eCQM Title | # Heart Failure (HF): Angiotensin-Converting Enzyme (ACE) Inhibitor or Angiotensin Receptor Blocker (ARB) or Angiotensin Receptor-Neprilysin Inhibitor (ARNI) Therapy for Left Ventricular Systolic Dysfunction (LVSD)
eCQM Identifier (Measure Authoring Tool) | 135 | eCQM Version Number | 11.1.000
NQF Number | 0081e | GUID | 430ffc53-4122-4421-88cc-2edd8117bb3c
Measurement Period | January 1, 20XX through December 31, 20XX
Measure Steward | American Heart Association
Measure Developer | American Medical Association (AMA)
Measure Developer | PCPI(R) Foundation (PCPI[R])
Measure Developer | American Heart Association
Endorsed By | National Quality Forum
Description |
    Percentage of patients aged 18 years and older with a diagnosis of heart failure (HF) with a current or prior left ventricular ejection fraction (LVEF) <=40% who were prescribed or already taking ACE inhibitor or ARB or ARNI therapy during the measurement period
Copyright |
    Copyright 2022 American College of Cardiology and American Heart Association. All Rights Reserved.
Disclaimer |
    The Measure is not a clinical guideline, does not establish a standard of medical care, and has not been tested for all potential applications.

    The Measure, while copyrighted, can be reproduced and distributed, without modification, for noncommercial purposes, e.g., use by health care providers in connection with their practices. Commercial use is defined as the sale, license, or distribution of the Measure for commercial gain, or incorporation of the Measure into a product or service that is sold, licensed or distributed for commercial gain.

    Commercial uses of the Measure require a license agreement between the user and the American College of Cardiology (ACC) or the American Heart Association (AHA). Neither the ACC, nor AHA, nor their members shall be responsible for any use of the Measure.

    ACC and AHA encourage use of the Measure by other health care professionals, where appropriate.

    THE MEASURE AND SPECIFICATIONS ARE PROVIDED "AS IS" WITHOUT WARRANTY OF ANY KIND.

    Limited proprietary coding is contained in the Measure specifications for convenience. Users of the proprietary code sets should obtain all necessary licenses from the owners of these code sets. The ACC and AHA and their members disclaim all liability for use or accuracy of any Current Procedural Terminology (CPT[R]) or other coding contained in the specifications.

    CPT(R) contained in the Measure specifications is copyright 2004-2021 American Medical Association. LOINC(R) is copyright 2004-2021 Regenstrief Institute, Inc. This material contains SNOMED Clinical Terms(R) (SNOMED CT[R]) copyright 2004-2021 International Health Terminology Standards Development Organisation. ICD-10 is copyright 2021 World Health Organization. All Rights Reserved.

    The American Medical Association’s and the PCPI(R) Foundation’s significant past efforts and contributions to the performance measure are gratefully acknowledged.

    Due to technical limitations, registered trademarks are indicated by (R) or [R].
Measure Scoring | Proportion
Measure Type | Process
Stratification |
    None
Risk Adjustment |
    None
Rate Aggregation |
    None
Rationale |
    Use of ACE inhibitor, ARB, or ARNI therapy has been associated with improved outcomes in patients with reduced LVEF. Long-term therapy with ARBs have also been shown to reduce morbidity and mortality, especially in ACE inhibitor–intolerant patients. More recently, ARNI therapy has also been shown to more significantly improve outcomes, such that the newest guidelines recommend replacement of ACE inhibitors or ARBs with ARNI therapy in eligible patients. However, despite the benefits of these drugs, use of ACE inhibitor, ARB, or ARNI remains suboptimal.
Clinical Recommendation Statement |
    The clinical strategy of inhibition of the renin angiotensin system with ACE inhibitors (Class 1, Level of Evidence: A), OR ARBs (Class 1, Level of Evidence: A), OR ARNI (Class 1, Level of Evidence: B-R) in conjunction with evidence-based beta blockers, and aldosterone antagonists in selected patients, is recommended for patients with chronic heart failure with reduced ejection fraction (HFrEF) to reduce morbidity and mortality (ACC/AHA/HFSA, 2017).

