eCQM Title | # Coronary Artery Disease (CAD): Beta-Blocker Therapy-Prior Myocardial Infarction (MI) or Left Ventricular Systolic Dysfunction (LVEF <=40%)
eCQM Identifier (Measure Authoring Tool) | 145 | eCQM Version Number | 12.0.000
NQF Number | 0070e | GUID | 80744ae2-de81-4b16-a71d-69522eb865c5
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 coronary artery disease seen within a 12-month period who also have a prior MI or a current or prior LVEF <=40% who were prescribed beta-blocker therapy
Copyright |
    Copyright 2023 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 2004-2002 American Medical Association. LOINC(R) is copyright 2004-2022 Regenstrief Institute, Inc. This material contains SNOMED Clinical Terms(R) (SNOMED CT[R]) copyright 2004-2022 International Health Terminology Standards Development Organisation. ICD-10 is copyright 2022 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 |
    This measure is intended to have one reporting rate, which aggregates the following populations into a single performance rate for reporting purposes:
    - Population 1: Patients with left ventricular systolic dysfunction (LVEF <=40%)
    - Population 2: Patients with a prior (within the past 3 years) myocardial infarction

    For the purposes of this measure, a single performance rate can be calculated as follows:
    Performance Rate = (Numerator 1 + Numerator 2)/ [(Denominator 1 - Denominator Exceptions 1) + (Denominator 2 - Denominator Exceptions 2)]
Rationale |
    For patients with coronary artery disease (CAD), beta-blockers are recommended for 3 years after myocardial infarction or acute coronary syndrome. Beta-blockers, particularly carvedilol, metoprolol succinate, or bisoprolol which have been shown to reduce risk of death, are recommended indefinitely for patients with CAD and LV systolic dysfunction. These agents have proven efficacy in reducing angina onset and improving the ischemic threshold during exercise. In patients who have suffered an MI, beta-blockers significantly reduce deaths and recurrent MIs (ACCF/AHA/ACP/AATS/PCNA/SCAI/STS, 2012).

    Nonadherence to cardioprotective medications is prevalent among outpatients with CAD and can be associated with a broad range of adverse outcomes, including all-cause and cardiovascular mortality, cardiovascular hospitalizations, and the need for revascularization procedures (ACC/AHA, 2002).

    This measure is intended to promote beta-blocker usage in select patients with CAD.
Clinical Recommendation Statement |
    Beta-blocker therapy should be started and continued for 3 years in all patients with normal LV function after MI or ACS (Class I, Level of Evidence: B) (ACCF/AHA/ACP/AATS/PCNA/SCAI/STS, 2012).

    Beta-blocker therapy should be used in all patients with LV systolic dysfunction (EF <= 40%) with heart failure or prior MI, unless contraindicated. (Use should be limited to carvedilol, metoprolol succinate, or bisoprolol, which have been shown to reduce risk of death.) (Class I, Level of Evidence: A) (ACCF/AHA/ACP/AATS/PCNA/SCAI/STS, 2012).
Improvement Notation |
    Higher score indicates better quality
Reference |
    Reference Type: CITATION
    Reference Text: 'Fihn, S. D., Gardin, J. M., Abrams, J., Berra, K., Blankenship, J. C., Dallas, A. P., … Williams, S. V. (2012). 2012 ACCF/AHA/ACP/AATS/PCNA/SCAI/STS Guideline for the diagnosis and management of patients with stable ischemic heart disease. Circulation, 126(25), e354–e471. doi: 10.1161/cir.0b013e318277d6a0'
Reference |
    Reference Type: CITATION
    Reference Text: 'Gibbons, R. J., Abrams, J., Chatterjee, K., Daley, J., Deedwania, P.K, Douglas J.S., … Smith Jr., S.C. (2002). ACC/AHA 2002 Guideline update for the management of patients with chronic stable angina: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (committee to update the 1999 guidelines for the management of patients with chronic stable angina). Circulation, 107(1), 149-158.  doi:10.1161/01.CIR.0000047041.66447.29'
Definition |
    Prescribed may include prescription given to the patient for beta-blocker therapy at one or more visits in the measurement period OR patient already taking beta-blocker therapy as documented in current medication list.

    Prior Myocardial Infarction (MI) for denominator 2 is limited to those occurring within the past 3 years.

