eMeasure Title Heart Failure (HF): Angiotensin-Converting Enzyme (ACE) Inhibitor or Angiotensin Receptor Blocker (ARB) Therapy for Left Ventricular Systolic Dysfunction (LVSD)
eMeasure Identifier
(Measure Authoring Tool)
135 eMeasure Version number 3
NQF Number 0081 GUID 430ffc53-4122-4421-88cc-2edd8117bb3c
Measurement Period January 1, 20xx through December 31, 20xx
Measure Steward American Medical Association-convened Physician Consortium for Performance Improvement(R) (AMA-PCPI)
Measure Developer American Medical Association-convened Physician Consortium for Performance Improvement(R) (AMA-PCPI)
Endorsed By National Quality Forum
Description
Percentage of patients aged 18 years and older with a diagnosis of heart failure (HF) with a current or prior left ventricular ejection fraction (LVEF) < 40% who were prescribed ACE inhibitor or ARB therapy either within a 12 month period when seen in the outpatient setting OR at each hospital discharge
Copyright
Copyright 2013 American College of Cardiology, American Heart Association and American Medical Association. All Rights Reserved.
Disclaimer
Physician Performance Measures (Measures) and related data specifications have been developed by the American Medical Association (AMA) - convened Physician Consortium for Performance Improvement(R) (PCPI[R]), American College of Cardiology (ACC) and American Heart Association (AHA). These Measures are not clinical guidelines and do not establish a standard of medical care, and have not been tested for all potential applications. The Measures, while copyrighted, can be reproduced and distributed, without modification, for noncommercial purposes, eg, use by health care providers in connection with their practices. Commercial use is defined as the sale, license, or distribution of the Measures for commercial gain, or incorporation of the Measures into a product or service that is sold, licensed or distributed for commercial gain. Commercial uses of the Measures require a license agreement between the user and the AMA, (on behalf of the PCPI), ACC or AHA. Neither the AMA, ACC, AHA, PCPI nor its members shall be responsible for any use of the Measures. 

THE MEASURES 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 AMA, ACC, AHA, the PCPI and its 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 2004-2013 American Medical Association. LOINC(R) copyright 2004-2013 Regenstrief Institute, Inc. This material contains SNOMED Clinical Terms(R) (SNOMED CT[R]) copyright 2004-2013 International Health Terminology Standards Development Organisation. ICD-10 copyright 2013 World Health Organization. All Rights Reserved.

Due to technical limitations, registered trademarks are indicated by (R) or [R] and unregistered trademarks are indicated by (TM) or [TM]
Measure Scoring Proportion
Measure Type Process
Stratification
None
Risk Adjustment
None
Rate Aggregation
None
Rationale
In the absence of contraindications, ACE inhibitors or ARBs are recommended for all patients with symptoms of heart failure and reduced left ventricular systolic function. ACE inhibitors remain the first choice for inhibition of the renin-angiotensin system in chronic heart failure, but ARBs can now be considered a reasonable alternative. Both pharmacologic agents have been shown to decrease the risk of death and hospitalization. Additional benefits of ACE inhibitors include the alleviation of symptoms and the improvement of clinical status and overall sense of well-being of patients with heart failure.
Clinical Recommendation Statement
Angiotensin converting enzyme inhibitors are recommended for all patients with current or prior symptoms of [heart failure] and reduced LVEF, unless contraindicated. (Class I, Level of Evidence: A) (ACCF/AHA, 2009)

Treatment with an [ACE inhibitor] should be initiated at low doses [see excerpt from guideline table below], followed by gradual increments in dose if lower doses have been well tolerated. Clinicians should attempt to use doses that have been shown to reduce the risk of cardiovascular events in clinical trials. If these target doses of an [ACE inhibitor] cannot be used or are poorly tolerated, intermediate doses should be used with the expectation that there are likely to be only small differences in efficacy between low and high doses. (ACCF/AHA, 2009)

Inhibitors of the Renin-Angiotensin-Aldosterone System  …Commonly Used for the
Treatment of Patients with [Heart Failure] with Low Ejection Fraction
Drug                       Initial Daily Dose(s)                             Maximum Doses(s)
ACE Inhibitors
   Captopril               6.25 mg 3 times                                50 mg 3 times
   Enalapril               2.5 mg twice                                    10 to 20 mg twice
   Fosinopril             5 to 10 mg once                                40 mg once
   Lisinopril              2.5 to 5 mg once                               20 to 40 mg once
   Perindopril           2 mg once                                        8 to 16 mg once
   Quinapril              5 mg twice                                       20 mg twice
   Ramipril               1.25 to 2.5 mg once                          10 mg once
   Trandolapril          1 mg once                                        4 mg once
Angiotensin Receptor Blockers
   Candesartan           4 to 8 mg once                                 32 mg once
   Losartan**             25 to 50 mg once                              50 to 100 mg once
   Valsartan               20 to 40 mg twice                             160 mg twice