    The use of ACE inhibitors is beneficial for patients with prior or current symptoms of chronic HFrEF to reduce morbidity and mortality (Class I, Level of Evidence A) (ACC/AHA/HFSA, 2017).

    Treatment with an ACE inhibitor should be initiated at low doses [see excerpt from guideline table below], followed by gradual dose increments if lower doses have been well tolerated... Clinicians should attempt to use doses that have been shown to reduce the risk of cardiovascular events in clinical trials. If these target doses of an ACE inhibitor cannot be used or are poorly tolerated, intermediate doses should be used with the expectation that there are likely to be only small differences in efficacy between low and high doses. Abrupt withdrawal of treatment with an ACE inhibitor can lead to clinical deterioration and should be avoided (ACCF/AHA, 2013).

    Drugs Commonly Used for Stage C HFrEF (abbreviated to align with focus of measure to include only ACE inhibitors,  ARB and ARNI therapy)
    Drug                       Initial Daily Dose(s)                           Maximum Dose(s)       Mean Doses Achieved in
                                                                                                                            Clinical Trials
    ACE Inhibitors
       Captopril              6.25 mg 3 times                               50 mg 3 times              122.7 mg/d
       Enalapril               2.5 mg twice                                    10 to 20 mg twice        16.6 mg/d
       Fosinopril             5 to 10 mg once                               40 mg once                  N/A
       Lisinopril              2.5 to 5 mg once                              20 to 40 mg once         32.5 to 35.0 mg/d
       Perindopril           2 mg once                                        8 to 16 mg once           N/A
       Quinapril              5 mg twice                                       20 mg twice                  N/A
       Ramipril               1.25 to 2.5 mg once                         10 mg once                  N/A
       Trandolapril          1 mg once                                        4 mg once                   N/A
    Angiotensin Receptor Blockers
       Candesartan         4 to 8 mg once                                32 mg once                  24 mg/d
       Losartan               25 to 50 mg once                             50 to 150 mg once      129 mg/d
       Valsartan              20 to 40 mg twice                           160 mg twice                 254 mg/d
    ARNI
       Sacubitril/             49/51 mg twice (sacubitril                97/103 mg twice          375 mg/d; target dose:
       valsartan              valsartan) (therapy may be              (sacubitril/                    24/26 mg, 49/51 mg OR
                                    initiated at 24/26 mg twice)              valsartan)                    97/103 mg twice

    The use of ARBs to reduce morbidity and mortality is recommended in patients with current or prior symptoms of chronic HFrEF who are intolerant to ACE inhibitors because of cough or angioedema (Class I, Level of Evidence A) (ACC/AHA/HFSA, 2017).

    ARBs are reasonable to reduce morbidity and mortality as alternatives to ACE inhibitors as first-line therapy for patients with HFrEF, especially for patients already taking ARBs for other indications, unless contraindicated (Class IIa, Level of Evidence: A) (ACCF/AHA, 2013).

    Addition of an ARB may be considered in persistently symptomatic patients with HFrEF who are already being treated with an ACE inhibitor and a beta blocker in whom an aldosterone antagonist is not indicated or tolerated (Class IIb, Level of Evidence: A) (ACCF/AHA, 2013).

    The clinical strategy of inhibition of the renin-angiotensin system with ACE inhibitors (Level of Evidence A), or ARBs (Level of Evidence A) or ARNI (Level of Evidence B-R) in conjunction with evidence-based beta-blockers, and aldosterone antagonists in selected patients, is recommended for patients with chronic HFrEF to reduce morbidity and mortality (Class I) (ACC/AHA/HFSA, 2017).

    In patients with chronic symptomatic HFrEF New York Heart Association (NYHA) class II or III who tolerate an ACE inhibitor or ARB, replacement by an ARNI is recommended to further reduce morbidity and mortality (Class I, Level of Evidence: B-R) (ACC/AHA/HFSA, 2017).

    ARNI should not be administered concomitantly with ACE inhibitors or within 36 hours of the last dose of an ACE inhibitor (Class III, Level of Evidence B-R) (ACC/AHA/HFSA, 2017).