    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 |
    Beta-blocker therapy:
    - For patients with prior MI, beta-blocker therapy includes any agent within the beta-blocker drug class. As of 2015, no recommendations or evidence are cited in current stable ischemic heart disease guidelines for preferential use of specific agents
    - For patients with prior LVEF <=40%, beta-blocker therapy includes the following: bisoprolol, carvedilol, or sustained release metoprolol succinate

    The requirement of two or more visits is 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.

    In order for the Ejection Fraction result pathway to be recognized as below 40%, the result must be reported as a number with unit of %. A text string of "below 40%" or "ejection fraction between 35 and 40%" will not be recognized through electronic data capture. Although, this criteria can also be met using the Diagnosis pathway if specified as "Moderate or Severe."

    If a patient has had a myocardial infarction (MI) within the past 3 years and a current or prior LVEF <=40% (or moderate or severe LVSD), the patient should only be counted in Population Criteria 1.

    This eCQM is a patient-based 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 coronary artery disease
Denominator |
    Equals Initial Population who also have prior (within the past 3 years) MI or a current or prior LVEF <=40%
Denominator Exclusions |
    None
Numerator |
    Patients who were prescribed beta-blocker therapy
Numerator Exclusions |
    Not Applicable
Denominator Exceptions |
    Documentation of medical reason(s) for not prescribing beta-blocker therapy (e.g., arrhythmia, asthma, bradycardia, hypotension, patients with atrioventricular block without cardiac pacer, observation of consecutive heart rates <50, allergy, intolerance, other medical reasons).

    Documentation of patient reason(s) for not prescribing beta-blocker 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

- Population Criteria 1
  - - Initial Population

      - -     AgeInYearsAt(date from start of "Measurement Period")>= 18
                and exists ( "Qualifying Encounter During Measurement Period" Encounter1
                    with "Qualifying Encounter During Measurement Period" Encounter2
                      such that Encounter2.id !~ Encounter1.id
                )
                and exists "Qualifying CAD Encounter"

  - - Denominator

      - -     "Initial Population"
                and exists "Qualifying CAD Encounter and History of Moderate or Severe LVSD"

  - - Denominator Exclusions

      - -     None

  - - Numerator

      - -     "Has Beta Blocker Therapy for LVSD Ordered"
                or "Is Currently Taking Beta Blocker Therapy for LVSD"

  - - Numerator Exclusions

      - -     None

  - - Denominator Exceptions

      - -     "Has Arrhythmia with Qualifying CAD Encounter and History of Moderate or Severe LVSD"
                or "Has Asthma with Qualifying CAD Encounter and History of Moderate or Severe LVSD"
                or "Has Bradycardia with Qualifying CAD Encounter and History of Moderate or Severe LVSD"
                or "Has Hypotension with Qualifying CAD Encounter and History of Moderate or Severe LVSD"
                or "Has Consecutive Heart Rates Less than 50 with Qualifying CAD Encounter and History of Moderate or Severe LVSD"
                or "Has Allergy or Intolerance to Beta Blocker Therapy Ingredient with Qualifying CAD Encounter and History of Moderate or Severe LVSD"
                or "Has Diagnosis of Allergy or Intolerance to Beta Blocker Therapy with Qualifying CAD Encounter and History of Moderate or Severe LVSD"
                or "Has Medical or Patient Reason for Not Ordering Beta Blocker for LVSD"
                or "Has Atrioventricular Block with Qualifying CAD Encounter and History of Moderate or Severe LVSD without Cardiac Pacer"

  - - Stratification

      - -     None

- Population Criteria 2
  - - Initial Population

      - -     AgeInYearsAt(date from start of "Measurement Period")>= 18
                and exists ( "Qualifying Encounter During Measurement Period" Encounter1
                    with "Qualifying Encounter During Measurement Period" Encounter2
                      such that Encounter2.id !~ Encounter1.id
                )
                and exists "Qualifying CAD Encounter"

  - - Denominator

      - -     "Initial Population"
                and exists "Qualifying CAD Encounter and Prior MI"

  - - Denominator Exclusions

      - -     None

  - - Numerator

      - -     "Has Beta Blocker Therapy Ordered"
                or "Is Currently Taking Beta Blocker Therapy"

