Heart Failure (HF): Beta-Blocker Therapy for Left Ventricular Systolic Dysfunction (LVSD) 10.0.000

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 beta-blocker therapy either within a 12-month period when seen in the outpatient setting OR at each hospital discharge

Copyright 2021 American College of Cardiology and American Heart Association. All Rights Reserved.

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CPT(R) contained in the Measure specifications is copyright 2004-2020 American Medical Association. LOINC(R) is copyright 2004-2020 Regenstrief Institute, Inc. This material contains SNOMED Clinical Terms(R) (SNOMED CT[R]) copyright 2004-2020 International Health Terminology Standards Development Organisation. ICD-10 is copyright 2020 World Health Organization. All Rights Reserved.

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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 who were prescribed beta-blocker therapy within a 12-month period when seen in the outpatient setting 
- Population 2: Patients who were prescribed beta-blocker therapy at each hospital discharge

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)]

Beta-blockers are recommended for all patients with stable heart failure and left ventricular systolic dysfunction, unless contraindicated. Treatment should be initiated as soon as a patient is diagnosed with left ventricular systolic dysfunction and does not have low blood pressure, fluid overload, or recent treatment with an intravenous positive inotropic agent. Beta-blockers have been shown to lessen the symptoms of heart failure, improve the clinical status of patients, reduce future clinical deterioration, and decrease the risk of mortality and the combined risk of mortality and hospitalization.

Use of 1 of the 3 beta blockers proven to reduce mortality (e.g., bisoprolol, carvedilol, and sustained-release metoprolol succinate) is recommended for all patients with current or prior symptoms of HFrEF [heart failure with reduced ejection fraction], unless contraindicated, to reduce morbidity and mortality (Class I, Level of Evidence: A) (ACCF/AHA, 2013).

Treatment with a beta blocker should be initiated at very low doses [see excerpt from guideline table below] followed by gradual increments in dose if lower doses have been well tolerated... Clinicians should make every effort to achieve the target doses of the beta blockers shown to be effective in major clinical trials. Even if symptoms do not improve, long-term treatment should be maintained to reduce the risk of major clinical events. Abrupt withdrawal of treatment with a beta blocker 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 Beta-blocker therapy)
Drug                               Initial Daily Dose(s)       Maximum Dose(s)        Mean Doses Achieved in Clinical Trials
                                                                                                                                                
Beta Blockers
Bisoprolol                         1.25 mg once               10 mg once                  8.6 mg/d
Carvedilol                         3.125 mg twice            50 mg twice                  37 mg/d
Carvedilol CR                  10 mg once                  80 mg once                   N/A
Metoprolol succinate        12.5 to 25 mg once      200 mg once                159 mg/d
extended release
(metoprolol CR/XL)

For the hospitalized patient:
In patients with HFrEF experiencing a symptomatic exacerbation of HF requiring hospitalization during chronic maintenance treatment with GDMT [guideline-directed medical therapy; GDMT represents optimal medical therapy as defined by ACCF/AHA guideline-recommended therapies (primarily Class I)], it is recommended that GDMT be continued in the absence of hemodynamic instability or contraindications (Class I, Level of Evidence: B) (ACCF/AHA, 2013).

Initiation of beta-blocker therapy is recommended after optimization of volume status and successful discontinuation of intravenous diuretics, vasodilators, and inotropic agents. Beta-blocker therapy should be initiated at a low dose and only in stable patients. Caution should be used when initiating beta blockers in patients who have required inotropes during their hospital course (Class I, Level of Evidence: B) (ACCF/AHA, 2013).

Higher score indicates better quality

Reference Type: CITATION

Reference Text: 'Yancy, C. W., Jessup, M., Bozkurt, B., Butler, J., Casey, D. E., Drazner, M. H., Fonarow, G. C., Geraci, S. A., Horwich, T., Januzzi, J. L., Johnson, M. R., Kasper, E. K., Levy, W. C., Masoudi, F. A., McBride, P. E., McMurray, J. J. V., Mitchell, J. E., Peterson, P. N., Riegel, B., . . . 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'

Prescribed-Outpatient setting: 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.