    ARNI should not be administered to patients with a history of angioedema (Class III Recommendation, Level of Evidence C-EO) (ACC/AHA/HFSA, 2017).
Improvement Notation |
    Higher score indicates better quality
Reference |
    Reference Type: CITATION
    Reference Text: 'Yancy, C. W., Jessup, M., Bozkurt, B., Butler, J., Casey, D. E., Drazner, M. H., … Wilkoff, B. L. (2013). 2013 ACCF/AHA Guideline for the Management of Heart Failure A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Circulation, 128(16), e240–e327. doi: https://doi.org/10.1161/CIR.0b013e31829e8776'
Reference |
    Reference Type: CITATION
    Reference Text: 'Yancy, C. W., Jessup, M., Bozkurt, B., Butler, J., Casey, D. E., Colvin, M. M., … Westlake, C. (2017). 2017 ACC/AHA/HFSA Focused Update of the 2013 ACCF/AHA Guideline for the Management of Heart Failure: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Failure Society of America. Circulation,136(6), e137–e161. doi: 10.1161/cir.0000000000000509'
Definition |
    Prescribed-Outpatient setting: prescription given to the patient for ACE inhibitor or ARB or ARNI therapy at one or more visits in the measurement period OR patient already taking ACE inhibitor or ARB or ARNI therapy as documented in current medication list.

    LVEF <=40% corresponds to qualitative documentation of moderate dysfunction or severe dysfunction (LVSD). The LVSD may be determined by quantitative or qualitative assessment, which may be current or historical. Examples of a quantitative or qualitative assessment may include an echocardiogram:
    1) that provides a numerical value of LVSD or 2) that uses descriptive terms such as moderately or severely depressed left ventricular systolic function. Any current or prior ejection fraction study documenting LVSD can be used to identify patients.
Guidance |
    This eCQM is to be reported as patient-based. To satisfy this measure, it must be reported for all heart failure patients at least once during the measurement period if seen in the outpatient setting.

    The requirement of two or more visits is used to establish that the eligible professional or eligible clinician has an existing relationship with the patient.

    A range value should satisfy the logic requirement for 'Ejection Fraction' as long as the ranged observation value clearly meets the less than or equal to 40% threshold noted in the denominator logic. A range that is greater than 40% would not meet the measure requirement.

    Eligible clinicians who have given a prescription for or whose patient is already taking an Angiotensin-Converting Enzyme Inhibitor (ACEI) or Angiotensin Receptor Blocker (ARB) would meet performance for this measure. Other combination therapies that consist of an ACEI plus diuretic, ARB + neprilysin inhibitor (ARNI), ARB plus diuretic, ACEI plus calcium channel blocker, ARB plus calcium channel blocker, or ARB plus calcium channel blocker plus diuretic would also meet performance for this measure.

    This version of the eCQM uses QDM version 5.6. Please refer to the eCQI resource center (https://ecqi.healthit.gov/qdm) for more information on the QDM.
Transmission Format |
    TBD
Initial Population |
    All patients aged 18 years and older with two qualifying encounters during the measurement period and a diagnosis of heart failure
Denominator |
    Equals Initial Population with a current or prior LVEF <= 40%
Denominator Exclusions |
    Patients with a history of heart transplant or with a Left Ventricular Assist Device (LVAD) prior to the end of the outpatient encounter with Moderate or Severe LVSD
Numerator |
    Patients who were prescribed or already taking ACE inhibitor or ARB or ARNI therapy during the measurement period
Numerator Exclusions |
    Not Applicable
Denominator Exceptions |
    Documentation of medical reason(s) for not prescribing ACE inhibitor or ARB or ARNI therapy (e.g., pregnancy, renal failure due to ACEI, allergy, intolerance, other medical reasons).