  - - Numerator Exclusions

      - -     None

  - - Denominator Exceptions

      - -     "Has Arrhythmia with Qualifying CAD Encounter and Prior MI"
                or "Has Asthma with Qualifying CAD Encounter and Prior MI"
                or "Has Bradycardia with Qualifying CAD Encounter and Prior MI"
                or "Has Hypotension with Qualifying CAD Encounter and Prior MI"
                or "Has Consecutive Heart Rates Less than 50 with Qualifying CAD Encounter and Prior MI"
                or "Has Allergy or Intolerance to Beta Blocker Therapy Ingredient with Qualifying CAD Encounter and Prior MI"
                or "Has Diagnosis of Allergy or Intolerance to Beta Blocker Therapy with Qualifying CAD Encounter and Prior MI"
                or "Has Medical or Patient Reason for Not Ordering Beta Blocker Therapy"
                or "Has Atrioventricular Block with Qualifying CAD Encounter and Prior MI without Cardiac Pacer"

  - - Stratification

      - -     None

### Definitions

- - Coronary Artery Disease Encounter

    - -     "Outpatient Encounter During Measurement Period" ValidQualifyingEncounter
              with ["Diagnosis": "Coronary Artery Disease No MI"] CoronaryArteryDisease
                such that CoronaryArteryDisease.prevalencePeriod overlaps day of ValidQualifyingEncounter.relevantPeriod

  - Denominator 1

    - -     "Initial Population"
              and exists "Qualifying CAD Encounter and History of Moderate or Severe LVSD"

  - Denominator 2

    - -     "Initial Population"
              and exists "Qualifying CAD Encounter and Prior MI"

  - Denominator Exceptions 1

    - -     "Has Arrhythmia with Qualifying CAD Encounter and History of Moderate or Severe LVSD"
              or "Has Asthma with Qualifying CAD Encounter and History of Moderate or Severe LVSD"
              or "Has Bradycardia with Qualifying CAD Encounter and History of Moderate or Severe LVSD"
              or "Has Hypotension with Qualifying CAD Encounter and History of Moderate or Severe LVSD"
              or "Has Consecutive Heart Rates Less than 50 with Qualifying CAD Encounter and History of Moderate or Severe LVSD"
              or "Has Allergy or Intolerance to Beta Blocker Therapy Ingredient with Qualifying CAD Encounter and History of Moderate or Severe LVSD"
              or "Has Diagnosis of Allergy or Intolerance to Beta Blocker Therapy with Qualifying CAD Encounter and History of Moderate or Severe LVSD"
              or "Has Medical or Patient Reason for Not Ordering Beta Blocker for LVSD"
              or "Has Atrioventricular Block with Qualifying CAD Encounter and History of Moderate or Severe LVSD without Cardiac Pacer"

  - Denominator Exceptions 2

    - -     "Has Arrhythmia with Qualifying CAD Encounter and Prior MI"
              or "Has Asthma with Qualifying CAD Encounter and Prior MI"
              or "Has Bradycardia with Qualifying CAD Encounter and Prior MI"
              or "Has Hypotension with Qualifying CAD Encounter and Prior MI"
              or "Has Consecutive Heart Rates Less than 50 with Qualifying CAD Encounter and Prior MI"
              or "Has Allergy or Intolerance to Beta Blocker Therapy Ingredient with Qualifying CAD Encounter and Prior MI"
              or "Has Diagnosis of Allergy or Intolerance to Beta Blocker Therapy with Qualifying CAD Encounter and Prior MI"
              or "Has Medical or Patient Reason for Not Ordering Beta Blocker Therapy"
              or "Has Atrioventricular Block with Qualifying CAD Encounter and Prior MI without Cardiac Pacer"

  - Has Allergy or Intolerance to Beta Blocker Therapy Ingredient with Qualifying CAD Encounter and History of Moderate or Severe LVSD

    - -     exists ( ["Allergy/Intolerance": "Beta Blocker Therapy Ingredient"]
              union ["Allergy/Intolerance": "Substance with beta adrenergic receptor antagonist mechanism of action (substance)"] ) BetaBlockerAllergyIntolerance
              with "Qualifying CAD Encounter and History of Moderate or Severe LVSD" CADEncounterModerateOrSevereLVSD
                such that BetaBlockerAllergyIntolerance.prevalencePeriod overlaps after day of CADEncounterModerateOrSevereLVSD.relevantPeriod

  - Has Allergy or Intolerance to Beta Blocker Therapy Ingredient with Qualifying CAD Encounter and Prior MI

