this was first year on EMR and didn’t have electronic data from prior year.
Clinic 2012 2013CommUnityCare E EEl Buen Samaritano E ELone Star Circle of Care E EPeople's Community Clinic E ESeton Community Clinics C CVolunteer Healthcare Clinic M M
5
Tobacco Poll CY 2013
• In your clinic, do you ask your patients about and document the status related to other tobacco use (non-cigarette)?
• Is there a timeline to make these changes? (no replies)
Note: Technically can be asked separately within NexGen, but due to workflow issue this is not actually done
Note: Data in this report has been provided by the individual reporting clinics, and therefore the ICC cannot directly verify the accuracy of the data. Since ICC cannot know for certain if there were any variations in data collection methodology and other variables, the reader should exercise caution in attempting to draw comparisons between clinics.
Clinic Y/NCommUnityCare YEl Buen Samaritano YLone Star Circle of Care YPeople's Community Clinic YSeton Community Clinics NVolunteer Healthcare Clinic N
6
Tobacco Use Screening CY 2013
4,8906,191
36,07136,722
5,5365,563
5,7295,739
00
CommUni-tyCare
El Buen LSCC Peoples Seton Clinics Volunteer0.0%
10.0%
20.0%
30.0%
40.0%
50.0%
60.0%
70.0%
80.0%
90.0%
100.0% 91.8%
79.0%
98.2% 99.5% 99.8%
0.0%
47,05551,261
Not Reported
Note: Data in this report has been provided by the individual reporting clinics, and therefore the ICC cannot directly verify the accuracy of the data. Since ICC cannot know for certain if there were any variations in data collection methodology and other variables, the reader should exercise caution in attempting to draw comparisons between clinics.
Denominator Patient age 13 +. Numerator Patients with smoking and/or other tobacco status assessed and recorded as structured data at last visit. (Any previous documented status in
patient chart is insufficient).
Tobacco Use Screening
7
Tobacco Cessation Intervention CY 2013
248386
4,6405,565
486596
163789
00
CommUni-tyCare
El Buen LSCC Peoples Seton Clinics Volunteer0.0%
10.0%
20.0%
30.0%
40.0%
50.0%
60.0%
70.0%
80.0%
90.0%
100.0%
46.4%
64.2%
83.4% 81.5%
20.7%
0.0%
4,4349,566
Not Reported
Note: Data in this report has been provided by the individual reporting clinics, and therefore the ICC cannot directly verify the accuracy of the data. Since ICC cannot know for certain if there were any variations in data collection methodology and other variables, the reader should exercise caution in attempting to draw comparisons between clinics.
Denominator Patient age 13 + identified as current cigarette smokers or other tobacco users. (Audit participants to determine how that is defined/recorded in their medical records/databases.)
Numerator Patients in whom tobacco cessation counseling was performed at least once during the measurment year.
Tobacco Users: Cessation Counseling
8
Blood Pressure Screening CY 2013
5,6545,974
30,29730,480
4,9714,993
4,1614,161
1,1721,188
46,96547,391
Note: Data in this report has been provided by the individual reporting clinics, and therefore the ICC cannot directly verify the accuracy of the data. Since ICC cannot know for certain if there were any variations in data collection methodology and other variables, the reader should exercise caution in attempting to draw comparisons between clinics.
Denominator Patient age 18+Numerator Patients with >/= 1 measurement of both systolic blood pressure and diastolic blood pressure during the audit timeframe.
CommUni-tyCare
El Buen LSCC Peoples Seton Clinics Volunteer0.0%
10.0%
20.0%
30.0%
40.0%
50.0%
60.0%
70.0%
80.0%
90.0%
100.0%
99.1%94.6%
99.4% 99.6% 100.0% 98.7%
9
Follow-Up Blood Pressure Screening CY 2013
307326
2,8432,900
111112
272272
00
CommUni-tyCare
El Buen LSCC Peoples Seton Clinics Volunteer0.0%
10.0%
20.0%
30.0%
40.0%
50.0%
60.0%
70.0%
80.0%
90.0%
100.0% 92.3% 94.2%98.0% 99.1% 100.0%
0.0%
1,0491,136
Note: Data in this report has been provided by the individual reporting clinics, and therefore the ICC cannot directly verify the accuracy of the data. Since ICC cannot know for certain if there were any variations in data collection methodology and other variables, the reader should exercise caution in attempting to draw comparisons between clinics.