    Documentation of patient reason(s) for not prescribing ACE inhibitor or ARB or ARNI therapy (e.g., patient declined, other patient reasons).
Supplemental Data Elements |
    For every patient evaluated by this measure also identify payer, race, ethnicity and sex

## Table of Contents

- Population Criteria
- Definitions
- Functions
- Terminology
- Data Criteria (QDM Data Elements)
- Supplemental Data Elements
- Risk Adjustment Variables

### Population Criteria

- - Initial Population

    - -     AgeInYearsAt(date from start of "Measurement Period")>= 18
              and Count("Qualifying Encounter During Measurement Period")>= 2
              and exists "Heart Failure Outpatient Encounter"

- - Denominator

    - -     "Initial Population"
              and exists "Heart Failure Outpatient Encounter with History of Moderate or Severe LVSD"

- - Denominator Exclusions

    - -     "Has Heart Transplant"
              or "Has Heart Transplant Related Diagnosis"
              or "Has Left Ventricular Assist Device"
              or "Has Left Ventricular Assist Device Related Diagnosis"

- - Numerator

    - -     "Has ACEI or ARB or ARNI Ordered"
              or "Is Currently Taking ACEI or ARB or ARNI"

- - Numerator Exclusions

    - -     None

- - Denominator Exceptions

    - -     "Has Medical or Patient Reason for Not Ordering ACEI or ARB or ARNI"
              or "Has Allergy or Intolerance to ACEI or ARB or ARNI Ingredient"
              or "Has Diagnosis of Allergy or Intolerance to ACEI or ARB"
              or "Has Diagnosis of Pregnancy"
              or "Has Diagnosis of Renal Failure Due to ACEI"

- - Stratification

    - -     None

### Definitions

- - Denominator

    - -     "Initial Population"
              and exists "Heart Failure Outpatient Encounter with History of Moderate or Severe LVSD"

  - Denominator Exceptions

    - -     "Has Medical or Patient Reason for Not Ordering ACEI or ARB or ARNI"
              or "Has Allergy or Intolerance to ACEI or ARB or ARNI Ingredient"
              or "Has Diagnosis of Allergy or Intolerance to ACEI or ARB"
              or "Has Diagnosis of Pregnancy"
              or "Has Diagnosis of Renal Failure Due to ACEI"

  - Denominator Exclusions

    - -     "Has Heart Transplant"
              or "Has Heart Transplant Related Diagnosis"
              or "Has Left Ventricular Assist Device"
              or "Has Left Ventricular Assist Device Related Diagnosis"

  - Has ACEI or ARB or ARNI Ordered

    - -     exists ["Medication, Order": "ACE Inhibitor or ARB or ARNI"] ACEIOrARBOrARNIOrdered
              with "Heart Failure Outpatient Encounter with History of Moderate or Severe LVSD" ModerateOrSevereLVSDHFOutpatientEncounter
                such that ACEIOrARBOrARNIOrdered.authorDatetime during ModerateOrSevereLVSDHFOutpatientEncounter.relevantPeriod

  - Has Allergy or Intolerance to ACEI or ARB or ARNI Ingredient

    - -     exists ( ["Allergy/Intolerance": "ACE Inhibitor or ARB Ingredient"]
              union ["Allergy/Intolerance": "Substance with angiotensin-converting enzyme inhibitor mechanism of action (substance)"]
              union ["Allergy/Intolerance": "Substance with angiotensin II receptor antagonist mechanism of action (substance)"]
              union ["Allergy/Intolerance": "Substance with neprilysin inhibitor mechanism of action (substance)"]
              union ["Allergy/Intolerance": "sacubitril"] ) ACEIOrARBOrARNIAllergyIntolerance
              with "Heart Failure Outpatient Encounter with History of Moderate or Severe LVSD" ModerateOrSevereLVSDHFOutpatientEncounter
                such that ACEIOrARBOrARNIAllergyIntolerance.prevalencePeriod overlaps after ModerateOrSevereLVSDHFOutpatientEncounter.relevantPeriod

  - Has Diagnosis of Allergy or Intolerance to ACEI or ARB

    - -     exists ( ["Diagnosis": "Allergy to ACE Inhibitor or ARB"]
              union ["Diagnosis": "Intolerance to ACE Inhibitor or ARB"] ) ACEIOrARBAllergyOrIntoleranceDiagnosis
              with "Heart Failure Outpatient Encounter with History of Moderate or Severe LVSD" ModerateOrSevereLVSDHFOutpatientEncounter
                such that ACEIOrARBAllergyOrIntoleranceDiagnosis.prevalencePeriod overlaps after ModerateOrSevereLVSDHFOutpatientEncounter.relevantPeriod