    - -     exists ( ["Allergy/Intolerance": "Beta Blocker Therapy Ingredient"]
              union ["Allergy/Intolerance": "Substance with beta adrenergic receptor antagonist mechanism of action (substance)"] ) BetaBlockerAllergyIntolerance
              with "Qualifying CAD Encounter and Prior MI" CADEncounterMI
                such that BetaBlockerAllergyIntolerance.prevalencePeriod overlaps after day of CADEncounterMI.relevantPeriod

  - Has Arrhythmia with Qualifying CAD Encounter and History of Moderate or Severe LVSD

    - -     exists ["Diagnosis": "Arrhythmia"] Arrhythmia
              with "Qualifying CAD Encounter and History of Moderate or Severe LVSD" CADEncounterModerateOrSevereLVSD
                such that Arrhythmia.prevalencePeriod overlaps day of CADEncounterModerateOrSevereLVSD.relevantPeriod

  - Has Arrhythmia with Qualifying CAD Encounter and Prior MI

    - -     exists ["Diagnosis": "Arrhythmia"] Arrhythmia
              with "Qualifying CAD Encounter and Prior MI" CADEncounterMI
                such that Arrhythmia.prevalencePeriod overlaps day of CADEncounterMI.relevantPeriod

  - Has Asthma with Qualifying CAD Encounter and History of Moderate or Severe LVSD

    - -     exists ["Diagnosis": "Asthma"] Asthma
              with "Qualifying CAD Encounter and History of Moderate or Severe LVSD" CADEncounterModerateOrSevereLVSD
                such that Asthma.prevalencePeriod overlaps day of CADEncounterModerateOrSevereLVSD.relevantPeriod

  - Has Asthma with Qualifying CAD Encounter and Prior MI

    - -     exists ["Diagnosis": "Asthma"] Asthma
              with "Qualifying CAD Encounter and Prior MI" CADEncounterMI
                such that Asthma.prevalencePeriod overlaps day of CADEncounterMI.relevantPeriod

  - Has Atrioventricular Block with Qualifying CAD Encounter and History of Moderate or Severe LVSD

    - -     exists ["Diagnosis": "Atrioventricular Block"] AtrioventricularBlock
              with "Qualifying CAD Encounter and History of Moderate or Severe LVSD" CADEncounterModerateOrSevereLVSD
                such that AtrioventricularBlock.prevalencePeriod overlaps day of CADEncounterModerateOrSevereLVSD.relevantPeriod

  - Has Atrioventricular Block with Qualifying CAD Encounter and History of Moderate or Severe LVSD without Cardiac Pacer

    - -     "Has Atrioventricular Block with Qualifying CAD Encounter and History of Moderate or Severe LVSD"
              and not "Has Diagnosis of Cardiac Pacer in Situ with Qualifying CAD Encounter and History of Moderate or Severe LVSD"
              and not "Has Cardiac Pacer Device Implanted with Qualifying CAD Encounter and History of Moderate or Severe LVSD"

  - Has Atrioventricular Block with Qualifying CAD Encounter and Prior MI

    - -     exists ["Diagnosis": "Atrioventricular Block"] AtrioventricularBlock
              with "Qualifying CAD Encounter and Prior MI" CADEncounterMI
                such that AtrioventricularBlock.prevalencePeriod overlaps day of CADEncounterMI.relevantPeriod

  - Has Atrioventricular Block with Qualifying CAD Encounter and Prior MI without Cardiac Pacer

    - -     "Has Atrioventricular Block with Qualifying CAD Encounter and Prior MI"
              and not "Has Diagnosis of Cardiac Pacer in Situ with Qualifying CAD Encounter and Prior MI"
              and not "Has Cardiac Pacer Device Implanted with Qualifying CAD Encounter and Prior MI"

  - Has Beta Blocker Therapy for LVSD Ordered

    - -     exists ["Medication, Order": "Beta Blocker Therapy for LVSD"] BetaBlockerForLVSDOrdered
              with "Qualifying CAD Encounter and History of Moderate or Severe LVSD" CADEncounterModerateOrSevereLVSD
                such that BetaBlockerForLVSDOrdered.authorDatetime during day of CADEncounterModerateOrSevereLVSD.relevantPeriod

