Population Health Metrics

Population health refers to our efforts to ensure that our whole population, or a discrete group such as those with a particular condition like diabetes or high blood pressure, receives high quality care as recommended by national guidelines.

We are constantly looking for ways to make it easier for you to know and act on your individual care needs. We discuss preventive care at most visits, provide easy access to upcoming health needs through MyChart, and will often reach out to you if you are overdue for a particular test.

We routinely measure how well we are doing in reaching our membership with important services and set goals to improve. When setting goals, Yale Health refers to a large national data source called HEDIS (Healthcare Effectiveness Data and Information Set) that tracks the performance of organizations like ours around the country. HEDIS gives us an idea of how we are performing compared with other similar organizations.

We share some of these measures with you below.

Breast Cancer Screening*

Our goal is 78% based on national targets. 2016=71.5%, 2017=69.1%, 2018=75.9%

What are we measuring and why?

  • Women between the ages of 50 and 74 who have been screened for breast cancer with a mammogram within the past 1-2 years
  • A mammogram can detect breast cancer before it can be felt
  • Early detection allows prompt treatment and improves the outcomes for women with breast cancer

How are we doing?

There are approximately 4,200 women who are eligible for breast cancer screening.  Of these, approximately 3,200  were screened in 2018.

What are we doing to improve?

  • Annual Birthday Letter reminders
  • Reminders through MyChart
  • Clinical team reminders at visits

What can you do?

  • Have regular mammograms
  • Speak with your provider if you notice changes in your breasts

*Included in Health Expectations Program for unionized employees

Cervical Cancer Screening*

Our goali is 80% based on national targets. 2016=64.7%, 2017=68.8%, 2018=71.0%

What are we measuring and why?

  • Women between the ages of 23 and 64 who have been screened for cervical cancer
  • Pap smears should be performed every 3-5 years
  • Regular Pap smear tests can detect abnormal or precancerous cells before cancer develops
  • Early treatment of abnormal Pap smears can prevent cervical cancer

How are we doing?

There are approximately 13,000 women who are eligible for cervical cancer screening, of these, approximately 9,300 were screened in 2018.

What are we doing to improve?

  • Annual birthday letter reminders
  • Reminders through MyChart
  • Clinical team reminders at visits

What can you do?

Have regular pap smears per the recommended schedule which is based on age and individual risk factors.

*Included in Health Expectations Program for unionized employees

Colorectal Cancer Screening*

Our goal is 74% based on national targets. 2016=71.0%, 2017=73.8%, 2018=77.0%

What are we measuring and why?

  • Men and women between the ages of 50 and 75 who have been screened for colon cancer with colonoscopy (every 10 years) or stool testing (“FIT” every year)
  • Screening tests can detect growths (polyps) in the colon. And removing polyps can prevent cancer
  • Cancers detected through screening can be treated more effectively and improve outcomes

How are we doing?

There are approximately 7,700 people who are eligible for colon cancer screening, of these, approximately 5,900 were screened in 2018.

What are we doing to improve?

  • Reminder letters (twice a year)
  • Offering FIT stool test kits during our annual flu clinics
  • Reminders through MyChart
  • Clinical team reminders at visits

What can you do?

Get regular screenings for colon cancer starting at age 50 or sooner based on your risk.

*Included in Health Expectations Program for unionized employees

Controlling High Blood Pressure

Controlling HIgh Blood Pressure Metrics. Our goal is 78% based on national targets. 2016=67.5%, 2017=68.7%, 2018=71.9%

What are we measuring and why?

  • Men and women with high blood pressure who have good blood pressure control (blood pressure less than 140/90) within the past 1 year
  • Good blood pressure control reduces the risk of heart disease, kidney disease and stroke

How are we doing?

There are approximately 4,300 people who have high blood pressure, of these, approximately 3,100 were in good blood control (blood pressure less than 140/90) in 2018.

What are we doing to improve?

  • Contacting patients who are due for blood pressure checks
  • Offering low cost home blood pressure monitors at the pharmacy
  • Developing an innovative program where pharmacists assist providers in adjusting medications

What can you do?

  • Have your blood pressure taken at least once a year
  • Take your blood pressure medications as prescribed
  • Follow a heart healthy diet and exercise 30 minutes daily

Control of Diabetes

Our gial is 66% based on national targets. 2016=65.1%, 2017=68%, 2018=68.4%

What are we measuring and why?