  - Has Diagnosis of Pregnancy

    - -     exists ["Diagnosis": "Pregnancy"] Pregnancy
              with "Heart Failure Outpatient Encounter with History of Moderate or Severe LVSD" ModerateOrSevereLVSDHFOutpatientEncounter
                such that Pregnancy.prevalencePeriod starts 9 months or less before or on start ModerateOrSevereLVSDHFOutpatientEncounter.relevantPeriod

  - Has Diagnosis of Renal Failure Due to ACEI

    - -     exists ["Diagnosis": "Acute renal failure caused by angiotensin-converting-enzyme inhibitor (disorder)"] RenalFailureDueToACEI
              with "Heart Failure Outpatient Encounter with History of Moderate or Severe LVSD" ModerateOrSevereLVSDHFOutpatientEncounter
                such that RenalFailureDueToACEI.prevalencePeriod overlaps ModerateOrSevereLVSDHFOutpatientEncounter.relevantPeriod

  - Has Heart Transplant

    - -     exists ["Procedure, Performed": "Heart Transplant"] HeartTransplant
              with "Heart Failure Outpatient Encounter with History of Moderate or Severe LVSD" ModerateOrSevereLVSDHFOutpatientEncounter
                such that ( Global."NormalizeInterval" ( HeartTransplant.relevantDatetime, HeartTransplant.relevantPeriod ) ) starts before
                end of ModerateOrSevereLVSDHFOutpatientEncounter.relevantPeriod

  - Has Heart Transplant Related Diagnosis

    - -     exists ["Diagnosis": "Heart Transplant Related Diagnoses"] HeartTransplantCondition
              with "Heart Failure Outpatient Encounter with History of Moderate or Severe LVSD" ModerateOrSevereLVSDHFOutpatientEncounter
                such that ( Global."NormalizeInterval" ( HeartTransplantCondition.authorDatetime, HeartTransplantCondition.prevalencePeriod ) ) starts before
                end of ModerateOrSevereLVSDHFOutpatientEncounter.relevantPeriod

  - Has Left Ventricular Assist Device

    - -     exists ["Procedure, Performed": "Left Ventricular Assist Device Placement"] LVADOutpatient
              with "Heart Failure Outpatient Encounter with History of Moderate or Severe LVSD" ModerateOrSevereLVSDHFOutpatientEncounter
                such that ( Global."NormalizeInterval" ( LVADOutpatient.relevantDatetime, LVADOutpatient.relevantPeriod ) ) starts before
                end of ModerateOrSevereLVSDHFOutpatientEncounter.relevantPeriod

  - Has Left Ventricular Assist Device Related Diagnosis

    - -     exists ["Diagnosis": "Left Ventricular Assist Device Related Diagnoses"] LVADCondition
              with "Heart Failure Outpatient Encounter with History of Moderate or Severe LVSD" ModerateOrSevereLVSDHFOutpatientEncounter
                such that ( Global."NormalizeInterval" ( LVADCondition.authorDatetime, LVADCondition.prevalencePeriod ) ) starts before
                end of ModerateOrSevereLVSDHFOutpatientEncounter.relevantPeriod

  - Has Medical or Patient Reason for Not Ordering ACEI or ARB or ARNI

    - -     exists ["Medication, Not Ordered": "ACE Inhibitor or ARB or ARNI"] NoACEIOrARBOrARNIOrdered
              with "Heart Failure Outpatient Encounter with History of Moderate or Severe LVSD" ModerateOrSevereLVSDHFOutpatientEncounter
                such that NoACEIOrARBOrARNIOrdered.authorDatetime during ModerateOrSevereLVSDHFOutpatientEncounter.relevantPeriod
              where ( NoACEIOrARBOrARNIOrdered.negationRationale in "Medical Reason"
                  or NoACEIOrARBOrARNIOrdered.negationRationale in "Patient Reason"
                  or NoACEIOrARBOrARNIOrdered.negationRationale in "Patient Reason for ACE Inhibitor or ARB Decline"
              )