  - Has Beta Blocker Therapy Ordered

    - -     exists ["Medication, Order": "Beta Blocker Therapy"] BetaBlockerOrdered
              with "Qualifying CAD Encounter and Prior MI" CADEncounterMI
                such that BetaBlockerOrdered.authorDatetime during day of CADEncounterMI.relevantPeriod

  - Has Bradycardia with Qualifying CAD Encounter and History of Moderate or Severe LVSD

    - -     exists ["Diagnosis": "Bradycardia"] Bradycardia
              with "Qualifying CAD Encounter and History of Moderate or Severe LVSD" CADEncounterModerateOrSevereLVSD
                such that Bradycardia.prevalencePeriod overlaps day of CADEncounterModerateOrSevereLVSD.relevantPeriod

  - Has Bradycardia with Qualifying CAD Encounter and Prior MI

    - -     exists ["Diagnosis": "Bradycardia"] Bradycardia
              with "Qualifying CAD Encounter and Prior MI" CADEncounterMI
                such that Bradycardia.prevalencePeriod overlaps day of CADEncounterMI.relevantPeriod

  - Has Cardiac Pacer Device Implanted with Qualifying CAD Encounter and History of Moderate or Severe LVSD

    - -     exists ["Procedure, Performed": "Cardiac Pacer"] ImplantedCardiacPacer
              with "Qualifying CAD Encounter and History of Moderate or Severe LVSD" CADEncounterModerateOrSevereLVSD
                such that ( Global."NormalizeInterval" ( ImplantedCardiacPacer.relevantDatetime, ImplantedCardiacPacer.relevantPeriod ) ) starts before
                end of CADEncounterModerateOrSevereLVSD.relevantPeriod

  - Has Cardiac Pacer Device Implanted with Qualifying CAD Encounter and Prior MI

    - -     exists ["Procedure, Performed": "Cardiac Pacer"] ImplantedCardiacPacer
              with "Qualifying CAD Encounter and Prior MI" CADEncounterMI
                such that ( Global."NormalizeInterval" ( ImplantedCardiacPacer.relevantDatetime, ImplantedCardiacPacer.relevantPeriod ) ) starts before
                end of CADEncounterMI.relevantPeriod

  - Has Consecutive Heart Rates Less than 50 with Qualifying CAD Encounter and History of Moderate or Severe LVSD

    - -     exists from
              ["Physical Exam, Performed": "Heart Rate"] HeartRate,
              "Qualifying CAD Encounter and History of Moderate or Severe LVSD" CADEncounterModerateOrSevereLVSD
              let PriorHeartRate: Last(["Physical Exam, Performed": "Heart Rate"] MostRecentPriorHeartRate
                  where Global."NormalizeInterval"(MostRecentPriorHeartRate.relevantDatetime, MostRecentPriorHeartRate.relevantPeriod)during CADEncounterModerateOrSevereLVSD.relevantPeriod
                    and Global."NormalizeInterval"(MostRecentPriorHeartRate.relevantDatetime, MostRecentPriorHeartRate.relevantPeriod)before Global."NormalizeInterval"(HeartRate.relevantDatetime, HeartRate.relevantPeriod)
                  sort by start of Global."NormalizeInterval"(relevantDatetime, relevantPeriod)
              )
              where Global."NormalizeInterval" ( HeartRate.relevantDatetime, HeartRate.relevantPeriod ) during CADEncounterModerateOrSevereLVSD.relevantPeriod
                and HeartRate.result < 50 '{beats}/min'
                and PriorHeartRate.result < 50 '{beats}/min'

  - Has Consecutive Heart Rates Less than 50 with Qualifying CAD Encounter and Prior MI

    - -     exists from
              ["Physical Exam, Performed": "Heart Rate"] HeartRate,
              "Qualifying CAD Encounter and Prior MI" CADEncounterMI
              let PriorHeartRate: Last(["Physical Exam, Performed": "Heart Rate"] MostRecentPriorHeartRate
                  where Global."NormalizeInterval"(MostRecentPriorHeartRate.relevantDatetime, MostRecentPriorHeartRate.relevantPeriod)during CADEncounterMI.relevantPeriod
                    and Global."NormalizeInterval"(MostRecentPriorHeartRate.relevantDatetime, MostRecentPriorHeartRate.relevantPeriod)before Global."NormalizeInterval"(HeartRate.relevantDatetime, HeartRate.relevantPeriod)
                  sort by start of Global."NormalizeInterval"(relevantDatetime, relevantPeriod)
              )
              where Global."NormalizeInterval" ( HeartRate.relevantDatetime, HeartRate.relevantPeriod ) during CADEncounterMI.relevantPeriod
                and HeartRate.result < 50 '{beats}/min'
                and PriorHeartRate.result < 50 '{beats}/min'

