Confidential Report for Your Organization

Confidential Report for Your Organization

Why does it matter?

2,000

2,000 people are estimated to have

diabetes in this ZIP.¹

1,400 (70%) of the 2,000 people estimated to have diabetes in this ZIP are in

this report.

Diabetes Profile for ZIP XXXXX

Who is included in this report?

1,400

This report includes adults with diabetes, aged 18-75, who live in this ZIP and receive primary carefrom a Wisconsin Collaborative for Healthcare Quality (WCHQ) member health system that reportson all WCHQ diabetes measures.

Examining the profile of the diabetes patient population in this ZIP may help you understand howmany patients are being tested regularly, are controlling the disease through behavior changes,and/or taking medications. Testing regularly and controlling the disease can reduce the risks ofheart disease, kidney disease, eye disease, and other complications.

Page 1, 8/23/2021

Sample


These measures can help you understand thenumber of patients that are being testedregularly. Regular testing is critical to monitoringand managing diabetes. It provides amechanism for feedback on progress and theimpact of behavior changes (e.g., healthyeating, increased activity, and stoppingsmoking) and medications.

These measures can help you understandprogress in controlling diabetes and the impactof behavior changes and taking medications.

The Optimal Control and Testing measures canhelp provide insight into what percentage ofpatients are meeting all recommendedmanagement and process metrics.

Blood Sugar Testing

Kidney FunctionMonitored

eGFR Test

Tobacco Free

Blood PressureControl

Blood Sugar Control

Statin Use

Daily Aspirin

Optimal Control

Optimal Testing

Testing Measures:

Control Measures:

Putting it All Together - SummaryMeasures:

Highest Performing QuartileHighest Middle Performing QuartileLowest Middle Performing QuartileLowest Performing Quartile

Page 5

Page 6

Page 7

Page 8

Page 9

Page 10

Page 11

Page 12

Page 13

Page 14

Page 2, 8/23/2021

Sample

% Female % Over Age 65 % Uninsured

Report50%

Report28%

Report0%

ACS51%

ACS14%

ACS4%

Females tend to live longer andhave fewer chronic illnesses.

Risk for many diseasesincreases with age.

Health insurance promotesimproved health.

Systemic racism creates barriers in access to goods and services that can promote health. Itcontributes to the development of chronic conditions.

Race/Ethnicity

What else impacts health in this neighborhood?The living conditions of a neighborhood shape health more than healthcare alone. To understandthe causes of poor health in a ZIP, consider:

1. Have current or past policies reinforced systemic racism and/or income inequality in theneighborhood? Think across key sectors like business, education, and criminal justice.

2. Do all residents have a fair chance to make a livable wage?3. Do all residents have access to safe, affordable housing?4. Are all residents able to receive quality medical care? What barriers may be preventing

this?5. Do all residents have convenient access to nutritious food options?

For more questions to consider and information about social determinants of health, visitnhp.wisc.edu/resources


Who lives in this ZIP?Learning about the people who live in a neighborhood can help you understand the health needs of the community. This section provides information about the people included in this report and how they compare to overall population estimates from the American Community Survey (ACS). The most recent ACS population of this ZIP is 40,000.

Page 3, 8/23/2021

Sample

Detailed Diabetes Measure Reports

Page 4, 8/23/2021

Sample

Blood Sugar Testing in Diabetes for ZIP XXXXXThis measure reports the percentage of adults with diabetes, aged 18-75, who receive primary care from a Wisconsin Collaborative for Healthcare Quality (WCHQ) member health system, and had two or more A1c tests within the 1-year measurement period.

Who had their blood sugar tested?

How does this ZIP compare to others?

Why does it matter?

Getting an A1c test at least twice a year helps manage diabetes and prevent complications. Highblood sugar levels can harm the heart, blood vessels, kidneys, feet, and eyes.²

How has this measure changed over time?

0%

50%

100%

Dec 2016 Jun 2017 Dec 2017 Jun 2018 Dec 2018

74% 73% 72% 71% 72%

72%72%

77%76%

96%

ZIP XXXXXX County Overall Average X County Highest Performing ZIP Wisconsin Overall Average Wisconsin Highest Performing ZIP

ZIP XXXXXCounty

BenchmarksState

Benchmarks

1,008 (72%) of the 1,400 people in this report had

their blood sugar tested as of Dec 2018.

1,0082,000



1,400 (70%) of the 2,000 people estimated to have diabetes in this

ZIP are in this report.

1,400

Page 5, 8/23/2021

Sample

Kidney Function Screening in Diabetes for ZIP XXXXXThis measure reports the percentage of adults with diabetes, aged 18-75, who receive primary care from a Wisconsin Collaborative for Healthcare Quality (WCHQ) member health system, and were screened and/or monitored for kidney disease within the 1-year measurement period.