  - Heart Failure Outpatient Encounter

    - -     ( ["Encounter, Performed": "Care Services in Long Term Residential Facility"]
              union ["Encounter, Performed": "Home Healthcare Services"]
              union ["Encounter, Performed": "Nursing Facility Visit"]
              union ["Encounter, Performed": "Office Visit"]
              union ["Encounter, Performed": "Outpatient Consultation"] ) QualifyingEncounter
              with ["Diagnosis": "Heart Failure"] HeartFailure
                such that HeartFailure.prevalencePeriod overlaps QualifyingEncounter.relevantPeriod
              where QualifyingEncounter.relevantPeriod during "Measurement Period"

  - Heart Failure Outpatient Encounter with History of Moderate or Severe LVSD

    - -     "Heart Failure Outpatient Encounter" HFOutpatientEncounter
              with "Moderate or Severe LVSD Findings" LVSDFindings
                such that Coalesce(LVSDFindings.prevalencePeriod, Global."NormalizeInterval"(LVSDFindings.relevantDatetime, LVSDFindings.relevantPeriod))starts before
                end of HFOutpatientEncounter.relevantPeriod

  - Initial Population

    - -     AgeInYearsAt(date from start of "Measurement Period")>= 18
              and Count("Qualifying Encounter During Measurement Period")>= 2
              and exists "Heart Failure Outpatient Encounter"

  - Is Currently Taking ACEI or ARB or ARNI

    - -     exists ["Medication, Active": "ACE Inhibitor or ARB or ARNI"] ActiveACEIOrARBOrARNI
              with "Heart Failure Outpatient Encounter with History of Moderate or Severe LVSD" ModerateOrSevereLVSDHFOutpatientEncounter
                such that ActiveACEIOrARBOrARNI.relevantPeriod overlaps after ModerateOrSevereLVSDHFOutpatientEncounter.relevantPeriod

  - Moderate or Severe LVSD Findings

    - -     ( ["Diagnostic Study, Performed": "Ejection Fraction"] EjectionFraction
                where EjectionFraction.result <= 40 '%'
            )
              union ["Diagnosis": "Moderate or Severe LVSD"]
              union ( ["Diagnosis": "Left ventricular systolic dysfunction (disorder)"] LVSD
                  where LVSD.severity in "Moderate or Severe"
              )

  - Numerator

    - -     "Has ACEI or ARB or ARNI Ordered"
              or "Is Currently Taking ACEI or ARB or ARNI"

  - Qualifying Encounter During Measurement Period

    - -     ( ["Encounter, Performed": "Office Visit"]
              union ["Encounter, Performed": "Outpatient Consultation"]
              union ["Encounter, Performed": "Nursing Facility Visit"]
              union ["Encounter, Performed": "Care Services in Long Term Residential Facility"]
              union ["Encounter, Performed": "Home Healthcare Services"]
              union ["Encounter, Performed": "Patient Provider Interaction"] ) ValidEncounter
              where ValidEncounter.relevantPeriod during "Measurement Period"

  - SDE Ethnicity

    - -     ["Patient Characteristic Ethnicity": "Ethnicity"]

  - SDE Payer

    - -     ["Patient Characteristic Payer": "Payer"]

  - SDE Race

    - -     ["Patient Characteristic Race": "Race"]

  - SDE Sex

    - -     ["Patient Characteristic Sex": "ONC Administrative Sex"]

### Functions

- - Global.NormalizeInterval(pointInTime DateTime, period Interval<DateTime>)

    - -     if pointInTime is not null then Interval[pointInTime, pointInTime]
              else if period is not null then period
              else null as Interval<DateTime>