Prescribed-Inpatient setting: prescription given to the patient for beta-blocker therapy at discharge OR beta-blocker therapy to be continued after discharge as documented in the discharge 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.

This eCQM is to be reported as patient-based or episode-based, depending on the clinical setting. 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. If the patient has an eligible inpatient discharge during the measurement period, as defined in the measure logic, it is expected to be reported at each hospital discharge.

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

Beta-blocker therapy:
-For patients with prior LVEF < 40%, beta-blocker therapy should include bisoprolol, carvedilol, or sustained release metoprolol succinate.

The requirement of two or more visits used in Population Criteria 1 is to establish that the eligible professional or eligible clinician has an existing relationship with the patient.

This version of the eCQM uses QDM version 5.5. Please refer to the eCQI resource center (https://ecqi.healthit.gov/qdm) for more information on the QDM.

All patients aged 18 years and older with a diagnosis of heart failure

Equals Initial Population with a current or prior LVEF < 40%

Patients who were prescribed beta-blocker therapy either within a 12-month period when seen in the outpatient setting OR at each hospital discharge

Documentation of medical reason(s) for not prescribing beta-blocker therapy (e.g., low blood pressure, fluid overload, asthma, patients recently treated with an intravenous positive inotropic agent, allergy, intolerance, other medical reasons).

Documentation of patient reason(s) for not prescribing beta-blocker therapy (e.g., patient declined, other patient reasons).

Documentation of system reason(s) for not prescribing beta-blocker therapy (e.g., other reasons attributable to the healthcare system).

For every patient evaluated by this measure also identify payer, race, ethnicity and sex

Population Criteria 1

Initial Population

exists ( ["Patient Characteristic Birthdate": "Birth date"] BirthDate
    where Global."CalendarAgeInYearsAt" ( BirthDate.birthDatetime, start of "Measurement Period" ) >= 18
)
  and Count("Qualifying Encounter During Measurement Period")>= 2
  and exists "Heart Failure Outpatient Encounter"

Denominator

"Initial Population 1"
  and exists "Heart Failure Outpatient Encounter with Moderate or Severe LVSD"

- Denominator Exclusions
  - None

Numerator

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

- Numerator Exclusions
  - None

Denominator Exceptions

"Has Consecutive Heart Rates Less than 50 Outpatient"
  or "Has Medical Patient or System Reason for Not Ordering Beta Blocker for LVSD Outpatient"
  or "Has Arrhythmia Diagnosis Outpatient"
  or "Has Hypotension Diagnosis Outpatient"
  or "Has Asthma Diagnosis Outpatient"
  or "Has Diagnosis of Allergy or Intolerance to Beta Blocker Therapy Outpatient"
  or "Has Bradycardia Diagnosis Outpatient"
  or "Has Allergy or Intolerance to Beta Blocker Therapy Ingredient Outpatient"
  or "Atrioventricular Block without Cardiac Pacer Outpatient"

- Stratification
  - None

Population Criteria 2

Initial Population

exists ( ["Patient Characteristic Birthdate": "Birth date"] BirthDate
    where Global."CalendarAgeInYearsAt" ( BirthDate.birthDatetime, start of "Measurement Period" ) >= 18
)
  and exists "Heart Failure Inpatient Encounter"

Denominator

"Initial Population 2"
  and exists "Heart Failure Inpatient Encounter with Moderate or Severe LVSD"

- Denominator Exclusions
  - None

Numerator

"Has Beta Blocker Therapy for LVSD at Inpatient Discharge"

