ABOUT THE DATA

Primary Care Practice

What is a primary care practice?

A primary care practice is a practice with doctors who specialize in Family Medicine and Internal Medicine.

What type of data is reported on YourHealthMatters?

YourHealthMatters reports ratings based on:

  • Clinical data which means it’s about medical treatment and testing. This covers the areas of diabetes, cardiovascular disease and colon cancer screening.
  • Patient surveys which are standardized and validated questionnaires asking about a patient’s experience after going to their doctor’s office. More information about patient survey data can be found here.

Why is this information important to me?

You can use the primary care practice results on this website to:

  • Learn what quality care is and what you should expect from your primary care doctor.
  • Compare quality ratings of primary care practices in Greater Cincinnati, to see how well they provide diabetes care, cardiovascular care and colon cancer screenings.
  • Help select a primary care practice for you and your family.
  • Learn about things you can do to take charge of your health.
Collecting the data

Primary Care Practices

The gold standard for collecting and measuring clinical data is to take the information directly from patient charts. While all primary care practices follow strict data submission guidelines and specifications, the data collection varies from one practice to another. The practices use electronic medical records, paper charts, or a combination of both, to collect the data.

After collecting the information, the primary care practices voluntarily submit the clinic data to the Health Improvement Collaborative, to be used for measurement and public reporting. All participating primary care practices follow a rigorous process of data reporting and are independently audited to confirm accuracy.

Analyzing the Data

Staff from the Health Collaborative assists primary care practices in formatting and submitting their data to a secure web-based data portal. Upon submission, the secure data portal automatically analyzes the data according to clinical goals. Preliminary results are provided to the primary care practices and their physicians for review. The Health Collaborative staff validates the data and after passing an audit, the preliminary scores are finalized for public reporting. 

Validating the Data

The Health Collaborative coordinates with primary care practices to randomly audit the submitted data. The practices do not know which charts will be audited, and according to the data submission guidelines, the data submitted must match the most recent data in the charts. If the data submitted were incorrect, an error is reported. The practices must pass an audit and be above the high standard for errors, such as errors related to data entry typos or not finding a more recent data value, before the data can be finalized and publicly reported.

Benchmarks

A benchmark is like a gauge or yardstick that helps us understand, measure and compare information. When a primary care practice regularly provides high quality care, this sets the benchmark for other primary care practices to achieve. For example, a result of 50% may not seem like a good result; however, if other primary care practices are at 15%, the primary care practice at 50% is doing much better, though there is still room for improvement.

Does a low score mean that doctors in the primary care practice give poor care?

A low score does not necessarily mean that the doctors in the primary care practice are providing poor care. Several factors can lower a practice’s score:

  • Timing: If the goals aren’t met within the required timeframe, they are not counted.
  • Patient participation: Not all patients follow doctor’s advice or follow through with recommended care.
  • Data lag: Your primary care practice’s performance may have changed since the most recent quality ratings were reported.
Risk Adjustment

The Health Collaborative is currently not reporting risk-adjusted data, but may choose to in the future. Risk adjustment is a statistical process of modifying the data to account for factors that affect primary care practice results, such as patient age, gender, severity of illness and complications. Risk adjustment is often used when comparing primary care practices that treat different types of patient populations, such as practices who treat patients with more complicated illnesses than other practices. Risk adjustment helps address differences that are within and outside a practice’s control, allowing for a more “apples-to-apples” comparison.

Diabetes

How Primary Care Practices Are Measured

YourHealthMatters shows how doctors in the Greater Cincinnati area did in providing diabetes care. The results show how well doctors and their patients did in meeting the five diabetes goals:

  • Blood pressure less than 140/90
  • Level of bad cholesterol (LDL) less than 100 mg/dl
  • Blood sugar (A1c) less than 8%
  • Remain tobacco-free
  • Take aspirin daily as recommended

The goals, when achieved together, represent the professionally recognized standard for managing diabetes, as established by the National Quality Forum (NQF). In order for a practice to get a single point, one patient must meet all five diabetes goals; missing just one goal results in the practice getting a score of zero for that patient.

Scores and Participating Practices

The most current diabetes data available are from 2013, with scores for previous years available from 2009-2013.

The data include the scores from providers that were in their practice at the specific point in time. The providers may or may not currently be affiliated with practices listed. Additionally, the practice may or may not have changed affiliation since the time of data collection.

