Table 6B: Quality of Care Measures

Prenatal Care Provided by Referral Only
Answer	Number of Health Centers	% Total
Yes	37	21.76%
No	133	78.24%

Section A - Age Categories for Prenatal Care Patients: Demographic Characteristics of Prenatal Care Patients

Line	Age	Number of Patients (a)	Percent
1.	Less than 15 Years	52	0.04%
2.	Ages 15–19	5,366	4.50%
3.	Ages 20–24	25,225	21.15%
4.	Ages 25–44	88,105	73.88%
5.	Ages 45 and Over	508	0.43%
6.	Total Patients (Sum of Lines 1–5)	119,256	100.00%

Section B - Early Entry into Prenatal Care

Line	Early Entry into Prenatal Care	Patients Having First Visit with Health Center (a)		Patients Having First Visit with Another Provider (b)		% Total
		(a)	%	(b)	%
7.	First Trimester	85,139	71.39%	6,874	5.76%	77.16%
8.	Second Trimester	20,383	17.09%	2,090	1.75%	18.84%
9.	Third Trimester	3,863	3.24%	907	0.76%	4.00%

Section C - Childhood Immunization Status

Line	Childhood Immunization Status	Total Patients with 2nd Birthday (a)	Estimated Number of Patients Immunized **	Estimated % of Patients Immunized
10.	MEASURE: Percentage of children 2 years of age who received age appropriate vaccines by their 2nd birthday	75,739	22,144	29.24%

Section D - Cervical and Breast Cancer Screening

Line	Cervical Cancer Screening	Total Female Patients Aged 24 through 64 (a)	Estimated Number of Patients Tested **	Estimated % of Patients Tested
11.	MEASURE: Percentage of women 24-64 years of age who were screened for cervical cancer	1,557,761	961,067	61.70%
Line	Breast Cancer Screening	Total Female Patients Aged 52 through 74 (a)	Estimated Number of Patients with Mammogram **	Estimated % of Patients with Mammogram
11a.	MEASURE: Percentage of women 52–74 years of age who had a mammogram to screen for breast cancer	680,916	404,490	59.40%

Section E - Weight Assessment and Counseling for Nutrition and Physical Activity of Children and Adolescents

Line	Weight Assessment and Counseling for Nutrition and Physical Activity for Children and Adolescents	Total Patients Aged 3 through 17 (a)	Estimated Number of Patients Assessed and Counseled **	Estimated % of Patients Assessed and Counseled
12.	MEASURE: Percentage of patients 3-17 years of age with a BMI percentile and counseling on nutrition and physical activity documented	1,129,352	836,227	74.04%

Section F – Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up Plan

Line	Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up Plan	Total Patients Aged 18 and Older (a)	Estimated Number of Patients with BMI Charted and Follow-Up Plan Documented as Appropriate **	Estimated % of Patients with BMI Charted and Follow-Up Plan Documented as Appropriate
13.	MEASURE: Percentage of patients 18 years of age and older with (1) BMI documented and (2) follow-up plan documented if BMI is outside normal parameters	3,389,874	2,332,704	68.81%

Section G – Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention

Line	Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention	Total Patients Aged 12 and Older (a)	Estimated Number of Patients Assessed for Tobacco Use and Provided Intervention if a Tobacco User **	Estimated % of Patients Assessed for Tobacco Use and Provided Intervention if a Tobacco User
14a.	MEASURE: Percentage of patients aged 12 years of age and older who (1) were screened for tobacco use one or more times during the measurement period, and (2) if identified to be a tobacco user received cessation counseling intervention	3,417,913	2,927,164	85.64%

Section H - Statin Therapy for the Prevention and Treatment of Cardiovascular Disease

Line	Statin Therapy for the Prevention and Treatment of Cardiovascular Disease	Total Patients Aged 21 And Older at High Risk of Cardiovascular Events (a)	Estimated Number of Patients Prescribed or On Statin Therapy **	Estimated % of Patients Prescribed or On Statin Therapy
17a.	MEASURE: Percentage of patients at high risk of cardiovascular events who were prescribed or were on statin therapy	810,332	639,616	78.93%

Section I - Ischemic Vascular Disease (IVD): Use of Aspirin or Another Antiplatelet

