Form 1 Quality Improvement Measures Data Collection Form

Appendix B
SCDTDRCP Quality Improvement Measures Data Collection Documents

Includes:
A Sample RedCap Quality Improvement Data Collection Form for a Local Site (pgs. 2–25)
Aggregate Quality Improvement Measures CoLab Data Entry Form for SCDTDRCP Grantees (pgs. 26-35)

All Quality Improvement Data Collection Forms developed for respondents, using Excel, RedCap or another database
form, will display the following burden statement:
An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it
displays a currently valid OMB control number. The OMB control number for this information collection is 0915-XXXX
and it is valid until XX/XX/202X. This information collection is voluntary. Public reporting burden for this collection of
information is estimated to average 13 hours per response, including the time for reviewing instructions, searching existing
data sources, and completing and reviewing the collection of information. Send comments regarding this burden estimate
or any other aspect of this collection of information, including suggestions for reducing this burden, to HRSA Reports
Clearance Officer, 5600 Fishers Lane, Room 14N136B, Rockville, Maryland, 20857 or paperwork@hrsa.gov.

Confidential
Page 3 of 26

QI Measure #la. Hydroxyurea use among Children/Adolescents.
Patients ≥ 9 months and < 18 years of age diagnosed with 55 or 5β-0 who were
prescribed HU in the last 6 months
Do you have data to report for this measure?

QYes
QNo

Please state reason for why data was not collected
for this measure

D We do not see any pediatric patients
D We do not have a system in place to collect this

(more than 1 choice is acceptable)

D We do not have sufficient staff to collect this

data
data

D Other
Please specify

Numerator:
Number 55 or 5β-0 patients � 9 months and < 18
years of age as of last day of the measurement
period who have a prescription for Hydroxyurea
provided during the six months preceding the end of
the measurement period.
NOTE: EXCLUDE those on chronic transfusion

Denominator:
Number of 55 or 5β-0 patients � 9 months and <
18 years of age as of last day of the measurement
period who are eligible candidates for Hydroxyurea.
NOTE: EXCLUDE those on chronic transfusion
Additional notes
(Please report any details regarding data
collection difficulty, delay, inaccuracy, etc. )

31/03/2020 2:35pm

projectredcap.org

EDCap

QI Measures
QI-1: Hydroxyurea Prescription, by Age Group 
≥9 months and <18 years of age, as of last day of the measurement period
Numerator
Numerator

Denominator
Denominator

Percent
Percent

Annotation
Annotation

No data

≥18 years of age, as of last day of the measurement period
Numerator
Numerator

Denominator
Denominator

Percent
Percent

Annotation
Annotation

No data

Overall (auto-calculated)
1/10

Numerator
0

Denominator
0

Percent
Percent

QI-2: Other Disease Modifying Therapies Prescription, by Age Group

≥9 months and <18 years of age, as of last day of the measurement period
Numerator
Numerator

Denominator
Denominator

Percent
Percent

Annotation
Annotation

No data

≥18 years of age, as of last day of the measurement period
Numerator
Numerator

Denominator
Denominator

Percent
Percent

2/10

Annotation
Annotation

No data

Overall (auto-calculated)
Numerator
0

Denominator
0

Percent
Percent

QI-3: Transcranial Doppler Screening
Numerator
Numerator

Denominator
Denominator

Percent
Percent

Annotation
Annotation

No data

QI-4a: Immunization <18 Years Old, by Vaccination Series 
PCV
Numerator
Numerator
3/10

Denominator
Denominator

Percent
Percent

Annotation
Annotation

No data

PPSV
Numerator
Numerator

Denominator
Denominator

Percent
Percent

Annotation
Annotation

No data

Men ACYW
Numerator
Numerator

Denominator
Denominator

Percent
Percent

Annotation

4/10

Annotation

No data

Hib
Numerator
Numerator

Denominator
Denominator

Percent
Percent

Annotation
Annotation

No data

Flu
Numerator
Numerator

Denominator
Denominator

Percent
Percent

Annotation
Annotation

No data

MenB
Numerator

5/10

Numerator

Denominator
Denominator

Percent
Percent

Annotation
Annotation

No data

All
Numerator
Numerator

Denominator
Denominator

Percent
Percent

Annotation
Annotation

No data

QI-4b: Immunization ≥18 Years Old, by Vaccination Series 
PCV
Numerator
Numerator

Denominator
Denominator

6/10

Percent
Percent

Annotation
Annotation

No data

PPSV
Numerator
Numerator

Denominator
Denominator

Percent
Percent

Annotation
Annotation

No data

Men ACYW
Numerator
Numerator

Denominator
Denominator

Percent
Percent

Annotation
Annotation

No data
7/10

Hib
Numerator
Numerator

Denominator
Denominator

Percent
Percent

Annotation
Annotation

No data

Flu
Numerator
Numerator

Denominator
Denominator

Percent
Percent

Annotation
Annotation

No data

MenB
Numerator
Numerator

Denominator
Denominator

8/10

Percent
Percent

Annotation
Annotation

No data

All
Numerator
Numerator

Denominator
Denominator

Percent
Percent

Annotation
Annotation

No data

QI-5: Transitions to Adult Care
Numerator
Numerator

Denominator
Denominator

Percent
Percent

Annotation
Annotation

No data
9/10

QI-6: ECHO
Count
Count

Annotation
Annotation

No data

10/10