- Numerator Exclusions
  - None

Denominator Exceptions

"Has Consecutive Heart Rates Less than 50 Inpatient"
  or "Has Medical Patient or System Reason for No Beta Blocker for LVSD at Inpatient Discharge"
  or "Has Arrhythmia Diagnosis Inpatient"
  or "Has Hypotension Diagnosis Inpatient"
  or "Has Asthma Diagnosis Inpatient"
  or "Has Diagnosis of Allergy or Intolerance to Beta Blocker Therapy Inpatient"
  or "Has Bradycardia Diagnosis Inpatient"
  or "Has Allergy or Intolerance to Beta Blocker Therapy Ingredient Inpatient"
  or "Atrioventricular Block without Cardiac Pacer Inpatient"

- Stratification
  - None

Atrioventricular Block without Cardiac Pacer Inpatient

"Has Atrioventricular Block Diagnosis Inpatient"
  and not "Has Diagnosis of Cardiac Pacer in Situ Inpatient"
  and not "Has Cardiac Pacer Device Implanted Inpatient"

Atrioventricular Block without Cardiac Pacer Outpatient

"Has Atrioventricular Block Diagnosis Outpatient"
  and not "Has Diagnosis of Cardiac Pacer in Situ Outpatient"
  and not "Has Cardiac Pacer Device Implanted Outpatient"

Denominator 1

"Initial Population 1"
  and exists "Heart Failure Outpatient Encounter with Moderate or Severe LVSD"

Denominator 2

"Initial Population 2"
  and exists "Heart Failure Inpatient Encounter with Moderate or Severe LVSD"

Denominator Exceptions 1

"Has Consecutive Heart Rates Less than 50 Outpatient"
  or "Has Medical Patient or System Reason for Not Ordering Beta Blocker for LVSD Outpatient"
  or "Has Arrhythmia Diagnosis Outpatient"
  or "Has Hypotension Diagnosis Outpatient"
  or "Has Asthma Diagnosis Outpatient"
  or "Has Diagnosis of Allergy or Intolerance to Beta Blocker Therapy Outpatient"
  or "Has Bradycardia Diagnosis Outpatient"
  or "Has Allergy or Intolerance to Beta Blocker Therapy Ingredient Outpatient"
  or "Atrioventricular Block without Cardiac Pacer Outpatient"

Denominator Exceptions 2

"Has Consecutive Heart Rates Less than 50 Inpatient"
  or "Has Medical Patient or System Reason for No Beta Blocker for LVSD at Inpatient Discharge"
  or "Has Arrhythmia Diagnosis Inpatient"
  or "Has Hypotension Diagnosis Inpatient"
  or "Has Asthma Diagnosis Inpatient"
  or "Has Diagnosis of Allergy or Intolerance to Beta Blocker Therapy Inpatient"
  or "Has Bradycardia Diagnosis Inpatient"
  or "Has Allergy or Intolerance to Beta Blocker Therapy Ingredient Inpatient"
  or "Atrioventricular Block without Cardiac Pacer Inpatient"

Has Allergy or Intolerance to Beta Blocker Therapy Ingredient Inpatient

exists ( ["Allergy/Intolerance": "Beta Blocker Therapy Ingredient"]
  union ["Allergy/Intolerance": "Substance with beta adrenergic receptor antagonist mechanism of action (substance)"] ) BetaBlockerAllergyIntolerance
  with "Heart Failure Inpatient Encounter with Moderate or Severe LVSD" ModerateOrSevereLVSDHFInpatientEncounter
    such that BetaBlockerAllergyIntolerance.prevalencePeriod overlaps after ModerateOrSevereLVSDHFInpatientEncounter.relevantPeriod

Has Allergy or Intolerance to Beta Blocker Therapy Ingredient Outpatient

exists ( ["Allergy/Intolerance": "Beta Blocker Therapy Ingredient"]
  union ["Allergy/Intolerance": "Substance with beta adrenergic receptor antagonist mechanism of action (substance)"] ) BetaBlockerAllergyIntolerance
  with "Heart Failure Outpatient Encounter with Moderate or Severe LVSD" ModerateOrSevereLVSDHFOutpatientEncounter
    such that BetaBlockerAllergyIntolerance.prevalencePeriod overlaps after ModerateOrSevereLVSDHFOutpatientEncounter.relevantPeriod