Line	Ischemic Vascular Disease (IVD): Use of Aspirin or Another Antiplatelet	Total Patients Aged 18 And Over With IVD Diagnosis or AMI, CABG, or PCI Procedure (a)	Estimated Number of Patients with Aspirin or Other Antiplatelet Therapy **	Estimated % of Patients with Documentation of Aspirin or Other Antiplatelet Therapy
18.	MEASURE: Percentage of patients 18 years of age and older with a diagnosis of IVD or AMI, CABG, or PCI procedure with aspirin or another antiplatelet	117,591	81,956	69.70%

Section J - Colorectal Cancer Screening

Line	Colorectal Cancer Screening	Total Patients Aged 46 through 75 (a)	Estimated Number of Patients with Appropriate Screening for Colorectal Cancer **	Estimated % of Patients with Appropriate Screening for Colorectal Cancer
19.	MEASURE: Percentage of patients 46 through 75 years of age who had appropriate screening for colorectal cancer	1,610,294	714,485	44.37%

Section K - HIV Measures

Line	HIV Linkage to Care	Total Patients First Diagnosed with HIV (a)	Estimated Number of Patients Seen Within 30 Days of First Diagnosis of HIV **	Estimated % of Patients Seen Within 30 Days of First Diagnosis of HIV
20.	MEASURE: Percentage of patients whose first-ever HIV diagnosis was made by health center personnel between December 1 of the prior year and November 30 of the measurement period and who were seen for follow-up treatment within 30 days of that first-ever diagnosis	1,561	1,221	78.22%
Line	HIV Screening	Total Patients Aged 15 through 65 (a)	Estimated Number of Patients Tested for HIV **	Estimated % of Patients Tested for HIV
20a.	MEASURE: Percentage of patients 15 through 65 years of age who were tested for HIV when within age range	3,337,971	2,140,390	64.12%

Section L – Depression Measures

Line	Preventive Care and Screening: Screening for Depression and Follow-Up Plan	Total Patients Aged 12 and Older (a)	Estimated Number of Patients Screened for Depression and Follow-up Plan Documented as Appropriate **	Estimated % of Patients Screened for Depression and Follow-up Plan Documented as Appropriate
21.	MEASURE: Percentage of patients 12 years of age and older who were (1) screened for depression with a standardized tool and, if screening was positive, (2) had a follow-up plan documented	4,003,046	2,848,809	71.17%
Line	Depression Remission at Twelve Months	Total Patients Aged 12 and Older with Major Depression or Dysthymia (a)	Estimated Number of Patients who Reached Remission **	Estimated % of Patients who Reached Remission
21a.	MEASURE: Percentage of patients 12 years of age and older with major depression or dysthymia who reached remission 12 months (+/- 60 days) after an index event	92,393	18,097	19.59%

Section M – Dental Sealants for Children between 6–9 Years

Line	Dental Sealants for Children between 6-9 Years	Total Patients Aged 6 through 9 at Moderate to High Risk for Caries (a)	Estimated Number of Patients with Sealants to First Molars **	Estimated % of Patients with Sealants to First Molars
22.	MEASURE: Percentage of children 6 through 9 years of age at moderate to high risk of caries who received a sealant on a first permanent molar	42,532	27,704	65.14%

Section N – Substance Use Disorder (SUD) Measures

Line	Initiation and Engagement of Substance Use Disorder (SUD) Treatment	Total Patients Aged 13 and Older Diagnosed with a New SUD Episode (a)	Number of Records Reviewed (b)	Number of Patients who Received SUD Treatment (c)
23a.	MEASURE: Percentage of patients with a new SUD episode who initiated treatment, including either an intervention or medication for the treatment of SUD, within 14 days of the new SUD episode	74,557	16,361	21.94%
23b.	MEASURE: Percentage of patients with a new SUD episode who engaged in ongoing treatment, including two additional interventions or medication treatment events for SUD, or one long-acting medication event for the treatment of SUD, within 34 days of the initiation	74,557	5,307	7.12%

Footnotes

'-' Data cannot be calculated or has been suppressed for confidentiality purposes.

'**' The number of patients meeting the requirements for each clinical quality measure and health outcome measure is weighted to account for chart sampling.

Cells that are shaded blue represent data that was not reported or null values.

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