Table 7 - Health Outcomes and Disparities

This table reports data on selected health outcomes and disparities indicators. It is designed to provide information on three variables identified by BPHC as key indicators of Health Center quality of care as well as indicators of the extent to which health centers help to reduce health disparities. Taken together, it is presumed that they give a good overall description of the quality of primary care being provided at the center and the success the center has had in addressing certain health care disparities. It is clear that this is a subset of possible quality of care indicators and that individual health centers may be using others in addition to these.

The table is included in the Universal Report.

·         The Universal Report reports on quality of care indicators for all patients served under the scope of service of the entire BPHC Section 330 grant. Where a grantee has multiple streams of Section 330 funding, the Universal Report will be based on a stratified random sample which should be representative of the entire grant including all of the separate BPHC funding streams. (See sampling discussions later in this section.)

Section A: Deliveries and Babies by Birth Weight – Lines 1 through 5.

All CHC prenatal care patients who also delivered during the reporting period[3], are reported on lines 1 – 5. This table is similar to a table previously collected in the UDS, but has a different population reported. Only grantees that provide or assume primary responsibility for some or all of a patient’s prenatal care services, whether or not the grantee does the delivery" are required to complete the prenatal tables.

Prenatal Care Patients Who Delivered During the Year (Line 1) – Report the total number of women who were known to have delivered during the year, even if the delivery was done by another provider. Include all deliveries, regardless of the outcome, but do not include deliveries where you have no documentation that the delivery occurred (for example, for women who may have moved out of the area and/or who were lost to follow-up.)

Deliveries by Center clinicians (Line 2) – Report the total number of deliveries performed by center clinicians during the reporting period in Column H. (This line is not reported by the race / ethnicity of the women delivered.) On this line ONLY, grantee is to include deliveries of women who were not part of the grantee’s prenatal care program during the calendar year. This would include such circumstances as the delivery of another doctor’s patients when the clinic provider participates in a call group and is on call at the time of delivery; emergency deliveries when the clinic provider is on-call for the emergency room; and deliveries of “un-doctored” patients who are assigned to the provider as a requirement for privileging at a hospital. Include as “health center clinicians” any clinician who is paid by the provider, regardless of the method of compensation.

Birthweight of Infants Born to Prenatal Care Patients During the Year (Lines 3 – 5.) Report the total number of live births during the reporting period for women who received prenatal care from the grantee or referral provider during the reporting period, according to the appropriate birthweight group. NOTE: Grantees must report deliveries and the birthweight of children delivered for all women who were in their prenatal care program and who delivered during the reporting period, regardless of whether the grantee did the delivery themselves, referred the delivery to another provider or was for a woman who transferred to another provider on her own. The number of deliveries reported on line 1 will normally not be the same as the total number of infants reported on lines 3 - 5 because of multiple births.

Sections B and C: Universe – Lines 6 and 9.

Enter the total number of health center patients who fit the criteria as defined below. Note that this will include patients who have not received the specific service being measured in particular. Because these populations are initially defined in terms of age (and gender) comparisons to the numbers on Table 3A will be made.

A multi-site grantee which is doing chart audits may opt to randomly select charts from a single site rather than from all sites. This will, of necessity, provide a lower quality of data and is not recommended, but it is permitted in light of the effort that might be required to audit charts at a large number of sites. It selecting data from one site that site should generally be:

·         The site with the largest number of patients or

·         The site with the largest number of targeted patients (e.g., a pediatric specialty clinic for the pediatric measures or a women’s health clinic for the Pap test measure) or

·         The site with the best organized medical records for the particular test (e.g., a test site where EHRs are in place.)

Regardless of whether or not a single site is being used, Column a will reflect the total number of patients meeting the criteria in the agency’s total patient population – not just the population at a single selected site. A grantee may choose to select a single site for all measures or for selected measures, however if a single site is used, check the box below the measure’s name. Do not check the box if you only operate one site.

Section B: Hypertension – Lines 6 through 8.

This section of Table 7 reports on all CHC adult patients, 18 years and older, who have been diagnosed as hypertensive before June 30 of the measurement year, and have been seen in the health center at least twice during the reporting year.

PERFORMANCE MEASURE:

Percentage of patients born on or before December 31,1990 with diagnosed hypertension (HTN) whose blood pressure (BP) was less than 140/90 (adequate control) at the time of the last reading

Numerator: Patients with last systolic blood pressure measurement <140 mm Hg and
diastolic blood pressure < 90 mm Hg during the measurement year among those patients in denominator.

Denominator: All patients = 18 years of age as of December 31 of the measurement year with diagnosis of hypertension (HTN), and have been seen at least twice during the reporting year, and have a diagnosis of hypertension before June 30 of the measurement year.

DEFINITIONS:

Line 6 – Universe: Enter the total number of patients who meet all of the following criteria:

•          Were born on or before December 31,1990 and
• Have been seen at least twice during the reporting year, and
•       Have a diagnosis of hypertension (HTN) before June 30 of the measurement yearas evidenced by an ICD-9 code of 401.xx. It does not matter if hypertension was treated or is currently being treated. The notation of hypertension may appear during or prior to the year 2008. Hypertension may also be identified by finding any of the following in chart notes, however it is not assumed that all charts will be screened for these references:

o        HTN

o        High blood pressure (HBP)

o        Elevated blood pressure

o        Borderline HTN

o        Intermittent HTN

o        History of HTN

Statements such as “rule out hypertension,” “possible hypertension,” “white-coat hypertension,” “questionable hypertension,” and “consistent hypertension” are not sufficient to confirm the diagnosis of hypertension if such statements are the only notations hypertension in the medical record.