  - Has Diagnosis of Allergy or Intolerance to Beta Blocker Therapy with Qualifying CAD Encounter and History of Moderate or Severe LVSD

    - -     exists ( ["Diagnosis": "Allergy to Beta Blocker Therapy"]
              union ["Diagnosis": "Intolerance to Beta Blocker Therapy"] ) BetaBlockerAllergyOrIntoleranceDiagnosis
              with "Qualifying CAD Encounter and History of Moderate or Severe LVSD" CADEncounterModerateOrSevereLVSD
                such that BetaBlockerAllergyOrIntoleranceDiagnosis.prevalencePeriod overlaps after day of CADEncounterModerateOrSevereLVSD.relevantPeriod

  - Has Diagnosis of Allergy or Intolerance to Beta Blocker Therapy with Qualifying CAD Encounter and Prior MI

    - -     exists ( ["Diagnosis": "Allergy to Beta Blocker Therapy"]
              union ["Diagnosis": "Intolerance to Beta Blocker Therapy"] ) BetaBlockerAllergyOrIntoleranceDiagnosis
              with "Qualifying CAD Encounter and Prior MI" CADEncounterMI
                such that BetaBlockerAllergyOrIntoleranceDiagnosis.prevalencePeriod overlaps after day of CADEncounterMI.relevantPeriod

  - Has Diagnosis of Cardiac Pacer in Situ with Qualifying CAD Encounter and History of Moderate or Severe LVSD

    - -     exists ["Diagnosis": "Cardiac Pacer in Situ"] CardiacPacerDiagnosis
              with "Qualifying CAD Encounter and History of Moderate or Severe LVSD" CADEncounterModerateOrSevereLVSD
                such that CardiacPacerDiagnosis.prevalencePeriod overlaps after day of CADEncounterModerateOrSevereLVSD.relevantPeriod

  - Has Diagnosis of Cardiac Pacer in Situ with Qualifying CAD Encounter and Prior MI

    - -     exists ["Diagnosis": "Cardiac Pacer in Situ"] CardiacPacerDiagnosis
              with "Qualifying CAD Encounter and Prior MI" CADEncounterMI
                such that CardiacPacerDiagnosis.prevalencePeriod overlaps after day of CADEncounterMI.relevantPeriod

  - Has History of Cardiac Surgery Prior to Encounter

    - -     "Outpatient Encounter During Measurement Period" ValidQualifyingEncounter
              with ["Procedure, Performed": "Cardiac Surgery"] CardiacSurgery
                such that Global."NormalizeInterval" ( CardiacSurgery.relevantDatetime, CardiacSurgery.relevantPeriod ) starts before
                end of ValidQualifyingEncounter.relevantPeriod

  - Has Hypotension with Qualifying CAD Encounter and History of Moderate or Severe LVSD

    - -     exists ["Diagnosis": "Hypotension"] Hypotension
              with "Qualifying CAD Encounter and History of Moderate or Severe LVSD" CADEncounterModerateOrSevereLVSD
                such that Hypotension.prevalencePeriod overlaps day of CADEncounterModerateOrSevereLVSD.relevantPeriod

  - Has Hypotension with Qualifying CAD Encounter and Prior MI

    - -     exists ["Diagnosis": "Hypotension"] Hypotension
              with "Qualifying CAD Encounter and Prior MI" CADEncounterMI
                such that Hypotension.prevalencePeriod overlaps day of CADEncounterMI.relevantPeriod

  - Has Medical or Patient Reason for Not Ordering Beta Blocker for LVSD

    - -     exists ["Medication, Not Ordered": "Beta Blocker Therapy for LVSD"] NoBetaBlockerForLVSDOrdered
              with "Qualifying CAD Encounter and History of Moderate or Severe LVSD" CADEncounterModerateOrSevereLVSD
                such that NoBetaBlockerForLVSDOrdered.authorDatetime during day of CADEncounterModerateOrSevereLVSD.relevantPeriod
              where ( NoBetaBlockerForLVSDOrdered.negationRationale in "Medical Reason"
                  or NoBetaBlockerForLVSDOrdered.negationRationale in "Patient Reason"
              )

