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

Initial Patient Population =
- AND: "Patient Characteristic Birthdate: birth date" >= 18 year(s) starts before start of "Measurement Period"
- AND:
  - OR: Count >= 2 of:
    - OR: "Encounter, Performed: Care Services in Long-Term Residential Facility"
    - OR: "Encounter, Performed: Home Healthcare Services"
    - OR: "Encounter, Performed: Nursing Facility Visit"
    - OR: "Encounter, Performed: Office Visit"
    - OR: "Encounter, Performed: Outpatient Consultation"
    - OR: "Encounter, Performed: Patient Provider Interaction"
  - OR: "Encounter, Performed: Discharge Services - Hospital Inpatient"
  - during "Measurement Period"
- AND:
  - OR:
    - AND: "Occurrence A of Encounter, Performed: Care Services in Long-Term Residential Facility" during "Measurement Period"
    - AND: "Occurrence A of Diagnosis, Active: Heart Failure" starts before or during "Occurrence A of Encounter, Performed: Care Services in Long-Term Residential Facility"
    - AND NOT: "Occurrence A of Diagnosis, Active: Heart Failure" ends before start of "Occurrence A of Encounter, Performed: Care Services in Long-Term Residential Facility"
  - OR:
    - AND: "Occurrence A of Encounter, Performed: Home Healthcare Services" during "Measurement Period"
    - AND: "Occurrence A of Diagnosis, Active: Heart Failure" starts before or during "Occurrence A of Encounter, Performed: Home Healthcare Services"
    - AND NOT: "Occurrence A of Diagnosis, Active: Heart Failure" ends before start of "Occurrence A of Encounter, Performed: Home Healthcare Services"
  - OR:
    - AND: "Occurrence A of Encounter, Performed: Nursing Facility Visit" during "Measurement Period"
    - AND: "Occurrence A of Diagnosis, Active: Heart Failure" starts before or during "Occurrence A of Encounter, Performed: Nursing Facility Visit"
    - AND NOT: "Occurrence A of Diagnosis, Active: Heart Failure" ends before start of "Occurrence A of Encounter, Performed: Nursing Facility Visit"
  - OR:
    - AND: "Occurrence A of Encounter, Performed: Office Visit" during "Measurement Period"
    - AND: "Occurrence A of Diagnosis, Active: Heart Failure" starts before or during "Occurrence A of Encounter, Performed: Office Visit"
    - AND NOT: "Occurrence A of Diagnosis, Active: Heart Failure" ends before start of "Occurrence A of Encounter, Performed: Office Visit"
  - OR:
    - AND: "Occurrence A of Encounter, Performed: Outpatient Consultation" during "Measurement Period"
    - AND: "Occurrence A of Diagnosis, Active: Heart Failure" starts before or during "Occurrence A of Encounter, Performed: Outpatient Consultation"
    - AND NOT: "Occurrence A of Diagnosis, Active: Heart Failure" ends before start of "Occurrence A of Encounter, Performed: Outpatient Consultation"
  - OR:
    - AND: "Occurrence A of Encounter, Performed: Face-to-Face Interaction" during "Measurement Period"
    - AND: "Occurrence A of Diagnosis, Active: Heart Failure" starts before or during "Occurrence A of Encounter, Performed: Face-to-Face Interaction"
    - AND NOT: "Occurrence A of Diagnosis, Active: Heart Failure" ends before start of "Occurrence A of Encounter, Performed: Face-to-Face Interaction"
  - OR:
    - AND: "Occurrence A of Encounter, Performed: Discharge Services - Hospital Inpatient" during "Measurement Period"
    - AND: "Occurrence A of Diagnosis, Active: Heart Failure" starts before or during "Occurrence A of Encounter, Performed: Discharge Services - Hospital Inpatient"
    - AND NOT: "Occurrence A of Diagnosis, Active: Heart Failure" ends before start of "Occurrence A of Encounter, Performed: Discharge Services - Hospital Inpatient"
Denominator =
- AND: "Initial Patient Population"
- AND:
  - OR: "Diagnostic Study, Result: Ejection Fraction (result < 40 %)"
  - OR: "Diagnosis, Active: Moderate or Severe LVSD"
  - OR: "Diagnosis, Active: Left Ventricular Systolic Dysfunction (severity: 'Moderate or Severe')"
  - starts before or during
    - OR: "Occurrence A of Encounter, Performed: Care Services in Long-Term Residential Facility"
    - OR: "Occurrence A of Encounter, Performed: Home Healthcare Services"
    - OR: "Occurrence A of Encounter, Performed: Nursing Facility Visit"
    - OR: "Occurrence A of Encounter, Performed: Office Visit"
    - OR: "Occurrence A of Encounter, Performed: Outpatient Consultation"
    - OR: "Occurrence A of Encounter, Performed: Face-to-Face Interaction"
    - OR: "Occurrence A of Encounter, Performed: Discharge Services - Hospital Inpatient"
Denominator Exclusions =
- None
Numerator =
- AND:
  - OR: "Medication, Order: Beta Blocker Therapy for LVSD" during
    - OR: "Occurrence A of Encounter, Performed: Care Services in Long-Term Residential Facility"
    - OR: "Occurrence A of Encounter, Performed: Home Healthcare Services"
    - OR: "Occurrence A of Encounter, Performed: Nursing Facility Visit"
    - OR: "Occurrence A of Encounter, Performed: Office Visit"
    - OR: "Occurrence A of Encounter, Performed: Outpatient Consultation"
    - OR: "Occurrence A of Encounter, Performed: Face-to-Face Interaction"
    - OR: "Occurrence A of Encounter, Performed: Discharge Services - Hospital Inpatient"
  - OR:
    - AND: "Occurrence A of Medication, Active: Beta Blocker Therapy for LVSD" starts before or during "Occurrence A of Encounter, Performed: Care Services in Long-Term Residential Facility"
    - AND NOT: "Occurrence A of Medication, Active: Beta Blocker Therapy for LVSD" ends before start of "Occurrence A of Encounter, Performed: Care Services in Long-Term Residential Facility"
  - OR:
    - AND: "Occurrence A of Medication, Active: Beta Blocker Therapy for LVSD" starts before or during "Occurrence A of Encounter, Performed: Home Healthcare Services"
    - AND NOT: "Occurrence A of Medication, Active: Beta Blocker Therapy for LVSD" ends before start of "Occurrence A of Encounter, Performed: Home Healthcare Services"
  - OR:
    - AND: "Occurrence A of Medication, Active: Beta Blocker Therapy for LVSD" starts before or during "Occurrence A of Encounter, Performed: Nursing Facility Visit"
    - AND NOT: "Occurrence A of Medication, Active: Beta Blocker Therapy for LVSD" ends before start of "Occurrence A of Encounter, Performed: Nursing Facility Visit"
  - OR:
    - AND: "Occurrence A of Medication, Active: Beta Blocker Therapy for LVSD" starts before or during "Occurrence A of Encounter, Performed: Office Visit"
    - AND NOT: "Occurrence A of Medication, Active: Beta Blocker Therapy for LVSD" ends before start of "Occurrence A of Encounter, Performed: Office Visit"
  - OR:
    - AND: "Occurrence A of Medication, Active: Beta Blocker Therapy for LVSD" starts before or during "Occurrence A of Encounter, Performed: Outpatient Consultation"
    - AND NOT: "Occurrence A of Medication, Active: Beta Blocker Therapy for LVSD" ends before start of "Occurrence A of Encounter, Performed: Outpatient Consultation"
  - OR:
    - AND: "Occurrence A of Medication, Active: Beta Blocker Therapy for LVSD" starts before or during "Occurrence A of Encounter, Performed: Face-to-Face Interaction"
    - AND NOT: "Occurrence A of Medication, Active: Beta Blocker Therapy for LVSD" ends before start of "Occurrence A of Encounter, Performed: Face-to-Face Interaction"
  - OR:
    - AND: "Occurrence A of Medication, Active: Beta Blocker Therapy for LVSD" starts before or during "Occurrence A of Encounter, Performed: Discharge Services - Hospital Inpatient"
    - AND NOT: "Occurrence A of Medication, Active: Beta Blocker Therapy for LVSD" ends before start of "Occurrence A of Encounter, Performed: Discharge Services - Hospital Inpatient"
Denominator Exceptions =
- AND:
  - OR:
    - AND: MOST RECENT:"Occurrence B of Physical Exam, Finding: Heart Rate" starts before start of "Occurrence A of Physical Exam, Finding: Heart Rate"
    - AND:
      - OR:
        
