Clinical Performance Metrics


We track and report 18 clinical performance metrics to federal agencies each year. These measures help us set goals for improvement and keep track of our progress toward those goals. See our performance trends and compare them with state and national benchmarks in the chart below.

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Click on the links below for more information on each metric.

Chronic Disease Management Pain Management Adult Preventative Health
1. Diabetes (Hemoglobin A1c Control) 7. Controlled Substance Agreement 12. Cervical Cancer Screening
2. Diabetes (Oral Exam) 13. Colorectal Cancer Screening
3. Hypertension Control Child and Adolescent Health 14. Depression Screening
4. Asthma (Pharmacological Therapy) 8. First Trimester Prenatal Care 15. Adult Weight Screening
5. Coronary Artery Disease (Lipid Therapy) 9. Birth Weight 16. Tobacco Use Assessment / Counseling
6. Ischemic Vascular Disease (Aspirin Therapy) 10. Child Immunizations 17. Senior Immunizations (Flu)
11. Child / Adolescent Weight Screening 18. Senior Immunizations (Pneumococcal)

 


1. Diabetes (Hemoglobin A1c Control)       GOAL: > 76%

Description:   Percent of diabetic patients whose last Hemoglobin A1c result in the past year was <= 9%.

Why Is It Important?   The hemoglobin A1c test is a blood test that helps doctors determine your average blood sugar control over the last 2 to 3 months. Specifically, it measures the percentage of your hemoglobin (a protein in red blood cells that carries oxygen) that is coated with sugar. It is important for diabetics to have this test regularly so that doctors can determine whether or not your diabetes is under control and treat the disease appropriately to help prevent diabetic complications. The higher the value, the greater the risk of developing diabetic complications related to your eyes, kidneys, cardiovascular system, and nervous system.

What Can You Do?   If you have diabetes, be sure to talk to your doctor about how often you should have your hemoglobin A1c tested and follow his or her recommendations. If you have the lab work done elsewhere, please make sure your doctor gets a copy of the results.

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2. Diabetes (Oral Exam)       GOAL: > 25%

Description:   Percent of diabetic patients who had a documented oral exam within the past 12 months.

Why Is It Important?   Patients with diabetes should have regular oral exams by their dentist or doctor. Higher levels of sugars and acids in the mouth as a result of diabetes increase susceptibility to gum disease, tooth decay, and other oral health problems, and gum disease can also make diabetes more difficult to control. Early symptoms of oral infections in diabetics are decreased saliva, dry mouth, and a burning mouth or tongue. Diabetes may cause the gums to pull away from the teeth and eventually loosen and fall out.

What Can You Do?   Have an oral exam completed at least once each year, and tell your doctor if you’ve had one.

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3. Hypertension Control       GOAL: > 78%

Description:   Percent of hypertensive patients whose most recent blood pressure was < 140/90.

Why Is It Important?   Patients with hypertension (i.e., repeated blood pressure measurements greater than 140/90) are at higher risk of experiencing coronary heart disease, stroke, congestive heart failure, and end-stage renal disease. However, hypertension is controllable with medication and/or lifestyle changes.

What Can You Do?   Talk to your doctor about ways to control your blood pressure and follow his or her recommendations. Monitor your blood pressure at home and contact your doctor if you see significant changes. Understand any medications you may be taking for your hypertension.

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4. Asthma (Pharmacological Therapy)       GOAL: > 92%

Description:   Percent of patients with persistent asthma who are on a long-term controller or other accepted pharmacological therapy.

Why Is It Important?   The severity and duration of asthma attacks can be reduced with appropriate pharmacological therapy, such as a long-term controller. Patients using such treatments are less likely to have asthma attacks, will require fewer emergency room visits, and will be less likely to develop complications related to asthma.

What Can You Do?   Talk to your doctor about asthma management and treatment, and create a plan together to manage your asthma. Monitor your symptoms to help you understand your triggers and recognize if it worsens. Understand the medications you are taking for your asthma.

