Coronary Artery Disease (CAD): Beta-Blocker Therapy-Prior Myocardial Infarction (MI) or Left Ventricular Systolic Dysfunction (LVEF <40%) 10.1.000

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

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 2004-2020 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.

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].

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)]

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.

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).

Higher score indicates better quality

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 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'

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.

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 40% threshold noted in the denominator logic. A range that is inclusive of or greater than 40% would not meet the measure requirement.

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 5.5. 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 coronary artery disease seen within a 12-month period

Equals Initial Population who also have prior (within the past 3 years) MI or a current or prior LVEF <40%

Patients who were prescribed beta-blocker therapy

Documentation of medical reason(s) for not prescribing beta-blocker therapy (e.g., 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 health care 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 "Qualifying CAD Encounter" )

Denominator

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

- 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 Count("Qualifying Encounter During Measurement Period")>= 2
  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 Patient or System Reason for Not Ordering Beta Blocker Therapy"
  or "Has Atrioventricular Block with Qualifying CAD Encounter and Prior MI without Cardiac Pacer"

- Stratification
  - None

Coronary Artery Disease Encounter

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

Denominator 1

"Initial Population"
  and exists "Qualifying CAD Encounter and 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 Moderate or Severe LVSD"
  or "Has Asthma with Qualifying CAD Encounter and Moderate or Severe LVSD"
  or "Has Bradycardia with Qualifying CAD Encounter and Moderate or Severe LVSD"
  or "Has Hypotension with Qualifying CAD Encounter and Moderate or Severe LVSD"
  or "Has Consecutive Heart Rates Less than 50 with Qualifying CAD Encounter and Moderate or Severe LVSD"
  or "Has Allergy or Intolerance to Beta Blocker Therapy Ingredient with Qualifying CAD Encounter and Moderate or Severe LVSD"
  or "Has Diagnosis of Allergy or Intolerance to Beta Blocker Therapy with Qualifying CAD Encounter and Moderate or Severe LVSD"
  or "Has Medical Patient or System Reason for Not Ordering Beta Blocker for LVSD"
  or "Has Atrioventricular Block with Qualifying CAD Encounter and 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 Patient or System 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 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 Moderate or Severe LVSD" CADEncounterModerateOrSevereLVSD
    such that BetaBlockerAllergyIntolerance.prevalencePeriod overlaps after 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 CADEncounterMI.relevantPeriod

Has Arrhythmia with Qualifying CAD Encounter and Moderate or Severe LVSD

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

Has Asthma with Qualifying CAD Encounter and Moderate or Severe LVSD

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

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

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

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

"Has Atrioventricular Block with Qualifying CAD Encounter and Moderate or Severe LVSD"
  and not "Has Diagnosis of Cardiac Pacer in Situ with Qualifying CAD Encounter and Moderate or Severe LVSD"
  and not "Has Cardiac Pacer Device Implanted with Qualifying CAD Encounter and 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 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 Moderate or Severe LVSD" CADEncounterModerateOrSevereLVSD
    such that BetaBlockerForLVSDOrdered.authorDatetime during 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 CADEncounterMI.relevantPeriod

Has Bradycardia with Qualifying CAD Encounter and Moderate or Severe LVSD

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

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

exists ["Device, Applied": "Cardiac Pacer"] ImplantedCardiacPacer
  with "Qualifying CAD Encounter and Moderate or Severe LVSD" CADEncounterModerateOrSevereLVSD
    such that ImplantedCardiacPacer.relevantPeriod overlaps after CADEncounterModerateOrSevereLVSD.relevantPeriod
      or ImplantedCardiacPacer.relevantDatetime before 
      end of CADEncounterModerateOrSevereLVSD.relevantPeriod

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

exists ["Device, Applied": "Cardiac Pacer"] ImplantedCardiacPacer
  with "Qualifying CAD Encounter and Prior MI" CADEncounterMI
    such that ImplantedCardiacPacer.relevantPeriod overlaps after CADEncounterMI.relevantPeriod
      or ImplantedCardiacPacer.relevantDatetime before 
      end of CADEncounterMI.relevantPeriod

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

exists from
  ["Physical Exam, Performed": "Heart Rate"] HeartRate,
  "Qualifying CAD Encounter and 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 Moderate or Severe LVSD

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

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

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

Has Hypotension with Qualifying CAD Encounter and Moderate or Severe LVSD

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

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

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

Has Medical Patient or System 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 CADEncounterMI.relevantPeriod
  where ( NoBetaBlockerOrdered.negationRationale in "Medical Reason"
      or NoBetaBlockerOrdered.negationRationale in "Patient Reason"
      or NoBetaBlockerOrdered.negationRationale in "System Reason"
  )

History of Cardiac Surgery

"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

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 "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 CADEncounterMI.relevantPeriod

Is Currently Taking Beta Blocker Therapy for LVSD

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

Qualifying CAD Encounter

"Coronary Artery Disease Encounter"
  union "History of Cardiac Surgery"

Qualifying CAD Encounter and 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
  without "Moderate or Severe LVSD Findings" LVSDFindings
    such that Coalesce(LVSDFindings.prevalencePeriod, Global."NormalizeInterval"(LVSDFindings.relevantDatetime, LVSDFindings.relevantPeriod))starts before 
    end of EncounterWithCADProxy.relevantPeriod

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"]

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" (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" (2.16.840.1.113883.3.526.3.1193)
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)
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: 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 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)"
"Procedure, Performed: Cardiac Surgery" using "Cardiac Surgery (2.16.840.1.113883.3.526.3.371)"

["Patient Characteristic Ethnicity": "Ethnicity"]

["Patient Characteristic Payer": "Payer"]

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

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

Coronary Artery Disease (CAD): Beta-Blocker Therapy-Prior Myocardial Infarction (MI) or Left Ventricular Systolic Dysfunction (LVEF <40%)

Table of Contents

Population Criteria

Definitions

Functions

Terminology

Data Criteria (QDM Data Elements)

Supplemental Data Elements

Risk Adjustment Variables