Not Reported
Denominator Patient age 18+ who have ever had a true diagnosis Hypertension and most recent reading is =>140/90 with one other reading, within 12 months of the most recent reading, being =>140/90.
Numerator Lab or Treatment Or EKG within reporting year
10
Follow-Up Blood Pressure Screening CY 2013
261411
3,3843,865
124128
5192
00
CommUni-tyCare
El Buen LSCC Peoples Seton Clinics Volunteer0.0%
10.0%
20.0%
30.0%
40.0%
50.0%
60.0%
70.0%
80.0%
90.0%
100.0%
84.4%
63.7%
87.6%
96.9%
55.4%
0.0%
1,7112,027
Note: Data in this report has been provided by the individual reporting clinics, and therefore the ICC cannot directly verify the accuracy of the data. Since ICC cannot know for certain if there were any variations in data collection methodology and other variables, the reader should exercise caution in attempting to draw comparisons between clinics.
Not Reported
Denominator Patient age 18+. With most recent reading is =>140/90 with one other reading, within 12 months of the most recent reading, being =>140/90.
Numerator Lab or Treatment Or EKG within reporting year
11
Diabetes: No A1c Test Frequency CY 2013
Denominator Patient age between 18 and 75 years. Active diagnosis of Diabetes (See Dx Code Sets sheet for ICD-9 definition of Diabetes).
Numerator Patients with no lab results for A1c recorded during audit timeframe. (A list of CPT/LOINC codes which can be used to help determine the presence of HgbA1c order/results is included in the Order Code Sets sheet. Note that many lab vendors return Results with a proprietary code, as opposed to a LOINC code.)
Diabetes: A1c Test Frequency (NQF 0057)
64676
4943,842
28587
1391,062
--60
CommUni-tyCare
El Buen LSCC Peoples Seton Clinics Volunteer0.0%
10.0%
20.0%
30.0%
40.0%
50.0%
60.0%
70.0%
80.0%
90.0%
100.0%
5.0%9.5% 12.9%
4.8%13.1%
0.0%
2815,606
Not Reported
12
Diabetes: A1c Test Frequency >=1 CY 2013
612676
3,3483,842
9281,062
8591,064
6060
CommUni-tyCare
El Buen LSCC Peoples Seton Clinics Volunteer80.0%
90.0%
100.0%
95.0%
90.5%
87.1%
95.2%
87.4%
100.0%
5,3255,606
Denominator Patient age between 18 and 75 years. Active diagnosis of Diabetes (See Dx Code Sets sheet for ICD-9 definition of Diabetes).
Numerator Patients with >=1 lab result for A1c recorded during audit timeframe. (A l ist of CPT/LOINC codes which can be used to help determine the presence of HgbA1c order/results is included in the Order Code Sets sheet. Note that many lab vendors return Results with a proprietary code, as opposed to a LOINC code.)
Exclusions Patients with diagnoses of Polycystic Ovaries, Steroid-Induced Diabetes, Gestational Diabetes (assuming those diagnoses were entered prior to the end of the reporting period). (See Dx Code Sets sheet for ICD-9 definitions of those diseases).
Note: Data in this report has been provided by the individual reporting clinics, and therefore the ICC cannot directly verify the accuracy of the data. Since ICC cannot know for certain if there were any variations in data collection methodology and other variables, the reader should exercise caution in attempting to draw comparisons between clinics.
13
Diabetes: A1c Test Frequency >/=2 CY 2013
331676
2,1243,842
383587
5571,062
4460
CommUni-tyCare
El Buen LSCC Peoples Seton Clinics Volunteer0.0%
10.0%
20.0%
30.0%
40.0%
50.0%
60.0%
70.0%
80.0%
90.0%
100.0%
66.3%
49.0%55.3%
65.2%
52.4%
73.3%
3,7185,606
Note: Data in this report has been provided by the individual reporting clinics, and therefore the ICC cannot directly verify the accuracy of the data. Since ICC cannot know for certain if there were any variations in data collection methodology and other variables, the reader should exercise caution in attempting to draw comparisons between clinics.
Denominator Patient age between 18 and 75 years. Active diagnosis of Diabetes (See Dx Code Sets sheet for ICD-9 definition of Diabetes).