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5. Coronary Artery Disease (Lipid Therapy)       GOAL: > 77%

Description:   Percent of patients with CAD who are currently taking a lipid-lowering medication.

Why Is It Important?   CAD is a type of heart disease in which fatty substances stick to the walls of the coronary arteries, building up and restricting or slowing blood flow to the heart and ultimately increasing risk of heart attack and sudden death. Lipid lowering medications help reduce the amount of lipids, such as cholesterol, in the blood, which can help reduce the likelihood of experiencing CAD-related clinical events such as heart attacks.

What Can You Do?   If you don’t already have a treatment plan for your CAD, talk to your doctor and create a plan together. Take medications as prescribed. Make healthy lifestyle changes. Let your doctor know all medications you’re taking, even if they’re prescribed elsewhere.

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6. Ischemic Vascular Disease (Aspirin Therapy)       GOAL: > 90%

Description:   Percent of patients diagnosed with IVD who had documentation of the use of aspirin or another antithrombotic during the past year.

Why Is It Important?   IVD occurs when plaque builds up inside blood vessels and restricts the normal blood flow. This disease can affect any artery in the body and can potentially cause strokes, heart attacks, kidney malfunction, and gangrene. Aspirin and other antithrombotic medications can help in the treatment of coronary and other vascular disease by helping to keep blood clots from forming.

What Can You Do?   If you don’t already have a treatment plan for your IVD, talk to your doctor and create a plan together. Take medications as prescribed. Make healthy lifestyle changes. Let your doctor know all the medications you’re taking, even if they’re over-the-counter (e.g., aspirin) or prescribed elsewhere.

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7. Controlled Substance Agreement       GOAL: > 85%

Description:   Percent of patients taking daily opiates for longer than 8 weeks in the past year who have a signed controlled substance agreement.

Why Is It Important?   Patients with chronic, severe pain may need a long-term pain management plan that includes taking a daily opiate (narcotic) medication. However, managing pain with these controlled substances can be complex and challenging, particularly since they can be addictive if not taken as prescribed. The controlled substance agreement documents the understanding between the patient and the medical provider, promoting clear and un-ambiguous communication that protects both the patient and the provider.

What Can You Do?   Discuss with your medical provider any concerns you have about your pain management plan and the controlled substance agreement. Understand the agreement fully before you sign it, including the medications covered by the agreement, how it affects emergency care, and consequences of breaking the agreement. Understand your rights and responsibilities.

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8. First Trimester Prenatal Care       GOAL: > 90%

Description:   Percent of patients seen for prenatal visits who initiated their prenatal care in the first trimester.

Why Is It Important?   Women who are pregnant should see a doctor to initiate prenatal care as soon as possible after learning they are pregnant. The goal of prenatal care is to make sure a healthy baby is born while minimizing the risk for the mother. For the best possible chance of achieving this objective, the doctor needs to be involved as early as possible to evaluate and monitor the health status of both mother and fetus, as well as to anticipate and treat problems.

What Can You Do?   Make an appointment to see an obstetrician as soon as you find out you’re pregnant. Make sure your primary care provider knows that you are pregnant and receives your OB records so that he or she can provide better comprehensive care.

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9. Birth Weight       GOAL: > 90%

Description:   Percent of infants weighing at least 2,500 grams at birth, of those born to women seen for prenatal care.

Why Is It Important?   Low birth weight is an important predictor of newborn health and survival as well as a higher risk of childhood mortality. It has also been found to be associated with delayed or diminished intellectual and physical development. Birth weight is affected by many factors, some of which include maternal age, number of previous pregnancies, nutrition, addictions, smoking status, whether the mother received prenatal care, environmental exposures, home hygiene, and maternal illness during pregnancy. Birth weights lower than 2500 grams (5.5 pounds) are considered low.

What Can You Do?   If you are pregnant, seek prenatal care as early as possible and follow the recommendations of your obstetrician.