  - Has Medical or Patient Reason for Not Ordering Beta Blocker Therapy

    - -     exists ["Medication, Not Ordered": "Beta Blocker Therapy"] NoBetaBlockerOrdered
              with "Qualifying CAD Encounter and Prior MI" CADEncounterMI
                such that NoBetaBlockerOrdered.authorDatetime during day of CADEncounterMI.relevantPeriod
              where ( NoBetaBlockerOrdered.negationRationale in "Medical Reason"
                  or NoBetaBlockerOrdered.negationRationale in "Patient Reason"
              )

  - Initial Population

    - -     AgeInYearsAt(date from start of "Measurement Period")>= 18
              and exists ( "Qualifying Encounter During Measurement Period" Encounter1
                  with "Qualifying Encounter During Measurement Period" Encounter2
                    such that Encounter2.id !~ Encounter1.id
              )
              and exists "Qualifying CAD Encounter"

  - Is Currently Taking Beta Blocker Therapy

    - -     exists ["Medication, Active": "Beta Blocker Therapy"] ActiveBetaBlocker
              with "Qualifying CAD Encounter and Prior MI" CADEncounterMI
                such that ActiveBetaBlocker.relevantPeriod overlaps after day of CADEncounterMI.relevantPeriod

  - Is Currently Taking Beta Blocker Therapy for LVSD

    - -     exists ["Medication, Active": "Beta Blocker Therapy for LVSD"] ActiveBetaBlockerForLVSD
              with "Qualifying CAD Encounter and History of Moderate or Severe LVSD" CADEncounterModerateOrSevereLVSD
                such that ActiveBetaBlockerForLVSD.relevantPeriod overlaps after day of CADEncounterModerateOrSevereLVSD.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 1

    - -     "Has Beta Blocker Therapy for LVSD Ordered"
              or "Is Currently Taking Beta Blocker Therapy for LVSD"

  - Numerator 2

    - -     "Has Beta Blocker Therapy Ordered"
              or "Is Currently Taking Beta Blocker Therapy"

  - Outpatient Encounter During Measurement Period

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

  - Qualifying CAD Encounter

    - -     "Coronary Artery Disease Encounter"
              union "Has History of Cardiac Surgery Prior to Encounter"

  - Qualifying CAD Encounter and History of Moderate or Severe LVSD

    - -     "Qualifying CAD Encounter" EncounterWithCADProxy
              with "Moderate or Severe LVSD Findings" LVSDFindings
                such that Coalesce(LVSDFindings.prevalencePeriod, Global."NormalizeInterval"(LVSDFindings.relevantDatetime, LVSDFindings.relevantPeriod))starts before
                end of EncounterWithCADProxy.relevantPeriod

  - Qualifying CAD Encounter and Prior MI

    - -     "Qualifying CAD Encounter" EncounterWithCADProxy
              with ["Diagnosis": "Myocardial Infarction"] MyocardialInfarction
                such that MyocardialInfarction.prevalencePeriod starts 3 years or less before day of start of EncounterWithCADProxy.relevantPeriod
                  and not exists "Moderate or Severe LVSD Findings"