### Terminology

- code "Acute renal failure caused by angiotensin-converting-enzyme inhibitor (disorder)" ("SNOMEDCT Code (422593004)")
- code "Left ventricular systolic dysfunction (disorder)" ("SNOMEDCT Code (134401001)")
- code "sacubitril" ("RXNORM Code (1656328)")
- code "Substance with angiotensin II receptor antagonist mechanism of action (substance)" ("SNOMEDCT Code (372913009)")
- code "Substance with angiotensin-converting enzyme inhibitor mechanism of action (substance)" ("SNOMEDCT Code (372733002)")
- code "Substance with neprilysin inhibitor mechanism of action (substance)" ("SNOMEDCT Code (786886009)")
- valueset "ACE Inhibitor or ARB Ingredient" (2.16.840.1.113883.3.526.3.1489)
- valueset "ACE Inhibitor or ARB or ARNI" (2.16.840.1.113883.3.526.3.1139)
- valueset "Allergy to ACE Inhibitor or ARB" (2.16.840.1.113883.3.526.3.1211)
- valueset "Care Services in Long Term Residential Facility" (2.16.840.1.113883.3.464.1003.101.12.1014)
- valueset "Ejection Fraction" (2.16.840.1.113883.3.526.3.1134)
- valueset "Ethnicity" (2.16.840.1.114222.4.11.837)
- valueset "Heart Failure" (2.16.840.1.113883.3.526.3.376)
- valueset "Heart Transplant" (2.16.840.1.113762.1.4.1178.33)
- valueset "Heart Transplant Related Diagnoses" (2.16.840.1.113762.1.4.1178.56)
- valueset "Home Healthcare Services" (2.16.840.1.113883.3.464.1003.101.12.1016)
- valueset "Intolerance to ACE Inhibitor or ARB" (2.16.840.1.113883.3.526.3.1212)
- valueset "Left Ventricular Assist Device Placement" (2.16.840.1.113762.1.4.1178.61)
- valueset "Left Ventricular Assist Device Related Diagnoses" (2.16.840.1.113762.1.4.1178.58)
- valueset "Medical Reason" (2.16.840.1.113883.3.526.3.1007)
- valueset "Moderate or Severe" (2.16.840.1.113883.3.526.3.1092)
- valueset "Moderate or Severe LVSD" (2.16.840.1.113883.3.526.3.1090)
- valueset "Nursing Facility Visit" (2.16.840.1.113883.3.464.1003.101.12.1012)
- valueset "Office Visit" (2.16.840.1.113883.3.464.1003.101.12.1001)
- valueset "ONC Administrative Sex" (2.16.840.1.113762.1.4.1)
- valueset "Outpatient Consultation" (2.16.840.1.113883.3.464.1003.101.12.1008)
- valueset "Patient Provider Interaction" (2.16.840.1.113883.3.526.3.1012)
- valueset "Patient Reason" (2.16.840.1.113883.3.526.3.1008)
- valueset "Patient Reason for ACE Inhibitor or ARB Decline" (2.16.840.1.113883.3.526.3.1140)
- valueset "Payer" (2.16.840.1.114222.4.11.3591)
- valueset "Pregnancy" (2.16.840.1.113883.3.526.3.378)
- valueset "Race" (2.16.840.1.114222.4.11.836)

