Table 1.
Chronic Disease Measures and Improvement Changes
| Disease groups | Measures (N = 211) | Specific measures (N) | Change % mean (SD) |
|---|---|---|---|
| Asthma | 18 | ||
| Process measures | 16 |
Assessment of asthma, environmental triggers, or level of control (5) Asthma action plan, controller medication, or follow-up visits (7) Flu vaccination (2) Smoking counseling (1) Use of spirometry (1) |
15.1% (13.1) |
| Outcome measures | 2 |
ER visits due to asthma Hospitalizations due to asthma |
1.3% (6.0) |
| Cancer | 37 | ||
| Breast cancer process measures | 19 |
Breast examination or self-examination (4) Chest radiography (1) Mammograms offered, mentioned, screening, or reports (10) Teaching breast exam (1) Unspecified breast cancer screening (3) |
8.0% (7.8) |
| Cervical cancer process measures | 6 |
Cervical cytology or pap smear (3) STD screening (1) Unspecified cervical cancer screening (2) |
4.9% (3.5) |
| Colorectal cancer process measures | 12 |
Digital rectal examination or sigmoidoscopy (2) Genetic screen for colorectal cancer (1) Increased fiber recommendation (1) Reduced fat recommendation (1) Smoking cessation counseling (1) Stool occult blood screening (1) Unspecified colorectal cancer screening (5) |
5.0% (5.0) |
| Cardiovascular disease | 66 | ||
| Process measures (cerebrovascular disease, hypertension, myocardial infarction, and unspecified) | 56 |
Blood pressure screening or monitoring (3) BMI, waist screening, weight control, weight control referral (4) Cholesterol screening or treatment (2) Folic acid supplement (2) Framingham Risk Score calculated (1) Influenza vaccination (2) Nicotine replacement therapy (1) Screening of aspirin or prescription of ACE/ARB and/or statin (3) Screening or intervention in alcohol use, diet and nutrition, physical activity, or tobacco use (36) Unspecified treatment of hypertension (2) |
10.3% (13.1) |
| Outcome measures (cerebrovascular disease, coronary artery disease, dyslipidemia, hypertension, peripheral vascular disease, and unspecified) | 10 |
Control or improvement in blood pressure (5) Control or improvement in cholesterol (3) Framingham Risk Score improved (1) Hospitalization rates improved (1) |
10.0% (9.9) |
| Chronic kidney disease | 21 | ||
| Process measures | 16 |
Anemia diagnosis (1) CKD diagnosis (1) Medication use (ACE inhibitor, ARB use or prescribed, aspirin, metformin, NSAID) (6) Screening of cholesterol, HbA1c, hemoglobin, urine, proteinuria, or vitamin D (8) |
6.1% (17.6) |
| Outcome measures | 5 |
Blood pressure improved (2) Cholesterol improved (1) GFR mean improved (1) Hba1c improved (1) |
0.2% (1.1) |
| Diabetes, type 2 | 69 | ||
| Process measures | 49 |
ACEI for hypertension or if proteinuria (2) Blood pressure, cholesterol, HbA1c, Triglycerides, microalbumin screening (14) Blood sugar/glucose monitoring or screening (3) Eye, retinal exam, or foot exam (13) Flu vaccination or pneumovax screening (4) Nephropathy or neuropathy screening (5) Nutrition counseling (1) Prescription of ACE inhibitor, antiplatelet therapy, statin (3) Self-management goals and support (2) Urinalysis for proteinuria (1) |
10.1% (8.9) |
| Outcome measures | 20 |
Blood pressure controlled and improved (6) Cholesterol controlled or improved (6) HbA1c controlled or improved (8) Triglyceride controlled (1) |
4.9% (3.9) |