Has Arrhythmia Diagnosis Inpatient

exists ["Diagnosis": "Arrhythmia"] Arrhythmia
  with "Heart Failure Inpatient Encounter with Moderate or Severe LVSD" ModerateOrSevereLVSDHFInpatientEncounter
    such that Arrhythmia.prevalencePeriod overlaps ModerateOrSevereLVSDHFInpatientEncounter.relevantPeriod

Has Arrhythmia Diagnosis Outpatient

exists ["Diagnosis": "Arrhythmia"] Arrhythmia
  with "Heart Failure Outpatient Encounter with Moderate or Severe LVSD" ModerateOrSevereLVSDHFOutpatientEncounter
    such that Arrhythmia.prevalencePeriod overlaps ModerateOrSevereLVSDHFOutpatientEncounter.relevantPeriod

Has Asthma Diagnosis Inpatient

exists ["Diagnosis": "Asthma"] Asthma
  with "Heart Failure Inpatient Encounter with Moderate or Severe LVSD" ModerateOrSevereLVSDHFInpatientEncounter
    such that Asthma.prevalencePeriod overlaps ModerateOrSevereLVSDHFInpatientEncounter.relevantPeriod

Has Asthma Diagnosis Outpatient

exists ["Diagnosis": "Asthma"] Asthma
  with "Heart Failure Outpatient Encounter with Moderate or Severe LVSD" ModerateOrSevereLVSDHFOutpatientEncounter
    such that Asthma.prevalencePeriod overlaps ModerateOrSevereLVSDHFOutpatientEncounter.relevantPeriod

Has Atrioventricular Block Diagnosis Inpatient

exists ["Diagnosis": "Atrioventricular Block"] AtrioventricularBlock
  with "Heart Failure Inpatient Encounter with Moderate or Severe LVSD" ModerateOrSevereLVSDHFInpatientEncounter
    such that AtrioventricularBlock.prevalencePeriod overlaps ModerateOrSevereLVSDHFInpatientEncounter.relevantPeriod

Has Atrioventricular Block Diagnosis Outpatient

exists ["Diagnosis": "Atrioventricular Block"] AtrioventricularBlock
  with "Heart Failure Outpatient Encounter with Moderate or Severe LVSD" ModerateOrSevereLVSDHFOutpatientEncounter
    such that AtrioventricularBlock.prevalencePeriod overlaps ModerateOrSevereLVSDHFOutpatientEncounter.relevantPeriod

Has Beta Blocker Therapy for LVSD at Inpatient Discharge

exists ["Medication, Discharge": "Beta Blocker Therapy for LVSD"] BetaBlockerAtDischarge
  with "Heart Failure Inpatient Encounter with Moderate or Severe LVSD" ModerateOrSevereLVSDHFInpatientEncounter
    such that BetaBlockerAtDischarge.authorDatetime during ModerateOrSevereLVSDHFInpatientEncounter.relevantPeriod

Has Beta Blocker Therapy for LVSD Ordered Outpatient

exists ["Medication, Order": "Beta Blocker Therapy for LVSD"] BetaBlockerOrdered
  with "Heart Failure Outpatient Encounter with Moderate or Severe LVSD" ModerateOrSevereLVSDHFOutpatientEncounter
    such that BetaBlockerOrdered.authorDatetime during ModerateOrSevereLVSDHFOutpatientEncounter.relevantPeriod

Has Bradycardia Diagnosis Inpatient

exists ["Diagnosis": "Bradycardia"] Bradycardia
  with "Heart Failure Inpatient Encounter with Moderate or Severe LVSD" ModerateOrSevereLVSDHFInpatientEncounter
    such that Bradycardia.prevalencePeriod overlaps ModerateOrSevereLVSDHFInpatientEncounter.relevantPeriod