Numerator Patients with >/= 2 lab result for A1c recorded during audit timeframe. (A list of CPT/LOINC codes which can be used to help determine the presence of HgbA1c order/results is included in the Order Code Sets sheet. Note that many lab vendors return results with a proprietary code, as opposed to a LOINC code.)
Exclusions Patients with diagnoses of Polycystic Ovaries, Steroid-Induced Diabetes, Gestational Diabetes (assuming those diagnoses were entered prior to the end of the reporting period). (See Dx Code Sets sheet for ICD-9 definitions of those diseases).
14
Diabetes: A1c Ideal Control <7.0% CY 2013
CommUni-tyCare
El Buen LSCC Peoples Seton Clinics Volunteer0.0%
10.0%
20.0%
30.0%
40.0%
50.0%
60.0%
70.0%
80.0%
90.0%
100.0%
36.1%41.9% 38.9%
35.4% 35.7% 36.7%
283676
1,4953,842
208587
3791,062
2,0215,606
2260
Denominator Patient age between 18 and 75 years. Active diagnosis of Diabetes (See Dx Code Sets sheet for ICD-9 definition of Diabetes).
Numerator Patients whose most recent A1c measurement is < 7.0%. (A l ist of CPT/LOINC codes which can be used to help determine the presence of HgbA1c order/results is included in the Order Code Sets sheet. Note that many lab vendors return Results with a proprietary code, as opposed to a LOINC code.)
Exclusions Patients with diagnoses of Polycystic Ovaries, Steroid-Induced Diabetes, Gestational Diabetes (assuming those diagnoses were entered prior to the end of the reporting period). (See Dx Code Sets sheet for ICD-9 definitions of those diseases).
Note: Data in this report has been provided by the individual reporting clinics, and therefore the ICC cannot directly verify the accuracy of the data. Since ICC cannot know for certain if there were any variations in data collection methodology and other variables, the reader should exercise caution in attempting to draw comparisons between clinics.
15
Diabetes: A1c Control 7.0% through 7.99% CY 2013
CommUni-tyCare
El Buen LSCC Peoples Seton Clinics Volunteer0.0%
10.0%
20.0%
30.0%
40.0%
50.0%
60.0%
70.0%
80.0%
90.0%
100.0%
20.6%13.8% 16.4% 15.7% 17.7%
23.3%
93676
6323,842
92587
1881,062
1,1535,606
1460
Denominator Patient age between 18 and 75 years. Active diagnosis of Diabetes (See Dx Code Sets sheet for ICD-9 definition of Diabetes).
Numerator Patients whose most recent A1c measurement is 7 thru 7.99%. (A l ist of CPT/LOINC codes which can be used to help determine the presence of HgbA1c order/results is included in the Order Code Sets sheet. Note that many lab vendors return Results with a proprietary code, as opposed to a LOINC code.)
Exclusions Patients with diagnoses of Polycystic Ovaries, Steroid-Induced Diabetes, Gestational Diabetes (assuming those diagnoses were entered prior to the end of the reporting period). (See Dx Code Sets sheet for ICD-9 definitions of those diseases).
Note: Data in this report has been provided by the individual reporting clinics, and therefore the ICC cannot directly verify the accuracy of the data. Since ICC cannot know for certain if there were any variations in data collection methodology and other variables, the reader should exercise caution in attempting to draw comparisons between clinics.
16
Diabetes: A1c Control <8.0% CY 2013
CommUni-tyCare
El Buen LSCC Peoples Seton Clinics Volunteer0.0%
10.0%
20.0%
30.0%
40.0%
50.0%
60.0%
70.0%
80.0%
90.0%
100.0%
56.6% 55.6% 55.4%51.1% 53.4%
60.0%
376676
2,1273,842
300587
5671,062
3660
3,1745,606
Denominator Patient age between 18 and 75 years. Active diagnosis of Diabetes (See Dx Code Sets sheet for ICD-9 definition of Diabetes).
Numerator Patients whose most recent A1c measurement is < 8.0%. (A l ist of CPT/LOINC codes which can be used to help determine the presence of HgbA1c order/results is included in the Order Code Sets sheet. Note that many lab vendors return Results with a proprietary code, as opposed to a LOINC code.)
Exclusions Patients with diagnoses of Polycystic Ovaries, Steroid-Induced Diabetes, Gestational Diabetes (assuming those diagnoses were entered prior to the end of the reporting period). (See Dx Code Sets sheet for ICD-9 definitions of those diseases).