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10. Child Immunizations       GOAL: > 53%

Description:   Percent of patients turning 2 years old in the past year who have received all of the following immunizations before their 2nd birthdays: 4 DTP/DTaP (diptheria, tetanus, pertussis), 3 IPV (polio), 1 MMR (measles, mumps, rubella), 3 Hib, 3 HepB (hepatitis B), 1 VZV (chickenpox), 4 PCV (pneumococcal), 1 HepA (hepatitis A), 2/3 Rotavirus, and 2 Influenza.

Why Is It Important?   Millions of lives have been saved by vaccines. Diseases that used to be common and even life-threatening can now be prevented by vaccination. Vaccine-preventable diseases are costly in terms of both resources (parents’ time off work to look after sick children, doctor’s visits, hospitalizations) and human life (premature deaths). However, children who receive their vaccinations in a timely fashion are less likely to contract vaccine preventable diseases or suffer from the consequences of those diseases.

What Can You Do?   Educate yourself about the facts regarding vaccination. Talk to your doctor about childhood immunizations at the first pediatric visit and develop a vaccination schedule that will ensure your child receives all recommended vaccinations in the recommended timeframe.

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11. Child and Adolescent Weight Assessment and Counseling       GOAL: > 50%

Description:   Percent of patients age 3-17 years who had BMI (body mass index) percentile, counseling for nutrition, and counseling for physical activity documented in their charts in the past year.

Why Is It Important?   Childhood and adolescent obesity is on the rise and has become a national concern due to the serious health consequences of obesity. Obesity is a risk factor for many serious diseases, including diabetes, heart disease, stroke, and high blood pressure, among others. Although many of the consequences of obesity may not become evident until adulthood, intervention during childhood and adolescence can improve weight and foster a healthier lifestyle at all stages of life. If body mass index (a measure of weight status) is recorded and patients and their parents are counseled and educated on nutrition and physical activity, then the likelihood of obesity and its consequences will be reduced.

What Can You Do?   Talk to your doctor about how you (as a parent or child) can make healthier lifestyle choices, including increasing physical activity and planning/eating healthier meals. The East Jordan Family Health Center has information available to help you.

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12. Cervical Cancer Screening       GOAL: > 54%

Description:   Percent of female patients age 24-64 years who have received a pap test in the past 3 years or, if age 30 or older, a pap test with a concurrent HPV test during the past 5 years.

Why Is It Important?   Cervical cancer screening can help find changes in the cervix before cancer has a chance to develop. It is key to detecting cervical cancer in its earlier, most treatable stages. Research shows that screening reduces cervical cancer rates by 60% to 90% in populations that previously had no screening. The US Preventive Services Task Force recommends that women age 21-65 have a pap test every 3 years. Alternatively, women over age 30 may instead have a pap test combined with an HPV test every 5 years.

What Can You Do?   Make sure that you schedule a pap test with your primary care provider or gynecologist according to these guidelines. Follow your doctor’s instructions if the test results show abnormalities. If you have the screening somewhere other than our clinic, please ask that your results be sent to your primary care provider so that he or she can better manage your care in a comprehensive, patient-centered way. Tell your primary care provider if you have been screened elsewhere.

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13. Colorectal Cancer Screening       GOAL: > 52%

Description:   Percent of patients age 50-75 years who had appropriate screening for colorectal cancer. Appropriate screening includes a colonoscopy in the past 10 years, a flexible sigmoidoscopy in the past 5 years, or a fecal occult blood test in the past 1 year.

Why Is It Important?   Colorectal cancer is one of the leading causes of cancer death in the United States. There is convincing evidence that screening with a recommended method reduces colorectal cancer deaths in adults between 50 and 75 years old. Screening is important to detect cancer early so that treatment can be more effective and premature death can be avoided.

What Can You Do?   If you are age 50 or older or have higher-than-average risk for colorectal cancer, talk to your doctor about the options available for screening. Colonoscopies only need to be done every 10 years but are not necessarily the best option for everyone. Fecal occult blood tests (FOBT) can also screen for colorectal cancer, can be done in the privacy of your home, and are inexpensive, but they need to be done every year. If you have or have had a colonoscopy or other screening elsewhere, please tell your primary care provider so that he or she can manage your overall care more effectively.