Greater Cincinnati Regional Average

The Greater Cincinnati Regional Average shows how well area practices and diabetes patients did in meeting all five diabetes goals.

The Greater Cincinnati Regional Average is calculated by adding the percentages of diabetes patients from each practice who met all five goals and dividing that sum by the number of practices reporting data.

2014 Greater Cincinnati Regional Averages

  • Overall Score: 36% This means that 36 out of 100 diabetes patients met all five goals.
  • Blood pressure less than 140/90: 82%. This means that 82 out of 100 diabetes patients have blood pressure under control.
  • Level of bad cholesterol (LDL) less than 100 mg/dl: 61%. This means that 61 out of 100 diabetes patients have bad cholesterol under control.
  • Blood sugar (A1c) less than 8%: 72%. This means that 72 out of 100 diabetes patients have blood sugar under control.
  • Remain tobacco-free: 84%. This means that 84 out of 100 diabetes patients don’t smoke.
  • Take aspirin daily as recommended: 98%. This means that 98 out of 100 diabetes patients take a daily aspirin as recommended.

2013 Greater Cincinnati Regional Averages

  • Overall Score: 35%. This means that 35 out of 100 diabetes patients met all five goals.
  • Blood pressure less than 140/90: 80%. This means that 80 out of 100 diabetes patients have blood pressure under control.
  • Level of bad cholesterol (LDL) less than 100 mg/dl: 60%. This means that 60 out of 100 diabetes patients have bad cholesterol under control.
  • Blood sugar (A1c) less than 8%: 72%. This means that 72 out of 100 diabetes patients have blood sugar under control.
  • Remain tobacco-free: 84%. This means that 84 out of 100 diabetes patients don’t smoke.
  • Take aspirin daily as recommended: 97%. This means that 97 out of 100 diabetes patients take a daily aspirin as recommended.

2012 Greater Cincinnati Regional Averages

  • Overall Score: 29%. This means that 29 out of 100 diabetes patients met all five goals.
  • Blood pressure less than 140/90: 75%. This means that 75 out of 100 diabetes patients have blood pressure under control.
  • Level of bad cholesterol (LDL) less than 100 mg/dl: 56%. This means that 56 out of 100 diabetes patients have bad cholesterol under control.
  • Blood sugar (A1c) less than 8%: 70%. This means that 70 out of 100 diabetes patients have blood sugar under control.
  • Remain tobacco-free: 82%. This means that 82 out of 100 diabetes patients don’t smoke.
  • Take aspirin daily as recommended: 97%. This means that 97 out of 100 diabetes patients take a daily aspirin as recommended.

2011 Greater Cincinnati Regional Averages

  • Overall Score: 30%. This means that 30 out of 100 diabetes patients met all five goals.
  • Blood pressure less than 140/90: 75%. This means that 75 out of 100 diabetes patients have blood pressure under control.
  • Level of bad cholesterol (LDL) less than 100 mg/dl: 57%. This means that 57 out of 100 diabetes patients have bad cholesterol under control.
  • Blood sugar (A1c) less than 8%: 71%. This means that 71 out of 100 diabetes patients have blood sugar under control.
  • Remain tobacco-free: 81%. This means that 81 out of 100 diabetes patients don’t smoke.
  • Take aspirin daily as recommended: 96%. This means that 96 out of 100 diabetes patients take a daily aspirin as recommended.

2010 Greater Cincinnati Regional Averages

  • Overall Score: 28%. This means that 28 out of 100 diabetes patients met all five goals.
  • Blood pressure less than 140/90: 75%. This means that 75 out of 100 diabetes patients have blood pressure under control.
  • Level of bad cholesterol (LDL) less than 100 mg/dl: 56%. This means that 56 out of 100 diabetes patients have bad cholesterol under control.
  • Blood sugar (A1c) less than 8%: 70%. This means that 70 out of 100 diabetes patients have blood sugar under control.
  • Remain tobacco-free: 80%. This means that 80 out of 100 diabetes patients don’t smoke.
  • Take aspirin daily as recommended: 96%. This means that 96 out of 100 diabetes patients take a daily aspirin as recommended.