Has Bradycardia Diagnosis Outpatient

exists ["Diagnosis": "Bradycardia"] Bradycardia
  with "Heart Failure Outpatient Encounter with Moderate or Severe LVSD" ModerateOrSevereLVSDHFOutpatientEncounter
    such that Bradycardia.prevalencePeriod overlaps ModerateOrSevereLVSDHFOutpatientEncounter.relevantPeriod

Has Cardiac Pacer Device Implanted Inpatient

exists ["Device, Applied": "Cardiac Pacer"] ImplantedCardiacPacer
  with "Heart Failure Inpatient Encounter with Moderate or Severe LVSD" ModerateOrSevereLVSDHFInpatientEncounter
    such that ImplantedCardiacPacer.relevantPeriod overlaps after ModerateOrSevereLVSDHFInpatientEncounter.relevantPeriod
      or ImplantedCardiacPacer.relevantDatetime before 
      end of ModerateOrSevereLVSDHFInpatientEncounter.relevantPeriod

Has Cardiac Pacer Device Implanted Outpatient

exists ["Device, Applied": "Cardiac Pacer"] ImplantedCardiacPacer
  with "Heart Failure Outpatient Encounter with Moderate or Severe LVSD" ModerateOrSevereLVSDHFOutpatientEncounter
    such that ImplantedCardiacPacer.relevantPeriod overlaps after ModerateOrSevereLVSDHFOutpatientEncounter.relevantPeriod
      or ImplantedCardiacPacer.relevantDatetime before 
      end of ModerateOrSevereLVSDHFOutpatientEncounter.relevantPeriod

Has Consecutive Heart Rates Less than 50 Inpatient

exists from
  ["Physical Exam, Performed": "Heart Rate"] HeartRate,
  "Heart Failure Inpatient Encounter with Moderate or Severe LVSD" ModerateOrSevereLVSDHFInpatientEncounter
  let PriorHeartRate: Last(["Physical Exam, Performed": "Heart Rate"] MostRecentPriorHeartRate
      where(Global."NormalizeInterval"(MostRecentPriorHeartRate.relevantDatetime, MostRecentPriorHeartRate.relevantPeriod))during ModerateOrSevereLVSDHFInpatientEncounter.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 ModerateOrSevereLVSDHFInpatientEncounter.relevantPeriod
    and HeartRate.result < 50 '{beats}/min'
    and PriorHeartRate.result < 50 '{beats}/min'

Has Consecutive Heart Rates Less than 50 Outpatient

exists from
  ["Physical Exam, Performed": "Heart Rate"] HeartRate,
  "Heart Failure Outpatient Encounter with Moderate or Severe LVSD" ModerateOrSevereLVSDHFOutpatientEncounter
  let PriorHeartRate: Last(["Physical Exam, Performed": "Heart Rate"] MostRecentPriorHeartRate
      where(Global."NormalizeInterval"(MostRecentPriorHeartRate.relevantDatetime, MostRecentPriorHeartRate.relevantPeriod))during ModerateOrSevereLVSDHFOutpatientEncounter.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 ModerateOrSevereLVSDHFOutpatientEncounter.relevantPeriod
    and HeartRate.result < 50 '{beats}/min'
    and PriorHeartRate.result < 50 '{beats}/min'

Has Diagnosis of Allergy or Intolerance to Beta Blocker Therapy Inpatient

exists ( ["Diagnosis": "Allergy to Beta Blocker Therapy"]
  union ["Diagnosis": "Intolerance to Beta Blocker Therapy"] ) BetaBlockerAllergyOrIntoleranceDiagnosis
  with "Heart Failure Inpatient Encounter with Moderate or Severe LVSD" ModerateOrSevereLVSDHFInpatientEncounter
    such that BetaBlockerAllergyOrIntoleranceDiagnosis.prevalencePeriod overlaps after ModerateOrSevereLVSDHFInpatientEncounter.relevantPeriod