### Data Criteria (QDM Data Elements)

- "Allergy/Intolerance: ACE Inhibitor or ARB Ingredient" using "ACE Inhibitor or ARB Ingredient (2.16.840.1.113883.3.526.3.1489)"
- "Allergy/Intolerance: sacubitril" using "sacubitril (RXNORM Code 1656328)"
- "Allergy/Intolerance: Substance with angiotensin II receptor antagonist mechanism of action (substance)" using "Substance with angiotensin II receptor antagonist mechanism of action (substance) (SNOMEDCT Code 372913009)"
- "Allergy/Intolerance: Substance with angiotensin-converting enzyme inhibitor mechanism of action (substance)" using "Substance with angiotensin-converting enzyme inhibitor mechanism of action (substance) (SNOMEDCT Code 372733002)"
- "Allergy/Intolerance: Substance with neprilysin inhibitor mechanism of action (substance)" using "Substance with neprilysin inhibitor mechanism of action (substance) (SNOMEDCT Code 786886009)"
- "Diagnosis: Acute renal failure caused by angiotensin-converting-enzyme inhibitor (disorder)" using "Acute renal failure caused by angiotensin-converting-enzyme inhibitor (disorder) (SNOMEDCT Code 422593004)"
- "Diagnosis: Allergy to ACE Inhibitor or ARB" using "Allergy to ACE Inhibitor or ARB (2.16.840.1.113883.3.526.3.1211)"
- "Diagnosis: Heart Failure" using "Heart Failure (2.16.840.1.113883.3.526.3.376)"
- "Diagnosis: Heart Transplant Related Diagnoses" using "Heart Transplant Related Diagnoses (2.16.840.1.113762.1.4.1178.56)"
- "Diagnosis: Intolerance to ACE Inhibitor or ARB" using "Intolerance to ACE Inhibitor or ARB (2.16.840.1.113883.3.526.3.1212)"
- "Diagnosis: Left Ventricular Assist Device Related Diagnoses" using "Left Ventricular Assist Device Related Diagnoses (2.16.840.1.113762.1.4.1178.58)"
- "Diagnosis: Left ventricular systolic dysfunction (disorder)" using "Left ventricular systolic dysfunction (disorder) (SNOMEDCT Code 134401001)"
- "Diagnosis: Moderate or Severe LVSD" using "Moderate or Severe LVSD (2.16.840.1.113883.3.526.3.1090)"
- "Diagnosis: Pregnancy" using "Pregnancy (2.16.840.1.113883.3.526.3.378)"
- "Diagnostic Study, Performed: Ejection Fraction" using "Ejection Fraction (2.16.840.1.113883.3.526.3.1134)"
- "Encounter, Performed: Care Services in Long Term Residential Facility" using "Care Services in Long Term Residential Facility (2.16.840.1.113883.3.464.1003.101.12.1014)"
- "Encounter, Performed: Home Healthcare Services" using "Home Healthcare Services (2.16.840.1.113883.3.464.1003.101.12.1016)"
- "Encounter, Performed: Nursing Facility Visit" using "Nursing Facility Visit (2.16.840.1.113883.3.464.1003.101.12.1012)"
- "Encounter, Performed: Office Visit" using "Office Visit (2.16.840.1.113883.3.464.1003.101.12.1001)"
- "Encounter, Performed: Outpatient Consultation" using "Outpatient Consultation (2.16.840.1.113883.3.464.1003.101.12.1008)"
- "Encounter, Performed: Patient Provider Interaction" using "Patient Provider Interaction (2.16.840.1.113883.3.526.3.1012)"
- "Medication, Active: ACE Inhibitor or ARB or ARNI" using "ACE Inhibitor or ARB or ARNI (2.16.840.1.113883.3.526.3.1139)"
- "Medication, Not Ordered: ACE Inhibitor or ARB or ARNI" using "ACE Inhibitor or ARB or ARNI (2.16.840.1.113883.3.526.3.1139)"
- "Medication, Order: ACE Inhibitor or ARB or ARNI" using "ACE Inhibitor or ARB or ARNI (2.16.840.1.113883.3.526.3.1139)"
- "Patient Characteristic Ethnicity: Ethnicity" using "Ethnicity (2.16.840.1.114222.4.11.837)"
- "Patient Characteristic Payer: Payer" using "Payer (2.16.840.1.114222.4.11.3591)"
- "Patient Characteristic Race: Race" using "Race (2.16.840.1.114222.4.11.836)"
- "Patient Characteristic Sex: ONC Administrative Sex" using "ONC Administrative Sex (2.16.840.1.113762.1.4.1)"
- "Procedure, Performed: Heart Transplant" using "Heart Transplant (2.16.840.1.113762.1.4.1178.33)"
- "Procedure, Performed: Left Ventricular Assist Device Placement" using "Left Ventricular Assist Device Placement (2.16.840.1.113762.1.4.1178.61)"

### Supplemental Data Elements

- SDE Ethnicity

  - -     ["Patient Characteristic Ethnicity": "Ethnicity"]

- SDE Payer

  - -     ["Patient Characteristic Payer": "Payer"]

- SDE Race

  - -     ["Patient Characteristic Race": "Race"]

- SDE Sex

  - -     ["Patient Characteristic Sex": "ONC Administrative Sex"]

### Risk Adjustment Variables

- None

Measure Set |
    None