  • Men and women who have diabetes that is in good control (A1c blood test below 8 within the past year)
  • Good diabetes control prevents complications like heart and kidney disease.

How are we doing?

There are approximately 1,150 people with diabetes, of these, approximately 775 had good A1c control in 2018.

What are we doing to improve?

  • Reminders through MyChart
  • Outreach to those overdue for testing
  • Counseling with our Diabetes Educator
  • Diabetes Education Classes
  • 1:1 nutrition counseling
  • Access to health coaching

What can you do?

  • Have your A1c tested at least once per year
  • Eat a healthy diet and exercise for 30 minutes daily
  • Maintain a healthy weight

Cholesterol-Lowering Medication* Use Among People with Diabetes

our goal is 68% based on national targets. 2016=62.6%, 2017=65.4%, 2018=75.0%

What are we measuring and why?

  • Men and women over age 40 who have diabetes and are prescribed a cholesterol-lowering medication (called a statin)
  • Statin medications have been shown to reduce the risk for heart attack in those with diabetes, even if cholesterol is normal

How are we doing?

There are approximately 750 people with diabetes who are eligible to take a statin, of these, approximately 560 were on a statin in 2018.

What are we doing to improve?

  • Clinician messaging to patients
  • Clinical team reminders during visits

What can you do?

  • Take your cholesterol-lowering medication(s) as prescribed
  • Maintain a healthy diet and exercise daily for 30 minutes

*Common statin medications include atorvastatin or simvastatin

Cholesterol-Lowering Medication Use Among People with Heart Disease

Cholesterol-Lowering Medication Use Among People with Heart Disease. Our goal is 84% based on national targets, 2016=85.0%, 2017=86.6%, 2018=86.5%

What are we measuring and why?

  • Men and women with heart disease who are prescribed a cholesterol-lowering medication (called a statin)
  • The use of statin medications in people who have had, or are at risk of, a heart attack saves lives and prevents future heart attacks

How are we doing?

There are approximately 600 people with heart disease, of these, approximately 520 were taking a statin in 2018.

What are we doing to improve?

  • Clinician messaging to patients
  • Clinical team reminders during visits

What can you do?

  • Take your cholesterol-lowering medication(s) as prescribed
  • Maintain a healthy diet and exercise daily for 30 minutes
     

Adolescents who Received at Least 1 Dose of the HPV Vaccine*

Adolescents who Received at Least 1 Dose of the HPV Vaccine. Our goal is 80% , 2017=75.0%, 2018=75.6%

What are we measuring and why?

  • Boys and girls between the ages of 13 and 17 who have had at least one dose of the human papillomavirus (HPV) vaccine series
  • The HPV virus is the most common cause of cervical cancer and other kinds of cancer
  • Completing the vaccine series can prevent cancer

How are we doing?

There are approximately 1,700 adolescents who are eligible to receive the HPV vaccine, of these, approximately 1,300 were vaccinated in 2018.

What are we doing to improve?

  • Letters to parents
  • Informational brochures
  • Clinical team reminders during visits

What can you do?

  • Follow the recommended schedule for the HPV vaccine
  • Speak with your provider about the risks and benefits
  • Speak with your child about the importance of getting the HPV vaccine

*The full HPV vaccine series includes 2 shots between ages of 11 and 15, or 3 shots if started after age 15.

2 Year-Olds who Received 2 Doses of the Flu Vaccine

2 Year-Olds who Received 2 Doses of the Flu Vaccine, Our goal is 73% based on national targets, 2017=93.2%, 2018=94.3%

What are we measuring and why?

  • Boys and girls who received 2 doses of the flu vaccine by their 2nd birthday
  • Flu vaccines provide modest to high protection against the flu virus

How are we doing?

There are approximately 315 2 year-olds eligible to receive 2 flu shots each year, of these, approximately 300 received 2 flu shots in 2018.

What are we doing to improve?

  • Annual reminder Letters
  • University-wide email
  • Advertisements in the Yale Health Care newsletters
  • Clinical team reminders during visits

What can you do?

  • Have your child vaccinated against the flu each year
  • Speak with your provider if you have any questions or concerns