2009 Greater Cincinnati Regional Averages

  • Overall Score: 9%. This means that 9 out of 100 diabetes patients met all five goals.
  • Blood pressure less than 130/80: 42%. This means that 42 out of 100 diabetes patients have blood pressure under control.
  • Level of bad cholesterol (LDL) less than 100 mg/dl: 56%. This means that 56 out of 100 diabetes patients have bad cholesterol under control.
  • Blood sugar (A1c) less than 7%: 49%. This means that 49 out of 100 diabetes patients have blood sugar under control.
  • Remain tobacco-free: 80%. This means that 80 out of 100 diabetes patients don’t smoke.
  • Take aspirin daily: 64%. This means that 64 out of 100 diabetes patients over the age of 40 take an aspirin daily.
Cardiovascular Health

How Primary Care Practices Are Measured

YourHealthMatters shows how doctors in the Greater Cincinnati area did in providing cardiovascular health. The results show how well doctors and their patients did in meeting the four cardiovascular health goals:

  • Blood pressure less than 140/90
  • Level of bad cholesterol (LDL) less than 100 mg/dl
  • Remain tobacco-free
  • Take aspirin daily as recommended

The goals, when achieved together, represent the professionally recognized standard for cardiovascular health, as established by the National Quality Forum (NQF). In order for a practice to get a single point, one patient must meet all four cardiovascular health goals; missing just one goal results in the practice getting a score of zero for that patient.

Scores and Participating Practices
The most current cardiovascular health data available are from 2012, 2014 with scores for previous years available from 2010.

The data include the scores from providers that were in their practice at that specific point in the time. The providers may or may not currently be affiliated with practices listed. Additionally, the practice may or may not have changed affiliation since the time of data collection.

Greater Cincinnati Regional Average
The Greater Cincinnati Regional Average shows how well area practices and cardiovascular patients did in meeting all four cardiovascular health goals.

The Greater Cincinnati Regional Average is calculated by adding the percentages of cardiovascular patients from each practice who met all four goals and dividing that sum by the number of practices reporting data.

2014 Greater Cincinnati Regional Averages

  • Overall Score: 42%. This means that 42 out of 100 cardiovascular patients met all four goals.
  • Blood pressure less than 140/90: 82%. This means that 82 out of 100 cardiovascular patients have blood pressure under control.
  • Level of bad cholesterol (LDL) less than 100 mg/dl: 63%. This means that 63 out of 100 cardiovascular patients have bad cholesterol under control.
  • Remain tobacco-free: 79%. This means that 79 out of 100 cardiovascular patients don’t smoke.
  • Take aspirin daily as recommended: 92%. This means that 92 out of 100 cardiovascular patients take a daily aspirin as recommended.

2013 Greater Cincinnati Regional Averages

  • Overall Score: 42%. This means that 42 out of 100 cardiovascular patients met all four goals.
  • Blood pressure less than 140/90: 82%. This means that 82 out of 100 cardiovascular patients have blood pressure under control.
  • Level of bad cholesterol (LDL) less than 100 mg/dl: 65%. This means that 65 out of 100 cardiovascular patients have bad cholesterol under control.
  • Remain tobacco-free: 81%. This means that 81 out of 100 cardiovascular patients don’t smoke.
  • Take aspirin daily as recommended: 89%. This means that 89 out of 100 cardiovascular patients take a daily aspirin as recommended.

2012 Greater Cincinnati Regional Averages

  • Overall Score: 30%. This means that 30 out of 100 cardiovascular patients met all four goals.
  • Blood pressure less than 140/90: 76%. This means that 76 out of 100 cardiovascular patients have blood pressure under control.
  • Level of bad cholesterol (LDL) less than 100 mg/dl: 59%. This means that 59 out of 100 cardiovascular patients have bad cholesterol under control.
  • Remain tobacco-free: 78%. This means that 78 out of 100 cardiovascular patients don’t smoke.
  • Take aspirin daily as recommended: 73%. This means that 73 out of 100 cardiovascular patients take a daily aspirin as recommended.

2011 Greater Cincinnati Regional Averages

  • Overall Score: 29%. This means that 29 out of 100 cardiovascular patients met all four goals.
  • Blood pressure less than 140/90: 77%. This means that 77 out of 100 cardiovascular patients have blood pressure under control.
  • Level of bad cholesterol (LDL) less than 100 mg/dl: 57%. This means that 57 out of 100 cardiovascular patients have bad cholesterol under control.
  • Remain tobacco-free: 66%. This means that 66 out of 100 cardiovascular patients don’t smoke.
  • Take aspirin daily as recommended: 83%. This means that 83 out of 100 cardiovascular patients take a daily aspirin as recommended.