Note: Data in this report has been provided by the individual reporting clinics, and therefore the ICC cannot directly verify the accuracy of the data. Since ICC cannot know for certain if there were any variations in data collection methodology and other variables, the reader should exercise caution in attempting to draw comparisons between clinics.
17
Diabetes: A1c Control 8.0% through 9% CY 2013
CommUni-tyCare
El Buen LSCC Peoples Seton Clinics Volunteer0.0%
10.0%
20.0%
30.0%
40.0%
50.0%
60.0%
70.0%
80.0%
90.0%
100.0%
13.8% 10.1% 11.6%15.7% 15.1% 15.0%
68676
4463,842
92587
1601,062
960
7765,606
Denominator Patient age between 18 and 75 years. Active diagnosis of Diabetes (See Dx Code Sets sheet for ICD-9 definition of Diabetes).
Numerator Patients whose most recent A1c measurement is 8 thru 9%. (A list of CPT/LOINC codes which can be used to help determine the presence of HgbA1c order/results is included in the Order Code Sets sheet. Note that many lab vendors return Results with a proprietary code, as opposed to a LOINC code.)
Exclusions Patients with diagnoses of Polycystic Ovaries, Steroid-Induced Diabetes, Gestational Diabetes (assuming those diagnoses were entered prior to the end of the reporting period). (See Dx Code Sets sheet for ICD-9 definitions of those diseases).
Note: Data in this report has been provided by the individual reporting clinics, and therefore the ICC cannot directly verify the accuracy of the data. Since ICC cannot know for certain if there were any variations in data collection methodology and other variables, the reader should exercise caution in attempting to draw comparisons between clinics.
18
Diabetes: A1c Poor Control >9.0% CY 2013
CommUni-tyCare
El Buen LSCC Peoples Seton Clinics Volunteer0.0%
10.0%
20.0%
30.0%
40.0%
50.0%
60.0%
70.0%
80.0%
90.0%
100.0%
24.5%
34.3%
20.2%
33.2% 31.5%25.0%
232676
7753,842
195587
3351,062
1560
1,3755,606
Denominator Patient age between 18 and 75 years. Active diagnosis of Diabetes (See Dx Code Sets sheet for ICD-9 definition of Diabetes).
Numerator Patients whose most recent A1c measurement is > 9.0% or is missing a result, or if an HbA1c was not done during the audit year (A l ist of CPT/LOINC codes which can be used to help determine the presence of HgbA1c order/results is included in the Order Code Sets sheet. Note that many lab vendors return Results with a proprietary code, as opposed to a LOINC code.)
Exclusions Patients with diagnoses of Polycystic Ovaries, Steroid-Induced Diabetes, Gestational Diabetes (assuming those diagnoses were entered prior to the end of the reporting period). (See Dx Code Sets sheet for ICD-9 definitions of those diseases).
Note: Data in this report has been provided by the individual reporting clinics, and therefore the ICC cannot directly verify the accuracy of the data. Since ICC cannot know for certain if there were any variations in data collection methodology and other variables, the reader should exercise caution in attempting to draw comparisons between clinics.
Note: No A1c included in >9 calculation
19
Diabetes: A1c CY 2013
CommUnity Care
El Buen LSCC Peoples Seton Clinics Volunteer
<7 0.360506600071352
0.418639053254438
0.389120249869859
0.354344122657581
0.356873822975518
0.366666666666667
7 - 7.99 0.205672493756689
0.137573964497041
0.164497657470068
0.156729131175469
0.177024482109228
0.233333333333333
8 - 9 0.138423118087763
0.100591715976331
0.116085372201978
0.156729131175469
0.150659133709981
0.15
>9 0.245272921869426
0.343195266272189
0.201717855283706
0.332197614991482
0.315442561205273
0.25
No A1C 0.0501248662147699
0.0946745562130178
0.128578865174388
0.0477001703577513
0.130885122410546
0
5.0%
25.0%
45.0%
65.0%
85.0%
Combined
Note: Data in this report has been provided by the individual reporting clinics, and therefore the ICC cannot directly verify the accuracy of the data. Since ICC cannot know for certain if there were any variations in data collection methodology and other variables, the reader should exercise caution in attempting to draw comparisons between clinics.
20
Diabetes: Lipid Panel Testing Frequency CY 2013
Denominator Patient age between 18 and 75 years. Active diagnosis of Diabetes (See Dx Code Sets sheet for ICD-9 definition of Diabetes).