Blood pressures that are self-reported by the patient (e.g. home and health-fair blood pressures reported by the patient) are not eligible.

Line 7: Sample: Enter the total number of health center patients for whom data have been reviewed. If no qualifying EHR is present, use all patients who fit the criteria or a scientifically drawn sample of 70 patients, whichever is less. The sampling method is described in Appendix D. If an EHR is present it may be used in lieu of a chart review of a sample of charts if and only if:

·         The EHR includes every patient aged 18 or older with diagnosed hypertension, regardless of whether or not they were specifically treated for hypertension.

·         Blood pressure is regularly recorded in the EHR for all patients

·         The EHR has been in place throughout the reporting year.

If the EHR is to be used in lieu of the chart audit, the number on line 7 will be equal to the number on line 6.

Line 8: Patients meeting performance measure: Hypertensive patients born on or before December 31,1990 (included in line 6 and line 7) whose systolic blood pressure measurement was less than 140 mm Hg and whose diastolic blood pressure was less than 90 mm Hg at the time of their last measurement in 2008. (Patients who have not had their blood pressure tested during the most recent medical visit will not be counted as meeting the performance measure.)

Section C: Diabetes: Lines 9 through 13.

This section of Table 7 reports on all CHC patients 18 and older who have been diagnosed as diabetic at some point during their time as a patient at the CHC.

Numerator: Number of adult patients whose most recent hemoglobin A1c level during the measurement year is less than 7%, greater than or equal to 7% or less than or equal to 9%, or greater than 9%, respectively, among those patients included in the denominator.

Denominator: Number of adult patients 18 and older as of December 31 of the measurement year with a diagnosis of type 1 or 2 diabetes who have been seen at least twice and do not meet exclusion criteria.

 PERFORMANCE MEASURE:

Percentage of adult patients born on or before December 31, 1990, with a diagnosis of Type I or Type II diabetes whose most recent hemoglobin A1c (HbA1c) was less than 7% (good control); whose most recent hemoglobin A1c (HbA1c) was greater than or equal to 7% and less than or equal to 9%, or whose most recent hemoglobin A1c (HbA1c) was greater than 9% (poor control).

DEFINITIONS:

Line 9 -- Universe: Enter the number of adult patients who meet the following criteria:

§         Were born on or before December 31,1990 and,

§         Have been seen at least twice for medical care during the reporting year and,

§         Have a diagnosis of diabetes. It does not matter if diabetes was treated or is currently being treated. The notation of diabetes may appear during or prior to the 2008. To confirm the diagnosis of diabetes, one of the following codes must be found in the medical record:

o        ICD-9-CM Codes 250, 357.2, 362.0, 366.41, 648, or

o        diabetic patients may be identified from pharmacy data (those who were dispensed insulin or oral hypoglycemics / antihyperglycemics.

Exclude any patients with a diagnosis of polycystic ovaries (ICD-9-CM Code 256.4) that do not have two face-to-face encounters with the diagnosis of diabetes, in any setting, during the measurement year or year prior to the measurement year. Also exclude any patients with gestational diabetes (ICD-9-CM Code 648.8) or steroid-induced diabetes (ICD-9-CM Code 962.0, 251.8) during the measurement year.

Line 10 - Number of Charts Sampled or EHR total. Enter the total number of health center patients for whom data have been reviewed. If no EHR is present, this will be the lesser of all diabetic patients or a scientifically drawn sample of 70 charts selected by following the procedure in Appendix D. If an EHR is present it may be used in lieu of a chart review of a sample of charts if and only if:

·         The EHR includes every diabetic patient.

·         Every item in the criteria is regularly recorded for all patients

·         The EHR has been in place throughout the performance year.

If the EHR is to be used in lieu of the chart audit, the number on line 10 will be equal to the number on line 9.

Line 11-13: Reported Hemoglobin A1c levels: For this report, the most recent hemoglobin A1c (HbA1c) level as documented through laboratory data or medical record review is reported If there is no HbA1c level during the measurement year, the level is considered to be greater than 9.0%. Thus a patient with no test during the current year is counted as poor HbA1c control.

     • Line 11: Number of patients included in the sample (i.e., in both lines 9 and 10) whose most recent HbA1c was less than 7%.
• Line 12: Number of patients included in the sample (i.e., in both lines 9 and 10) whose most recent HbA1c was greater than or equal to 7%, but less than or equal to 9%.
• Line 13: Number of patients included in the sample (i.e., in both lines 9 and 10) whose most recent HbA1c was greater than 9%.

Section D: Deliveries and Low Birthweight by Ethnicity
- Report the same as for Section A, by ethnicity.

Section E: Hypertension by Ethnicity
- Report the same as for Section B, by ethnicity.

Section F: Diabetes by Ethnicity
- Report the same as for Section C, by ethnicity.

Questions and Answers for Table 7

1.      Are there any changes to this table?

Yes, Section A is not new. However, Section B, C, E and F are new data elements.

2.      Data are requested by race and ethnicity. How are these to be coded?

Race and ethnicity are coded on this table in the exact same manner that is used for coding on Table 3B. Refer to instructions for Table 3B for further information.

3. Are patients with diabetes required to bring to the health center documentation of HbA1c tests received from outside the health center?

Patients are encouraged to provide documentation of HbA1c immunizations received elsewhere, but this is not required. Health centers are encouraged to document HbA1c tests s by contacting providers of tests directly in order to obtain documentation by FAX, or by requesting Health Center patients to mail a copy of test results, or through other appropriate means. Health Center patients should not be requested to return to the center to provide test documentation.

TABLE 7 – HEALTH OUTCOMES AND DISPARITIES