2010 Greater Cincinnati Regional Averages

  • Overall Score: 28%. This means that 28 out of 100 cardiovascular patients met all four goals.
  • Blood pressure less than 140/90: 77%. This means that 77 out of 100 cardiovascular patients have blood pressure under control.
  • Level of bad cholesterol (LDL) less than 100 mg/dl: 57%. This means that 57 out of 100 cardiovascular patients have bad cholesterol under control.
  • Remain tobacco-free: 62%. This means that 62 out of 100 cardiovascular patients don’t smoke.
  • Take aspirin daily as recommended: 87%. This means that 87 out of 100 cardiovascular patients take a daily aspirin as recommended.
Colon Cancer Screening

How Primary Care Practices Are Measured

YourHealthMatters shows how well doctors in the Greater Cincinnati area did in providing their patients appropriate screening for colon cancer. The goal for doctors and their patients is that all patients ages 50-75 should be screened for colon cancer.

Patients are up to date in their screening for colon cancer if they’ve had one of the recommended screening tests below:

  • Colonoscopy in the past 10 years. This is a test where the doctor examines the entire large intestine or colon using a scope while the patient is asleep.
  • Sigmoidoscopy in the past 5 years. This is a test where the doctor inserts a small scope to examine only the lower portion of the large intestine. Most patients are awake for this exam.
  • Blood Stool Tests done within the year. This is a test where the doctor checks a stool sample for hidden blood.

This represents the professionally recognized standard for colon cancer screening, as established by the United States Preventive Services Task Force (USPSTF) and endorsed by the local chapter of the American Cancer Society and the National Quality Forum (NQF). In order for a practice to get a point toward their score, patients ages 50-75 must have received one of the approved screening tests outlined above within the time period identified and this has to be documented in the patient’s medical chart with their Primary Care Physician.

Scores and Participating Practices

Data on colon cancer screening rates is collected on an every other year schedule. The most current colon cancer screening data was collected from the charts of patients who visited their primary care practice physician January 2013-December 2013. Scores are also available for data collected in 2010.

The data include the results from providers that were in their practice at that specific point in time. The providers may or may not currently be affiliated with practices listed. Additionally, the practice may or may not have changed affiliation since the time of data collection.

Greater Cincinnati Regional Average

The Greater Cincinnati Regional Average shows how well area practices and their patients age 50-75 did in getting screened for colon cancer. The current regional average is 64%.

Patient Survey Results

What is Patient Experience?

Patient experience refers to everything that happens to patients from the time they enter a doctor’s office until they leave. It also includes all other contact patients have with the doctor’s office before or after appointments.

Why are Patients Asked About Their Experience?

Some patients are given a survey asking about their experience after going to their doctor’s office. The questions in the survey are closely linked to health care quality, the strength of the doctor-patient relationship and access to care, all important things to consider when choosing a doctor.

Greater Cincinnati Regional Average

The Greater Cincinnati Regional Average is the average for all of the practices that reported on that particular question category.

The questions in the survey focus on the following main categories:

  • Getting Care When Needed
  • How Well Doctors Communicate
  • Courteous and Helpful Office Staff
  • Doctors with an Exceptional Rating

The scores for each of these four categories is different and is created by taking an average of the number of patients who answered “Yes” or “Always” or gave a high rating when answering the questions.

What do the scores mean?

The charts and percentages on the Compare page tell you patients’ opinions after a visit to a primary care doctor’s office. A score of 80% on the “Doctor spent enough time with you” question means that 8 out of 10 patients thought that the doctor spent enough time with the patient. The percentages and bar charts show ratings for each individual primary care practice.

Higher scores mean that the doctor and staff provided high quality care. Your doctor’s scores on the questions may be affected by how many patients answered the survey and how many patients gave high ratings of their visit. It is important to know that small differences in doctor’s scores do not necessarily mean you will receive a higher or lower quality of care. Remember to look at the bigger differences in scores. Also, be sure to talk with your doctor if you have other questions or concerns.

How did we get the scores?

The scores are based on patients’ answers to a survey called the Clinician and Group Consumer Assessment of Healthcare Providers and Systems (CG-CAHPS). The CG-CAPHS survey was mailed to a random sample of patients 18 and older who visited their doctor in the 12 months. Doctor’s offices chose to share their scores from this survey with us so we could share these scores with you.