  - 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 day of "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 "Left ventricular systolic dysfunction (disorder)" ("SNOMEDCT Code (134401001)")
- code "Substance with beta adrenergic receptor antagonist mechanism of action (substance)" ("SNOMEDCT Code (373254001)")
- valueset "Allergy to Beta Blocker Therapy" (2.16.840.1.113883.3.526.3.1177)
- valueset "Arrhythmia" (2.16.840.1.113883.3.526.3.366)
- valueset "Asthma" (2.16.840.1.113883.3.526.3.362)
- valueset "Atrioventricular Block" (2.16.840.1.113883.3.526.3.367)
- valueset "Beta Blocker Therapy" (2.16.840.1.113883.3.526.3.1174)
- valueset "Beta Blocker Therapy for LVSD" (2.16.840.1.113883.3.526.3.1184)
- valueset "Beta Blocker Therapy Ingredient" (2.16.840.1.113883.3.526.3.1493)
- valueset "Bradycardia" (2.16.840.1.113883.3.526.3.412)
- valueset "Cardiac Pacer" (2.16.840.1.113762.1.4.1178.53)
- valueset "Cardiac Pacer in Situ" (2.16.840.1.113883.3.526.3.368)
- valueset "Cardiac Surgery" (2.16.840.1.113883.3.526.3.371)
- valueset "Care Services in Long-Term Residential Facility" (2.16.840.1.113883.3.464.1003.101.12.1014)
- valueset "Coronary Artery Disease No MI" (2.16.840.1.113883.3.526.3.369)
- valueset "Ejection Fraction" (2.16.840.1.113883.3.526.3.1134)
- valueset "Ethnicity" (2.16.840.1.114222.4.11.837)
- valueset "Heart Rate" (2.16.840.1.113883.3.526.3.1176)
- valueset "Home Healthcare Services" (2.16.840.1.113883.3.464.1003.101.12.1016)
- valueset "Hypotension" (2.16.840.1.113883.3.526.3.370)
- valueset "Intolerance to Beta Blocker Therapy" (2.16.840.1.113883.3.526.3.1178)
- 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 "Myocardial Infarction" (2.16.840.1.113883.3.526.3.403)
- 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 "Payer" (2.16.840.1.114222.4.11.3591)
- valueset "Race" (2.16.840.1.114222.4.11.836)

### Data Criteria (QDM Data Elements)

- "Allergy/Intolerance: Beta Blocker Therapy Ingredient" using "Beta Blocker Therapy Ingredient (2.16.840.1.113883.3.526.3.1493)"
- "Allergy/Intolerance: Substance with beta adrenergic receptor antagonist mechanism of action (substance)" using "Substance with beta adrenergic receptor antagonist mechanism of action (substance) (SNOMEDCT Code 373254001)"
- "Diagnosis: Allergy to Beta Blocker Therapy" using "Allergy to Beta Blocker Therapy (2.16.840.1.113883.3.526.3.1177)"
- "Diagnosis: Arrhythmia" using "Arrhythmia (2.16.840.1.113883.3.526.3.366)"
- "Diagnosis: Asthma" using "Asthma (2.16.840.1.113883.3.526.3.362)"
- "Diagnosis: Atrioventricular Block" using "Atrioventricular Block (2.16.840.1.113883.3.526.3.367)"
- "Diagnosis: Bradycardia" using "Bradycardia (2.16.840.1.113883.3.526.3.412)"
- "Diagnosis: Cardiac Pacer in Situ" using "Cardiac Pacer in Situ (2.16.840.1.113883.3.526.3.368)"
- "Diagnosis: Coronary Artery Disease No MI" using "Coronary Artery Disease No MI (2.16.840.1.113883.3.526.3.369)"
- "Diagnosis: Hypotension" using "Hypotension (2.16.840.1.113883.3.526.3.370)"
- "Diagnosis: Intolerance to Beta Blocker Therapy" using "Intolerance to Beta Blocker Therapy (2.16.840.1.113883.3.526.3.1178)"
- "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: Myocardial Infarction" using "Myocardial Infarction (2.16.840.1.113883.3.526.3.403)"
- "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: Beta Blocker Therapy" using "Beta Blocker Therapy (2.16.840.1.113883.3.526.3.1174)"
- "Medication, Active: Beta Blocker Therapy for LVSD" using "Beta Blocker Therapy for LVSD (2.16.840.1.113883.3.526.3.1184)"
- "Medication, Not Ordered: Beta Blocker Therapy" using "Beta Blocker Therapy (2.16.840.1.113883.3.526.3.1174)"
- "Medication, Not Ordered: Beta Blocker Therapy for LVSD" using "Beta Blocker Therapy for LVSD (2.16.840.1.113883.3.526.3.1184)"
- "Medication, Order: Beta Blocker Therapy" using "Beta Blocker Therapy (2.16.840.1.113883.3.526.3.1174)"
- "Medication, Order: Beta Blocker Therapy for LVSD" using "Beta Blocker Therapy for LVSD (2.16.840.1.113883.3.526.3.1184)"
- "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)"
- "Physical Exam, Performed: Heart Rate" using "Heart Rate (2.16.840.1.113883.3.526.3.1176)"
- "Procedure, Performed: Cardiac Pacer" using "Cardiac Pacer (2.16.840.1.113762.1.4.1178.53)"
- "Procedure, Performed: Cardiac Surgery" using "Cardiac Surgery (2.16.840.1.113883.3.526.3.371)"

### 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