Has Diagnosis of Allergy or Intolerance to Beta Blocker Therapy Outpatient

exists ( ["Diagnosis": "Allergy to Beta Blocker Therapy"]
  union ["Diagnosis": "Intolerance to Beta Blocker Therapy"] ) BetaBlockerAllergyOrIntoleranceDiagnosis
  with "Heart Failure Outpatient Encounter with Moderate or Severe LVSD" ModerateOrSevereLVSDHFOutpatientEncounter
    such that BetaBlockerAllergyOrIntoleranceDiagnosis.prevalencePeriod overlaps after ModerateOrSevereLVSDHFOutpatientEncounter.relevantPeriod

Has Diagnosis of Cardiac Pacer in Situ Inpatient

exists ["Diagnosis": "Cardiac Pacer in Situ"] CardiacPacerDiagnosis
  with "Heart Failure Inpatient Encounter with Moderate or Severe LVSD" ModerateOrSevereLVSDHFInpatientEncounter
    such that CardiacPacerDiagnosis.prevalencePeriod overlaps after ModerateOrSevereLVSDHFInpatientEncounter.relevantPeriod

Has Diagnosis of Cardiac Pacer in Situ Outpatient

exists ["Diagnosis": "Cardiac Pacer in Situ"] CardiacPacerDiagnosis
  with "Heart Failure Outpatient Encounter with Moderate or Severe LVSD" ModerateOrSevereLVSDHFOutpatientEncounter
    such that CardiacPacerDiagnosis.prevalencePeriod overlaps after ModerateOrSevereLVSDHFOutpatientEncounter.relevantPeriod

Has Hypotension Diagnosis Inpatient

exists ["Diagnosis": "Hypotension"] Hypotension
  with "Heart Failure Inpatient Encounter with Moderate or Severe LVSD" ModerateOrSevereLVSDHFInpatientEncounter
    such that Hypotension.prevalencePeriod overlaps ModerateOrSevereLVSDHFInpatientEncounter.relevantPeriod

Has Hypotension Diagnosis Outpatient

exists ["Diagnosis": "Hypotension"] Hypotension
  with "Heart Failure Outpatient Encounter with Moderate or Severe LVSD" ModerateOrSevereLVSDHFOutpatientEncounter
    such that Hypotension.prevalencePeriod overlaps ModerateOrSevereLVSDHFOutpatientEncounter.relevantPeriod

Has Medical Patient or System Reason for No Beta Blocker for LVSD at Inpatient Discharge

exists ["Medication, Not Discharged": "Beta Blocker Therapy for LVSD"] NoBetaBlockerAtDischarge
  with "Heart Failure Inpatient Encounter with Moderate or Severe LVSD" ModerateOrSevereLVSDHFInpatientEncounter
    such that NoBetaBlockerAtDischarge.authorDatetime during ModerateOrSevereLVSDHFInpatientEncounter.relevantPeriod
  where ( NoBetaBlockerAtDischarge.negationRationale in "Medical Reason"
      or NoBetaBlockerAtDischarge.negationRationale in "Patient Reason"
      or NoBetaBlockerAtDischarge.negationRationale in "System Reason"
  )

Has Medical Patient or System Reason for Not Ordering Beta Blocker for LVSD Outpatient

exists ["Medication, Not Ordered": "Beta Blocker Therapy for LVSD"] NoBetaBlockerOrdered
  with "Heart Failure Outpatient Encounter with Moderate or Severe LVSD" ModerateOrSevereLVSDHFOutpatientEncounter
    such that NoBetaBlockerOrdered.authorDatetime during ModerateOrSevereLVSDHFOutpatientEncounter.relevantPeriod
  where ( NoBetaBlockerOrdered.negationRationale in "Medical Reason"
      or NoBetaBlockerOrdered.negationRationale in "Patient Reason"
      or NoBetaBlockerOrdered.negationRationale in "System Reason"
  )

Heart Failure Inpatient Encounter

["Encounter, Performed": "Discharge Services - Hospital Inpatient"] InpatientDischarge
  with ["Diagnosis": "Heart Failure"] HeartFailure
    such that HeartFailure.prevalencePeriod overlaps InpatientDischarge.relevantPeriod
  where InpatientDischarge.relevantPeriod during "Measurement Period"