NumeratorPatients with >/= 1 lab result for l ipid panel recorded during audit timeframe. (A l ist of CPT/LOINC codes which can be used to help determine the presence of l ipid order/results is included in the Order Code Sets sheet. Note that many lab vendors return Results with a proprietary code, as opposed to a LOINC code.)
ExclusionsPatients with diangoses of Polcystic Ovaries, Steroid-Induced Diabetes, Gestational Diabetes (assuming those diagnoses were entered prior to the end of the reporting period). (See Dx Code Sets sheet for ICD-9 definitions of those diseases).
CommUni-tyCare
El Buen LSCC Peoples Seton Clinics Volunteer0.0%
10.0%
20.0%
30.0%
40.0%
50.0%
60.0%
70.0%
80.0%
90.0%86.8%
37.1%
75.8% 76.0%71.1%
83.3%
249676
2,9133,842
446587
7551,062
5060
4,8675,606
Note: Data in this report has been provided by the individual reporting clinics, and therefore the ICC cannot directly verify the accuracy of the data. Since ICC cannot know for certain if there were any variations in data collection methodology and other variables, the reader should exercise caution in attempting to draw comparisons between clinics.
21
Diabetes: LDL Control CY 2013
CommUni-tyCare
El Buen LSCC Peoples Seton Clinics Volunteer0.0%
10.0%
20.0%
30.0%
40.0%
50.0%
60.0%
70.0%
80.0%
90.0%
100.0%
51.0%
40.8% 39.4% 38.5% 41.1%46.7%
249676
1,5153,842
226587
4361,062
2860
2,8615,606
Denominator Patient age between 18 and 75 years. Active diagnosis of Diabetes (See Dx Code Sets sheet for ICD-9 definition of Diabetes).
Numerator Patients whose most recent LDL measurement is < 100 mg/dL. (A l ist of CPT/LOINC codes which can be used to help determine the presence of l ipid order/results is included in the Order Code Sets sheet. Note that many lab vendors return Results with a proprietary code, as opposed to a LOINC code.)
Exclusions Patients with diagnoses of Polycystic Ovaries, Steroid-Induced Diabetes, Gestational Diabetes (assuming those diagnoses were entered prior to the end of the reporting period). (See Dx Code Sets sheet for ICD-9 definitions of those diseases).
Note: Data in this report has been provided by the individual reporting clinics, and therefore the ICC cannot directly verify the accuracy of the data. Since ICC cannot know for certain if there were any variations in data collection methodology and other variables, the reader should exercise caution in attempting to draw comparisons between clinics.
22
Diabetes: No LDL CY 2013
CommUni-tyCare
El Buen LSCC Peoples Seton Clinics Volunteer0.0%
10.0%
20.0%
30.0%
40.0%
50.0%
60.0%
70.0%
80.0%
90.0%
100.0%
13.2%
29.0%24.2% 24.0% 26.6%
16.7%
196676
9293,842
141587
2851,062
1060
7395,606
Denominator Patient age between 18 and 75 years. Active diagnosis of Diabetes (See Dx Code Sets sheet for ICD-9 definition of Diabetes).
Numerator Patients with NO LDL
Exclusions Patients with diagnoses of Polycystic Ovaries, Steroid-Induced Diabetes, Gestational Diabetes (assuming those diagnoses were entered prior to the end of the reporting period). (See Dx Code Sets sheet for ICD-9 definitions of those diseases).
Note: Data in this report has been provided by the individual reporting clinics, and therefore the ICC cannot directly verify the accuracy of the data. Since ICC cannot know for certain if there were any variations in data collection methodology and other variables, the reader should exercise caution in attempting to draw comparisons between clinics.
23
Diabetes: Ideal Blood Pressure Control CY 2013
Denominator Patient age between 18 and 75 years. Active diagnosis of Diabetes (See Dx Code Sets sheet for ICD-9 definition of Diabetes).
Numerator Patients whose most recent blood pressure measurement is SBP < 130 mm Hg AND DBP < 80 mm Hg
ExclusionsPatients with diangoses of Polcystic Ovaries, Steroid-Induced Diabetes, Gestational Diabetes (assuming those diagnoses were entered prior to the end of the reporting period). (See Dx Code Sets sheet for ICD-9 definitions of those diseases).
