Definitions Used for Care Gaps
| Care Gap | Definition |
|---|---|
| Laboratory tests overdue | Diabetes and no HbA1c result in past 12 months |
| Overdue for screening or treatment | Last mammogram more than 2 years ago (for women aged 50-74 years) |
| Last colorectal cancer screening more than 1 year ago (for adults aged >50 years) | |
| Treatment for osteoporosis not started (for adults at high risk for fracture, defined as first fracture among women aged >60 years and men aged >70 years) | |
| Not at goal | For patients with diabetes, last HbA1c ≥8% |
| For patients with hypertension, last 2 SBP ≥140 mm Hg or last SBP ≥150 mm Hg | |
| For patients with cardiovascular disease, last LDL cholesterol level ≥160 mg/dL | |
| For patients with persistent asthma, asthma Med Ratio <0 | |
| Medication adherence <80% in past year | For patients with diabetes, aged <75 years and last HbA1c ≥8% |
| For patients with hypertension and last 2 SBP ≥140 mm Hg | |
| For patients with cardiovascular disease and last LDL cholesterol level ≥100 mg/dL | |
| Current smoker | – |
| Depression monitoring | For patients with depression diagnosis, missing PHQ9 |
Asthma Med Ratio = ratio of controller to total asthma medications; HbA1c = hemoglobin A1c; LDL = low-density lipoprotein; PHQ9 = 9-question depression scale from the Patient Health Questionnaire; SBP = systolic blood pressure.