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14. Depression Screening and Follow-Up Plan      GOAL: > 56%

Description:   Percent of patients age 12 and older who were screened with a PHQ-2 standardized depression screening tool in the past year and who had a follow-up plan documented in their chart if diagnosed with depression.

Why Is It Important?   Clinical depression is a serious illness that can complicate other medical conditions and even lead to suicide. Screening for depression helps us identify and help people who might not realize what they are experiencing is not “normal”, who are reluctant to start the conversation about it, who are unaware their medical provider can help, or who are unaware it can often be treated effectively.

What Can You Do?   Talk to your doctor or their nurse if you think you might be depressed (see the PHQ-2 questions on our current Focus Corner page). If you are diagnosed with depression, work with your doctor to understand treatment options and create a plan to manage your depression. Understand any medications you are taking for your depression.

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15. Adult Weight Assessment and Follow-Up       GOAL: > 70%

Description:   Percent of adult patients who had their Body Mass Index (BMI) calculated within the last 6 months and, if the BMI was outside parameters, had a follow-up plan documented in their chart.

Why Is It Important?   Body mass index (BMI), calculated using a person’s height and weight, is an easy-to-measure indicator of body fatness for most people. As your BMI increases, so does your risk for many serious illnesses, including heart attack, stroke, diabetes, and high blood pressure, to name a few. Routinely calculating and recording BMI and developing follow-up plans when needed can reduce the likelihood of the debilitating consequences of serious weight problems.

What Can You Do?   Talk to your doctor or nurse about the health risks associated with obesity, and discuss your readiness to work toward becoming healthier. Your provider can help you develop a plan to become healthier and reduce your risk of developing debilitating illnesses.

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16. Tobacco Use Assessment and Counseling       GOAL: > 93%

Description:   Percent of adult patients who (a) were asked whether they use tobacco, and (b) received cessation counseling or medication if identified as a tobacco user.

Why Is It Important?   Tobacco use (including smokeless tobacco) is an important risk factor for many serious illnesses, including cancer, heart disease, stroke, and respiratory disease. It is the leading preventable cause of death in the United States. The US Preventive Services Task Force has found convincing evidence that smoking cessation counseling by doctors increases quit rates.

What Can You Do?   If you use tobacco, talk to your doctor about the health risks of continued tobacco use and your readiness to quit. In addition to directing you toward resources that can help you, they may be able to prescribe a medication that will aid you in your efforts to quit.

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17. Senior Immunizations (Flu)       GOAL: > 61%

Description:   Percent of patients age 65 and older who received a flu vaccine in the past year.

Why Is It Important?   Our immune systems tend to weaken as we get older, putting us at higher risk for certain illnesses and diseases, including seasonal influenza (“the flu”). Furthermore, the severity of the illness can be higher for older adults. It is recommended that anyone age 65 and older have a seasonal flu vaccination every year to prevent potentially debilitating illness.

What Can You Do?   In the fall of every year, ask your doctor for a flu shot or get one at a community flu clinic or health department. If you get your vaccination outside the Health Center, please tell your doctor so he or she may note it in your health record and better manage your overall care.

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18. Senior Immunizations (Pneumococcal)       GOAL: > 60%

Description:   Percent of patients age 65 and older who received a pneumococcal vaccine within the last 10 years or after age 65.

Why Is It Important?   Our immune systems tend to weaken as we get older, putting us at higher risk for certain illnesses and diseases, including pneumococcal diseases that cause infections in the lungs, blood, brain, and ear. The severity of these illnesses can also be higher for older adults. It is recommended that anyone age 65 and older have a pneumococcal vaccination to prevent potentially debilitating illness. A single vaccination is sufficient according to current guidelines.

What Can You Do?   If you are age 65 or older, ask your doctor for a pneumococcal vaccination. If you get your vaccination outside the Health Center, please tell your doctor so he or she may note it in your health record and better manage your overall care.

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