Evaluation Measures

Below is the ESCALATES and Regional Cooperatives' harmonized practice-level data dictionary.



ABCS measures will be collected quarterly with a rolling 12, retrospective measurement period.


* = Optional Items

MeasureItem DescriptionSource
IDCooperative ID; practice ID; practice service organization ID, data quarter, data source1: Report generated from practice EHR certified by ONC after 2014

2: Report generated from practice EHR certified prior to 2014

3: Chart review using EHR data sampling used

4: Chart review using paper health record – sampling used

5: Measured calculated using registry data

6: Data from an organization / network assisting practice with capture and reporting of data
Ischemic Vascular Disease (IVD): Use of Aspirin or Another Antithrombotic
CMS 164v4 NQF 0068
Proportion of patients 18 years of age and older who were discharged alive for acute myocardial infarction (AMI), coronary artery bypass graft (CABG) or percutaneous coronary interventions (PCI) in the 12 months prior to the measurement period, or who had an active diagnosis of ischemic vascular disease (IVD) during the measurement period, and who had documentation of use of aspirin or another antithrombotic during the measurement period.
Controlling High Blood Pressure
CMS 165v4 NQF 0018
Proportion of patients 18-85 years of age who had a diagnosis of hypertension and whose blood pressure was adequately controlled (<140/90mmHg) during the measurement period.
Statin Therapy for the Prevention and Treatment of Cardiovascular Disease
CMS 347
Proportion of high-risk adult patients aged >= 21 years who were previously diagnosed with or currently have an active diagnosis of clinical atherosclerotic cardiovascular disease (ASCVD); OR adult patients aged >=21 years with a fasting or direct Low-Density Lipoprotein Cholesterol (LDL-C) level >= 190 mg/ dL; OR patients aged 40-75 years with a diagnosis of diabetes with a fasting or direct LDL-C level of 70-189 mg/dL; who were prescribed or are already on statin medication therapy during the measurement year.
Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention
CMS 138v4 NQF 0028
Proportion of patients aged 18 years and older who were screened for tobacco use one or more times within 24 months AND who received cessation counseling intervention if identified as a tobacco user.
Stratified ABCS*ABCS stratified by gender, race, ethnicity, and insurance status



Surveys will be collected at three time points: baseline, post intervention, and six months post intervention.

Practice Member Survey is completed by >70% of practice members.

Practice Survey is completed by one respondent per practice.


* = Optional Items

Practice Infrastructure

MeasureItem DescriptionSource
IDCooperative ID; practice ID, datePractice Survey
Geographic LocationZipcode
Staff CompositionClinician number
Staff number/FTE
Patient Visits/week
Panel Size/clinician
Practice TypeSingle vs. multi-specialty
Time under ownership
Panel CharacteristicsRace
Medically Underserved Area
Practice EHREHR vendor; EHR version
EHR usage
Quality Reports
EHR satisfaction
Future EHR change

Practice Contextual Characteristics

Participation in ACOParticipation in ACOPractice Survey
Future participation in ACO
PCMH Recognition
Receiving Incentives For Meeting Quality Standards
Meaningful Use

Practice Organizational Characteristics

Recent ChangesChanges to EHR or billing system; staff turnover; purchased by larger org, new locationPractice Survey
Participation in ACORegistry use
CVD prevention guidelines
Management of at risk CVD patients guidelines
Quality ReportsAbility to produce quality reports for ABCS measures
Patient Needs & ResourcesAssessing patient needs and expectations
Using data from patients to improve care
Clinician Attitudes Towards New GuidelinesHypertension guidelines
Cholesterol guidelines
Statin therapy*
Respondent CharacteristicsRole; years worked in practice; FTE
BurnoutAssessing practice member burnoutPractice Member Survey

Practice Capacity

PCMH-A*Quality Improvement StrategyPractice Survey
Organized, Evidence-Based Care
CPCQExtent of strategies used to improve cardiovascular care
External Reporting on Clinical Quality Measures
Adaptive ReserveLearning CulturePractice Member Survey
Work Environment
Respectful Interaction
Psychological Safety
Readiness for ImplementationChange
Change commitment*
Change efficacy*

Intervention Tracking


Surveys will be collected at three time points: baseline, post intervention, and six months post intervention.


* = Optional Items

MeasureItem DescriptionSource
Dose Delivered*Practice IDCooperative’s Intervention Tracking Database
Date of contact
Type of support provided
Personnel providing support
Mode of contact
Duration of contact
Dose Received*Practice ID
Practice strategies to improve ABCS
Practice engagement in intervention

Intervention Experiences


Practice site visits and semi-structured interviews will be conducted with a subset of practices during the implementation period, helping to understand what distinguishes high and low performing practices.