Who had their kidney function screened?


Why does it matter?

People who have diabetes are more likely to develop kidney disease and usually do not havesymptoms. It is important to monitor kidney function to get early treatment for kidney disease.³


0%

50%

100%


94% 95% 95% 94% 94%

94%94%

99%95%

100%


ZIP XXXXXCounty

BenchmarksState

Benchmarks


their kidney function screened as of Dec 2018.

1,3162,000





1,400

Page 6, 8/23/2021

Sample

eGFR Test in Diabetes for ZIP XXXXXThis measure reports the percentage of adults with diabetes, aged 18-75, who receive primary care from a Wisconsin Collaborative for Healthcare Quality (WCHQ) member health system, and have had an estimated glomerular filtration (eGFR) test within the 1-year measurement period.

Who had an eGFR test?


Why does it matter?

People who have diabetes are more likely to develop kidney disease and usually do not havesymptoms. It is important to monitor kidney function to get early treatment for kidney disease.³


0%

50%

100%


92% 91% 92% 90% 85%

85%88%

95%93%

100%


ZIP XXXXXCounty

BenchmarksState

Benchmarks

1,190 (85%) of the 1,400 people in this report had an eGFR test as of Dec 2018.

1,1902,000





1,400

Page 7, 8/23/2021

Sample

Tobacco-Free in Diabetes for ZIP XXXXXThis measure reports the percentage of adults with diabetes, aged 18-75, who receive primary care from a Wisconsin Collaborative for Healthcare Quality (WCHQ) member health system, whose most recent tobacco status was tobacco-free within the 1-year measurement period.

Who were tobacco-free?


Why does it matter?

Quitting smoking reduces the risk of heart attack, stroke, nerve disease, kidney disease, eyedisease, and amputation.²


0%

50%

100%


81% 82% 82% 82% 80%

80%87%

93%86%

99%


ZIP XXXXXCounty

BenchmarksState

Benchmarks

1,120 (80%) of the 1,400 people in this report were

tobacco-free as of Dec 2018.

1,1202,000





1,400

Page 8, 8/23/2021

Sample

Blood Pressure Control in Diabetes for ZIP XXXXXThis measure reports the percentage of adults with diabetes, aged 18-75, who receive primary care from a Wisconsin Collaborative for Healthcare Quality (WCHQ) member health system, whose most recent blood pressure reading within the 1-year measurement period was controlled to less than 140/90 mmHg.

Who had their blood pressure under control?


Why does it matter?

Every 10 mmHg reduction in systolic blood pressure significantly reduces the risk of majorcardiovascular disease events, coronary heart disease, stroke, and heart failure.


0%

50%

100%


85% 87% 86% 88% 84%

84%84%

89%84%

96%


ZIP XXXXXCounty

BenchmarksState

Benchmarks


their blood pressure under control as of Dec 2018.

1,1762,000





1,400

Page 9, 8/23/2021

Sample

Blood Sugar Control in Diabetes for ZIP XXXXXThis measure reports the percentage of adults with diabetes, aged 18-75, who receive primary care from a Wisconsin Collaborative for Healthcare Quality (WCHQ) member health system, and whose most recent A1c blood sugar level was controlled to less than 8.0% within the 1-year measurement period.

Who had their blood sugar under control?


Why does it matter?

High blood sugar levels can harm the heart, blood vessels, kidneys, feet, and eyes.²


0%

50%

100%


68% 66% 66% 63% 59%

59%65%

78%72%

86%


ZIP XXXXXCounty

BenchmarksState

Benchmarks

826 (59%) of the 1,400 people in this report had their blood sugar under control as of Dec 2018.

8262,000





1,400

Page 10, 8/23/2021

Sample

Statin Use in Diabetes for ZIP XXXXXThis measure reports the percentage of adults with diabetes, aged 40-75, or with diabetes and heart disease regardless of age, who receive primary care from a Wisconsin Collaborative for Healthcare Quality (WCHQ) member health system, and have documented statin use within the 1-year measurement period.

Who used a statin?


Why does it matter?

Taking statins reduces the risk of heart attack or stroke in some people with diabetes.²


0%

50%

100%


82% 82% 83% 85% 84%

84%84%

92%87%

98%


ZIP XXXXXCounty

BenchmarksState

Benchmarks

1,008 (84%) of the 1,200 people in this report used a

statin as of Dec 2018.

1,0081,200





1,200

Page 11, 8/23/2021

Sample

Daily Aspirin in Heart Disease and Diabetes for ZIP XXXXXThis measure reports the percentage of adults with diabetes and heart disease, aged 18-75, who receive primary care from a Wisconsin Collaborative for Healthcare Quality (WCHQ) member health system, with documentation in their medical record of daily aspirin or other daily antiplatelet therapy within the 1-year measurement period.

