INSTRUCTIONS FOR TABLE 7 - HEALTH OUTCOMES AND DISPARITIES

This table reports data on selected health outcome indicators by race and ethnicity. The health outcome indicators are commonly seen in the health care community as indicators of overall community health. These indicators are “intermediate outcome measures” which means that they document intermediate outcomes of care as a proxy for good long term health outcomes. By achieving measurable intermediate outcomes, we know that negative health outcomes can be reduced. Thus, by increasing the proportion of health center patients who have a good intermediate health outcome, we can expect improved health status of the patient population in the future. For example,

• Low Birthweight: If there are fewer low birthweight children born, then there will be fewer children who suffer the multiple negative sequela of low birthweight.
• Controlled Hypertension: If there is less uncontrolled hypertension, then there will be less cardiovascular damage, fewer heart attacks, less organ damage later in life.
• Controlled Diabetes: If there is less uncontrolled diabetes then there will be fewer amputations, less blindness, less organ damage later in life.

While the selected health outcome indicators give a good description of the overall quality of primary care being provided at the center, it is clear that this is a subset of possible health outcome indicators and that individual health centers may be using others in addition to these.

Table 7 reports health outcomes by race and ethnicity to provide information on the extent to which health centers help reduce health disparities. The total number of patients reported by race must equal the total reported by ethnicity. That is, the totals reported in Column h by race must equal the totals reported in Column k by ethnicity. Race and ethnicity is self-reported by patients and should be collected as part of a standard registration process. Health centers who report on a sample of patients are cautioned against using their data to evaluate disparities given small sample sizes. However, on a state and national level, reported data will provide health outcome indicators which can be used to evaluate disparities for BPHC-funded programs, overall.

The table is included only in the Universal Report.

HIV POSITIVE PREGNANT WOMEN, TOP LINE
Report the total number of HIV positive pregnant women served by the health center in column (h).

DELIVERIES AND LOW BIRTH WEIGHT BY RACE AND ETHNICITY, SECTIONS A AND D (LINES 1-5)

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 Section A. 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.

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 PERFORMED BY GRANTEE PROVIDER (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 and still births.

HYPERTENSION AND DIABETES BY RACE AND ETHNICITY, SECTIONS B AND C

In these sections, grantees will report on the findings of their reviews of services provided to targeted populations of current medical users (i.e., medical patients who had at least two medical encounters during the reporting period):

SECTION B: HYPERTENSION (Lines 6-8)
Proportion of hypertensive patients whose most recent blood pressure showed a systolic
pressure under 140 and a diastolic pressure under 90.

SECTION C: DIABETES (Lines 9-13)
The proportion of diabetic patients whose most recent HbA1c is in a given range: HbA1c levels less than 7%,7% to 9%, greater than 9%.

Data for this section may be obtained from an audit of charts selected through a process of scientific random sampling or through the use of Electronic Health Records whose templates permit the recovery of all records for all patients which fit the sampling profile.

For each of the two populations being surveyed very rigid and specific definitions are to be used in order to identify the universe from which the sample will be drawn. These are described in detail below and must be carefully followed to avoid misreporting findings. (Special care must be taken since mistakes in this area may portray a lower quality of care than is actually the case.)

 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.

TOTAL PATIENTS AGED 18+ WITH  HYPERTENSION, ROW 6

•  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 year as 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 such as when a patient calls in a blood pressure from home are generally not eligible unless a clinical management decision is made using that reading.  If the patient is equipped with reliable technology and the provider is confident that the reading is reliable such that the provider is recoding the automated BP reading and making prescription changes based on those readings, the health center can use the measurement.

CHARTS SAMPLED OR EHR TOTAL, ROW 7

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 C. 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.

PATIENTS WITH CONTROLLED BLOOD PRESSURE, ROW 8

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 reporting year will not be counted as meeting the performance measure.)

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.

PERFORMANCE MEASURE:

Proportion 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 (HbAlc) was less than 7% (good control); whose most recent hemoglobin A1c (HbAlc) was greater than or equal to 7% and less than or equal to 9%, or whose most recent hemoglobin A1c (HbAlc) was greater than 9% (poor control).

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.

TOTAL PATIENTS AGED 18+ WITH TYPE I OR II DIABETES, LINE 9

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:
  • ICD-9-CM Codes 250, 357.2, 362.0, 366.41, 648.0, or
  • 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.

CHARTS SAMPLED OR EHR TOTAL, ROW 10

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 C. 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.

REPORTED HEMOGLOBIN A1c LEVELS, ROW 11-13

For this report, the most recent hemoglobin A1c (HbAlc) level as documented through laboratory data or medical record review is reported. If there is no HbAlc 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 HbAlc control.

• Patients with HBA1c < 7% (Line 11): Number of patients included in the sample (i.e., in both lines 9 and 10) whose most recent HbAlc was less than 7%.
• Patients with 7% ≤ HBA1c ≤ 9% (Line 12): Number of patients included in the sample (i.e., in both lines 9 and 10) whose most recent HbAlc was greater than or equal to 7%, but less than or equal to 9%.
• Patients with HBA1c > 9% (Line 13): Number of patients included in the sample (i.e., in both lines 9 and 10) whose most recent HbAlc 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

TABLE 7 – HEALTH OUTCOMES AND DISPARITIES

³ Note that this is a change from prior years. In prior years only those patients who had also had a prenatal care visit in the reporting period were counted, and some patients who delivered in the first few days of the new year were left out. This new table counts those women as well. .