The patient survey covers the following:

  1. Getting Care When Needed
    • Patient got appointment for urgent care as soon as needed.
    • Patient got appointment for non-urgent care as soon as needed.
    • Patient got answer to medical question the same day he/she phoned doctor’s office.
    • Patient got answers to medical question as soon as he/she needed when phone doctor’s office after hours.
    • Patient saw doctor within 15 minutes of appointment time.
  2. How Well Doctors Communicate
    • Doctors explained things in a way that was easy to understand.
    • Doctor listened carefully to patient.
    • Doctor gave easy to understand instructions about taking care of health problems or concerns.
    • Doctor knew important information about patients’ medical history.
    • Doctor respected patient’s comments.
    • Doctor spent enough time with you.
  3. Courteous and Helpful Office Staff
    • Clerks and receptionists were helpful.
    • Clerks and receptionists were courteous and respectful.
  4. Doctors with an Exceptional Rating

Doctor’s offices can choose whether or not they participate in the survey. If your doctor’s office results are not listed that means either:

  1. The doctor’s office may have chosen not to survey their patients about their experience
  2. Patients were surveyed but the office chose not to publicly share their scores, or
  3. There were not enough patient scores to reliably report the information.

Learn more about the CG-CAHPS survey >

Hospital Stays

Where do the hospital quality ratings come from?

Hospitals give quality information to the Centers for Medicaid and Medicare (CMS). The information given to CMS is posted for the public on the Hospital Compare website.  Once this information is posted to this site, The Commonwealth Fund, downloads that data and posts it to their Why Not The Best? website (where they perform their own calculations for benchmarks and composite measures). The hospital quality information shown on YourHealthMatters.org comes from the Hospital Compare and Why Not The Best? websites.  However, because both websites are intended for health care professionals and not the average person, we have tried to make the information on YourHealthMatters.org easier to read and understand for the general public.

Hospital data is updated twice a year with current information. You have access to the annual composite ratings through this website, which encourages patient participation and engagement in their care.

Where does the information on the hospital profile page come from?

Each hospital provided us with the list of their accreditations, insurances accepted and a description of their quality improvement efforts.

How do I know how up-to-date the information is on YourHealthMatters?

Refer to the “Last Updated” date located on the top right hand corner of the Patient Experience & Timely and Effective Care page or to the “Profile Updated” date in the bottom left hand corner of the Hospital Profile Page.

How often is the hospital information on this website updated?

The hospital information on YourHealthMatters.org is updated twice a year and includes the most up-to-date information available.

How do I know that the information on the website is correct?

Hospitals have several processes in place to make sure that the information that they submit to Medicare is correct.  Medicare also checks hospital information before putting it on a hospital website. The YourHealthMatters team at the Health Collaborative also checks hospital information for accuracy before it is posted on the website.

How are the Overall Effectiveness scores calculated?

A method used by the Joint Commission (a national organization that monitors hospitals)  is used to create overall scores for each condition. The overall score is the number of times a hospital performed the recommended treatment across all measures for that condition, divided by the number of opportunities the hospital had to provide appropriate care for that condition. Learn more on how the composite scores are created >

How are the Patient Experience scores calculated?

Patients are randomly selected and asked to complete a 27-question survey after leaving the hospital that asks about important aspects of their hospital experience. The answers from these 27 questions are grouped into 10 categories. The percentages listed for each category are the percent of patients who gave the hospital the highest rating. For example, if a hospital scored 80% in the “Quietness at Night” category, that means that 80% of patients thought the hospital was always quiet at night.

DATA COLLECTED
Electronic medical records, paper charts, or a combination of both, is used to collect the data.

Electronic medical records, paper charts, or a combination of both, is used to collect the data.

DATA SUBMITTED
The process of data reporting is rigorous and data is independently audited to confirm accuracy.

The process of data reporting is rigorous and data is independently audited to confirm accuracy.

DATA ANALYZED
When data is submitted, the secure data portal automatically analyzes the data according to clinical goals

When data is submitted, the secure data portal automatically analyzes the data according to clinical goals

PUBLIC REPORTED
Data is reviewed for accuracy before being publicly reported.

Data is reviewed for accuracy before being publicly reported.