249676
1,3763,842
178587
4581,062
2360
CommUni-tyCare
El Buen LSCC Peoples Seton Clinics Volunteer0.0%
10.0%
20.0%
30.0%
40.0%
50.0%
60.0%
70.0%
80.0%
90.0%
100.0%
41.7%
69.5%
35.8%30.3%
43.1%38.3%
2,3365,606
Note: Data in this report has been provided by the individual reporting clinics, and therefore the ICC cannot directly verify the accuracy of the data. Since ICC cannot know for certain if there were any variations in data collection methodology and other variables, the reader should exercise caution in attempting to draw comparisons between clinics.
24
Diabetes: Blood Pressure Control CY 2013
Denominator Patient age between 18 and 75 years. Active diagnosis of Diabetes (See Dx Code Sets sheet for ICD-9 definition of Diabetes).
Numerator Patients whose most recent blood pressure measurement is SBP < 140 mm Hg AND DBP < 90 mm Hg
ExclusionsPatients with diagnoses of Polcystic Ovaries, Steroid-Induced Diabetes, Gestational Diabetes (assuming those diagnoses were entered prior to the end of the reporting period). (See Dx Code Sets sheet for ICD-9 definitions of those diseases).
249676
2,6193,842
380587
7601,062
4660
CommUni-tyCare
El Buen LSCC Peoples Seton Clinics Volunteer0.0%
10.0%
20.0%
30.0%
40.0%
50.0%
60.0%
70.0%
80.0%
90.0%
100.0%
70.9%
36.8%
68.2%64.7%
71.6%76.7%
3,9735,606
Note: Data in this report has been provided by the individual reporting clinics, and therefore the ICC cannot directly verify the accuracy of the data. Since ICC cannot know for certain if there were any variations in data collection methodology and other variables, the reader should exercise caution in attempting to draw comparisons between clinics.
25
Hypertension: Blood Pressure Control CY 2013
5041,008
4,2717,263
511916
1,4741,594
4178
CommUni-tyCare
El Buen LSCC Peoples Seton Clinics Volunteer0.0%
10.0%
20.0%
30.0%
40.0%
50.0%
60.0%
70.0%
80.0%
90.0%
100.0%
57.9%50.0%
58.8%55.8%
92.5%
52.6%
4,7408,192
Denominator Patient age between 18 and 85 years. Active diagnosis of Hypertension (See Dx Code Sets sheet for ICD-9 definition of Hypertension).
Numerator Patients whose most recent blood pressure measurement (obtained within the audit timeframe) is SBP < 140 mm Hg AND DBP < 90 mm Hg.
Exclusions Patients who have End Stage Renal Disease or active Pregnancy. (See Dx Code Sets sheet for ICD-9 definitions of those diseases).
Note: Data in this report has been provided by the individual reporting clinics, and therefore the ICC cannot directly verify the accuracy of the data. Since ICC cannot know for certain if there were any variations in data collection methodology and other variables, the reader should exercise caution in attempting to draw comparisons between clinics.
26
Hyper-Cholesterolemia LDL Control CY 2013
CommUni-tyCare
El Buen LSCC Peoples Seton Clinics Volunteer0.0%
10.0%
20.0%
30.0%
40.0%
50.0%
60.0%
70.0%
80.0%
90.0%
100.0%
32.6%
52.0%
35.9% 38.8%42.1%
0.0%
276531
5631,567
161415
93221
00
6161,888
Not Reported
Denominator Patient age between 20and 79 years. Active diagnosis of hypercholesterolemia (See Dx Code Sets sheet for ICD-9 definition of Hypercholesterolemia).
Numerator Patients whose most recent LDL result was <130 mg/dL. (A list of CPT/LOINC codes which can be used to help determine the presence of l ipid order/results is included in the Order Code Sets sheet. Note that many lab vendors return Results with a proprietary code, as opposed to a LOINC code.)
Exclusions Patients with comorbid diagnoses of Diabetes and/or Ischemic Vascular Disease, as those diagnoses demand a lower LDL and have their own measures in this audit. (See Dx Code Sets sheet for ICD-9 definitions of those diseases).
Note: Data in this report has been provided by the individual reporting clinics, and therefore the ICC cannot directly verify the accuracy of the data. Since ICC cannot know for certain if there were any variations in data collection methodology and other variables, the reader should exercise caution in attempting to draw comparisons between clinics.