**[Note: Among ARBs, Losartan has the weakest evidence supporting its value in heart failure patients.] Additionally, while the 2009 guidelines recommended a maximum dosage of 100mg, the maximum dosage recommendation for Losartan has been increased to 150mg based on the HEAAL trial. (Konstam MA, et al. Lancet 2009 Nov 28;374:1840-8)

An ARB should be administered to post-[myocardial infarction (MI)] patients without [heart failure] who are intolerant of [ACE inhibitors] and have a low LVEF. (Class I, Level of Evidence: B) (ACCF/AHA, 2009)

Angiotensin II receptor blockers are reasonable to use as alternatives to [ACE inhibitors] as first-line therapy for patients with mild to moderate [heart failure] and reduced LVEF, especially for patients already taking ARBs for other indications. (Class IIa, Level of Evidence: A) (ACCF/AHA, 2009)

For the hospitalized patient:
--In patients with reduced ejection fraction experiencing a symptomatic exacerbation of [heart failure] requiring hospitalization during chronic maintenance treatment with oral therapies known to improve outcomes, particularly ACE inhibitors or ARBs and beta-blocker therapy, it is recommended that these therapies be continued in most patients in the absence of hemodynamic instability or contraindications. (Class I, Level of Evidence: C) (ACCF/AHA, 2009)
--In patients hospitalized with [heart failure] with reduced ejection fraction not treated with oral therapies known to improve outcomes, particularly ACE inhibitors or ARBs and beta-blocker therapy, initiation of these therapies is recommended in stable patients prior to hospital discharge. 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. Particular 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, 2009)
Improvement Notation
Higher score indicates better quality
Reference
Jessup M, Abraham WT, Casey DE, et al., writing on behalf of the 2005 Guideline Update for the Diagnosis and Management of Chronic Heart Failure in the Adult Writing Committee. 2009 focused update: ACCF/AHA guidelines for the diagnosis and management of heart failure in adults: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol. 2009;53:1343– 82.
Reference
Konstam MA, Neaton JD, Dickstein K, Drexler H, Komajda M, Martinez FA, Riegger GA, Malbecq W, Smith RD, Guptha S, Poole-Wilson PA. Effects of high-dose versus low-dose losartan on clinical outcomes in patients with heart failure (HEAAL study): a randomised, double-blind trial. Lancet 2009 Nov 28;374:1840-8
Definition
Outpatient setting: prescription given to the patient for ACE inhibitor or ARB therapy at one or more visits in the measurement period OR patient already taking ACE inhibitor or ARB therapy as documented in current medication list.

Inpatient setting: prescription given to the patient for ACE inhibitor or ARB therapy at discharge OR ACE inhibitor or ARB 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.
Guidance
To meet this measure, it must be reported for all heart failure patients a minimum of once during the measurement period when seen in the outpatient setting AND reported at each hospital discharge during the measurement period.

The requirement of “Count >=2 of Encounter, Performed“ is to establish that the eligible professional has an existing relationship with the patient.
Transmission Format
TBD
Initial Patient Population
All patients aged 18 years and older with a diagnosis of heart failure
Denominator
Equals Initial Patient Population with a current or prior LVEF < 40%
Denominator Exclusions
None
Numerator
Patients who were prescribed ACE inhibitor or ARB therapy either within a 12 month period when seen in the outpatient setting OR at each hospital discharge
Numerator Exclusions
Not Applicable
Denominator Exceptions
Documentation of medical reason(s) for not prescribing ACE inhibitor or ARB therapy (eg, hypotensive patients who are at immediate risk of cardiogenic shock, hospitalized patients who have experienced marked azotemia, allergy, intolerance, other medical reasons)
Documentation of patient reason(s) for not prescribing ACE inhibitor or ARB therapy (eg, patient declined, other patient reasons)
Documentation of system reason(s) for not prescribing ACE inhibitor or ARB therapy (eg, other system reasons)
Measure Population
Not Applicable
Measure Observations
Not Applicable
Supplemental Data Elements
For every patient evaluated by this measure also identify payer, race, ethnicity and sex.

Table of Contents


Population criteria

Data criteria (QDM Data Elements)

Reporting Stratification

Supplemental Data Elements




Measure Set
None