1

ICC Community CY 2013 Chart Audit

September 9, 2014

Audit Timeframe: Jan 1, 2013 – Dec 31, 2013

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)