27
Hyper-Cholesterolemia No LDL 2013
CommUni-tyCare
El Buen LSCC Peoples Seton Clinics Volunteer0.0%
10.0%
20.0%
30.0%
40.0%
50.0%
60.0%
70.0%
80.0%
90.0%
100.0%
12.5%
36.9% 35.9%31.6%
14.9%
0.0%
196531
5571,567
131415
33221
00
2361,888
Not Reported
Denominator Patient age between 20 and 79 years. Active diagnosis of hypercholesterolemia (See Dx Code Sets sheet for ICD-9 definition of Hypercholesterolemia).
Numerator Patients with NO LDLExclusions Patients with comorbid diagnoses of Diabetes and/or Ischemic Vascular Disease, as those diagnoses demand a lower LDL and
have their own measures in this audit. (See Dx Code Sets sheet for ICD-9 definitions of those diseases).
Note: Data in this report has been provided by the individual reporting clinics, and therefore the ICC cannot directly verify the accuracy of the data. Since ICC cannot know for certain if there were any variations in data collection methodology and other variables, the reader should exercise caution in attempting to draw comparisons between clinics.
28
Hyper-Cholesterolemia Combined CY 2013
CommUnity Care
El Buen LSCC Peoples Seton Clinics Volunteer
LDL Control 0.326271186440678
0.519774011299435
0.359285258455648
0.387951807228916
0.420814479638009
0
LDL Uncontrolled 0.548728813559322
0.111111111111111
0.285258455647735
0.296385542168675
0.429864253393665
0
No LDL 0.125 0.369114877589454
0.355456285896618
0.31566265060241
0.149321266968326
0
5.0%
15.0%
25.0%
35.0%
45.0%
55.0%
65.0%
75.0%
85.0%
95.0%
Combined
Note: Data in this report has been provided by the individual reporting clinics, and therefore the ICC cannot directly verify the accuracy of the data. Since ICC cannot know for certain if there were any variations in data collection methodology and other variables, the reader should exercise caution in attempting to draw comparisons between clinics.
Not Reported
29
IVD: Aspirin Use CY 2013
CommUni-tyCare
El Buen LSCC Peoples Seton Clinics Volunteer0.0%
10.0%
20.0%
30.0%
40.0%
50.0%
60.0%
70.0%
80.0%
90.0%
100.0%85.1%
33.3%
82.2% 84.4%
29.7%
0.0%
1236
732890
108128
54182
00
774910
Not Reported
Note: Data in this report has been provided by the individual reporting clinics, and therefore the ICC cannot directly verify the accuracy of the data. Since ICC cannot know for certain if there were any variations in data collection methodology and other variables, the reader should exercise caution in attempting to draw comparisons between clinics.
Denominator Patient age 18+. Active diagnosis of IVD (Ischemic Vascular Disease). (See Dx Code Sets sheet for ICD-9 definition of Ischemic Vascular Disease).
Numerator Patients whose Active Medication List includes Aspirin or an Antithrombotic. (Medication defined as : pletal/cilostazol, persantine/dipyridamole, effient/prasugrel, ticlid/ticlopidine, pradaxa/dabigatran, coumadin/warfarin, Plavix/clopidogrl, aspirin, Aggrenox/dipyrimadole-aspirin, lovenox/enoxaparin) "Active Aspirin Use" was defined as having been on aspirin or an antithrombotic at any point during the chart audit time frame.
Exclusions None. Although the validity of adding exclusions for those at high bleeding risk was discussed, the NQF measure does not have exclusions.
IVD: Aspirin Use (NQF 0068)
30
IVD: Lipid Panel Testing Frequency CY 2013
CommUni-tyCare
El Buen LSCC Peoples Seton Clinics Volunteer0.0%
10.0%
20.0%
30.0%
40.0%
50.0%
60.0%
70.0%
80.0%
90.0%
100.0%
83.1%
100.0%
78.0% 77.3%
59.3%
0.0%
3636
694890
99128
108182
00
756910
Not Reported
Note: Data in this report has been provided by the individual reporting clinics, and therefore the ICC cannot directly verify the accuracy of the data. Since ICC cannot know for certain if there were any variations in data collection methodology and other variables, the reader should exercise caution in attempting to draw comparisons between clinics.
Denominator Patient age 18+. Active diagnosis of IVD (Ischemic Vascular Disease). (See Dx Code Sets sheet for ICD-9 definition of Ischemic Vascular Disease).