Heart Failure Inpatient Encounter with Moderate or Severe LVSD

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

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 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 1

exists ( ["Patient Characteristic Birthdate": "Birth date"] BirthDate
    where Global."CalendarAgeInYearsAt" ( BirthDate.birthDatetime, start of "Measurement Period" ) >= 18
)
  and Count("Qualifying Encounter During Measurement Period")>= 2
  and exists "Heart Failure Outpatient Encounter"

Initial Population 2

exists ( ["Patient Characteristic Birthdate": "Birth date"] BirthDate
    where Global."CalendarAgeInYearsAt" ( BirthDate.birthDatetime, start of "Measurement Period" ) >= 18
)
  and exists "Heart Failure Inpatient Encounter"

Is Currently Taking Beta Blocker Therapy for LVSD Outpatient

exists ["Medication, Active": "Beta Blocker Therapy for LVSD"] ActiveBetaBlocker
  with "Heart Failure Outpatient Encounter with Moderate or Severe LVSD" ModerateOrSevereLVSDHFOutpatientEncounter
    such that ActiveBetaBlocker.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 1

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

Numerator 2

"Has Beta Blocker Therapy for LVSD at Inpatient Discharge"

Qualifying Encounter During Measurement Period

( ["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"]
  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"]

Global.CalendarAgeInYearsAt(BirthDateTime DateTime, AsOf DateTime)
- - years between ToDate(BirthDateTime)and ToDate(AsOf)

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>

Global.ToDate(Value DateTime)

DateTime(year from Value, month from Value, day from Value, 0, 0, 0, 0, timezoneoffset from Value)

code "Birth date" ("LOINC Code (21112-8)")
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 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" (2.16.840.1.113883.3.526.3.1193)
valueset "Cardiac Pacer in Situ" (2.16.840.1.113883.3.526.3.368)
valueset "Care Services in Long-Term Residential Facility" (2.16.840.1.113883.3.464.1003.101.12.1014)
valueset "Discharge Services - Hospital Inpatient" (2.16.840.1.113883.3.464.1003.101.12.1007)
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 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 "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)
valueset "System Reason" (2.16.840.1.113883.3.526.3.1009)

"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)"
"Device, Applied: Cardiac Pacer" using "Cardiac Pacer (2.16.840.1.113883.3.526.3.1193)"
"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: Heart Failure" using "Heart Failure (2.16.840.1.113883.3.526.3.376)"
"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)"
"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: Discharge Services - Hospital Inpatient" using "Discharge Services - Hospital Inpatient (2.16.840.1.113883.3.464.1003.101.12.1007)"
"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 for LVSD" using "Beta Blocker Therapy for LVSD (2.16.840.1.113883.3.526.3.1184)"
"Medication, Discharge: Beta Blocker Therapy for LVSD" using "Beta Blocker Therapy for LVSD (2.16.840.1.113883.3.526.3.1184)"
"Medication, Not Discharged: 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 for LVSD" using "Beta Blocker Therapy for LVSD (2.16.840.1.113883.3.526.3.1184)"
"Medication, Order: Beta Blocker Therapy for LVSD" using "Beta Blocker Therapy for LVSD (2.16.840.1.113883.3.526.3.1184)"
"Patient Characteristic Birthdate: Birth date" using "Birth date (LOINC Code 21112-8)"
"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)"

["Patient Characteristic Ethnicity": "Ethnicity"]

["Patient Characteristic Payer": "Payer"]

```
["Patient Characteristic Race": "Race"]
```

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

Heart Failure (HF): Beta-Blocker Therapy for Left Ventricular Systolic Dysfunction (LVSD)

Table of Contents

Population Criteria

Definitions

Functions

Terminology

Data Criteria (QDM Data Elements)

Supplemental Data Elements

Risk Adjustment Variables