Who had daily aspirin prescribed?


Why does it matter?

A daily aspirin can help prevent heart attacks and strokes for those with diabetes and heart disease,but it is not safe for everyone.²


0%

50%

100%


96% 98% 98% 97% 99%

99%97%99%98%

100%


ZIP XXXXXCounty

BenchmarksState

Benchmarks

129 (99%) of the 130 people in this report had

daily aspirin prescribed as of Dec 2018.

129500

500 people are estimated to have


130 (26%) of the 500 people estimated to have diabetes in this


130

Page 12, 8/23/2021

Sample

Optimal Control in Diabetes for ZIP XXXXXThis measure reports the percentage of adults with diabetes, aged 18-75, who receive primary care from a Wisconsin Collaborative for Healthcare Quality (WCHQ) member health system, and met all of the following conditions within the 1-year measurement period: most recent A1c test result was less than 8%, most recent blood pressure measurement was less than 140/90 mmHg, most recent tobacco status was tobacco-free, were prescribed daily aspirin or other antiplatelet for adults with heart disease, and used a statin.Who had optimal control in diabetes?


Why does it matter?

Managing diabetes reduces the risk of heart disease, kidney disease, eye disease, andamputation.²


0%

50%

100%


40% 40% 41% 41% 38%

38%43%

59%47%

64%


ZIP XXXXXCounty

BenchmarksState

Benchmarks

532 (38%) of the 1,400 people in this report had

optimal control in diabetes as of Dec 2018.

5322,000





1,400

Page 13, 8/23/2021

Sample

Optimal Testing in Diabetes for ZIP XXXXXThis measure reports the percentage of adults with diabetes, aged 18-75, who receive primary care from a Wisconsin Collaborative for Healthcare Quality (WCHQ) member health system, and met all of the following conditions: two A1c tests performed within the 1-year measurement period, one kidney function test performed and/or diagnosis and treatment of kidney disease within the 1-year measurement period, and a minimum of one eGFR test within the 1-year measurement period.

Who had optimal testing in diabetes?


Why does it matter?

Getting regular tests is important for managing diabetes and preventing complications.²


0%

50%

100%


71% 69% 68% 66% 63%

63%64%

74%72%

96%


ZIP XXXXXCounty

BenchmarksState

Benchmarks

882 (63%) of the 1,400 people in this report had

optimal testing in diabetes as of Dec 2018.

8822,000





1,400

Page 14, 8/23/2021

Sample

References

Diabetes Profile for ZIP XXXXXWhere do the health system data come from?The primary data source is the Wisconsin Collaborative for Healthcare Quality. Health system data may include duplicate patient records if a patient receives care from more than one system. As of the date of this report, participating health systems include:

¹Data from U.S. Census 2014-2018 American Community Survey 5-Year estimates are used for population size and demographics. The Wisconsin Behavioral Risk Factor Survey 2011-2017, along with the ACS data, is used to calculate condition prevalence and report coverage.

²The National Institute of Diabetes and Digestive and Kidney Diseases. Diabetes, Heart Disease, and Stroke. February 2017. https://www.niddk.nih.gov/health-information/diabetes/overview/preventing-problems/heart-disease-stroke/

³The National Institute of Diabetes and Digestive and Kidney Diseases. Diabetic Kidney Disease. February 2017. https://www.niddk.nih.gov/health-information/diabetes/overview/preventing-problems/diabetic-kidney-disease

Ettehad D, Emdin CA, Kiran A, et al. Blood pressure lowering for prevention of cardiovascular disease and death: a systematic review and meta-analysis. Lancet. 2016;387(10022):957-967.

Supplemental MaterialsFor more information on the data used in this report, read "Making Sense of the Data“ atnhp.wisc.edu/data.

CitationUniversity of Wisconsin ICTR Neighborhood Health Partnerships Program and Wisconsin Collaborative for Healthcare Quality. Diabetes Profile Report for ZIP XXXXX as of December 2018, August 2021.NoteThis report is for use only by the requester and their partners in efforts to improve neighborhood health. Do not post or distribute publicly without written permission from the NHP program. For questions, support, or more information, contact [email protected]

Page 15, 8/23/2021

Sample

mailto:[email protected]

https://www.niddk.nih.gov/health-information/diabetes/overview/preventing-problems/heart-

https://www.niddk.nih.gov/health-information/diabetes/overview/preventing-problems/diabetic-kidney-disease

Diabetes Profile for ZIP XXXXXIs there anything else I should know about the data in this report?There are no known issues with missing health system data in this report.

If you have questions, please contact [email protected].

Page 16, 8/23/2021

Sample

mailto:[email protected]

Documents

Confidential Report for Your Organization