Numerator Patients with >/= 1 lab result for lipid panel recorded during audit timeframe. (A list of CPT/LOINC codes which can be used to help determine the presence of lipid order/results is included in the Order Code Sets sheet. Note that many lab vendors return Results with a proprietary code, as opposed to a LOINC code.)
IVD: Lipid Panel Testing Frequency (NQF 0075, part 1)
31
IVD: LDL Control CY 2013
1536
424890
62128
72182
00
CommUni-tyCare
El Buen LSCC Peoples Seton Clinics Volunteer0.0%
10.0%
20.0%
30.0%
40.0%
50.0%
60.0%
70.0%
80.0%
90.0%
100.0%
54.5%
41.7%47.6% 48.4%
39.6%
0.0%
496910
Not Reported
Note: Data in this report has been provided by the individual reporting clinics, and therefore the ICC cannot directly verify the accuracy of the data. Since ICC cannot know for certain if there were any variations in data collection methodology and other variables, the reader should exercise caution in attempting to draw comparisons between clinics.
Denominator Patient age 18+. Active diagnosis of IVD (Ischemic Vascular Disease). (See Dx Code Sets sheet for ICD-9 definition of Ischemic Vascular Disease).
Numerator Patients whose most recent LDL result was <100 mg/dL. (A list of CPT/LOINC codes which can be used to help determine the presence of lipid order/results is included in the Order Code Sets sheet. Note that many lab vendors return Results with a proprietary code, as opposed to a LOINC code.)
IVD: LDL Control (NQF 0075, part 2)
32
IVD: No LDL CY 2013
736
211890
29128
69182
00
CommUni-tyCare
El Buen LSCC Peoples Seton Clinics Volunteer0.0%
10.0%
20.0%
30.0%
40.0%
50.0%
60.0%
70.0%
80.0%
90.0%
100.0%
17.7% 19.4%23.7% 22.7%
37.9%
0.0%
161910
Note: Data in this report has been provided by the individual reporting clinics, and therefore the ICC cannot directly verify the accuracy of the data. Since ICC cannot know for certain if there were any variations in data collection methodology and other variables, the reader should exercise caution in attempting to draw comparisons between clinics.
Not Reported
Denominator Patient age 18+. Active diagnosis of IVD (Ischemic Vascular Disease). (See Dx Code Sets sheet for ICD-9 definition of Ischemic Vascular Disease).
Numerator Patients with NO LDL result in the measurement year.
IVD: LDL Control (NQF 0075, part 2)
33
IVD: LDL CY 2013
CommUni-tyCare
El Buen LSCC Peoples Seton Clin-ics
Volunteer
LDL <100 0.545054945054945
0.416666666666667
0.476404494382023
0.484375 0.395604395604396
0
LDL 100+ 0.278021978021978
0.388888888888889
0.286516853932584
0.2890625 0.225274725274725
0
No LDL 0.176923076923077
0.194444444444444
0.237078651685393
0.2265625 0.379120879120879
0
5.0%
25.0%
45.0%
65.0%
85.0%
Combined
Note: Data in this report has been provided by the individual reporting clinics, and therefore the ICC cannot directly verify the accuracy of the data. Since ICC cannot know for certain if there were any variations in data collection methodology and other variables, the reader should exercise caution in attempting to draw comparisons between clinics.
Not Reported
34
IVD: Blood Pressure Control CY 2013
2136
594890
84128
162182
CommUni-tyCare
El Buen LSCC Peoples Seton Clinics Volunteer0.0%
10.0%
20.0%
30.0%
40.0%
50.0%
60.0%
70.0%
80.0%
90.0%
100.0%
67.8%
58.3%
66.7% 65.6%
89.0%
0.0%
617910
Not Reported
Note: Data in this report has been provided by the individual reporting clinics, and therefore the ICC cannot directly verify the accuracy of the data. Since ICC cannot know for certain if there were any variations in data collection methodology and other variables, the reader should exercise caution in attempting to draw comparisons between clinics.
00
Denominator Patient age 18+. Active diagnosis of IVD (Ischemic Vascular Disease). (See Dx Code Sets sheet for ICD-9 definition of Ischemic Vascular Disease).
Numerator Patients whose most recent blood pressure measurement is SBP < 140 mm Hg AND DBP < 90 mm Hg
IVD: Blood Pressure Control (NQF 0073)