        AND: "Occurrence A of Physical Exam, Finding: Heart Rate (result < 50 bpm)" during "Occurrence A of Encounter, Performed: Care Services in Long-Term Residential Facility"
        
        AND: "Occurrence B of Physical Exam, Finding: Heart Rate (result < 50 bpm)" during "Occurrence A of Encounter, Performed: Care Services in Long-Term Residential Facility"
      - OR:
        
        AND: "Occurrence A of Physical Exam, Finding: Heart Rate (result < 50 bpm)" during "Occurrence A of Encounter, Performed: Home Healthcare Services"
        
        AND: "Occurrence B of Physical Exam, Finding: Heart Rate (result < 50 bpm)" during "Occurrence A of Encounter, Performed: Home Healthcare Services"
      - OR:
        
        AND: "Occurrence A of Physical Exam, Finding: Heart Rate (result < 50 bpm)" during "Occurrence A of Encounter, Performed: Nursing Facility Visit"
        
        AND: "Occurrence B of Physical Exam, Finding: Heart Rate (result < 50 bpm)" during "Occurrence A of Encounter, Performed: Nursing Facility Visit"
      - OR:
        
        AND: "Occurrence A of Physical Exam, Finding: Heart Rate (result < 50 bpm)" during "Occurrence A of Encounter, Performed: Office Visit"
        
        AND: "Occurrence B of Physical Exam, Finding: Heart Rate (result < 50 bpm)" during "Occurrence A of Encounter, Performed: Office Visit"
      - OR:
        
        AND: "Occurrence A of Physical Exam, Finding: Heart Rate (result < 50 bpm)" during "Occurrence A of Encounter, Performed: Outpatient Consultation"
        
        AND: "Occurrence B of Physical Exam, Finding: Heart Rate (result < 50 bpm)" during "Occurrence A of Encounter, Performed: Outpatient Consultation"
      - OR:
        
        AND: "Occurrence A of Physical Exam, Finding: Heart Rate (result < 50 bpm)" during "Occurrence A of Encounter, Performed: Face-to-Face Interaction"
        
        AND: "Occurrence B of Physical Exam, Finding: Heart Rate (result < 50 bpm)" during "Occurrence A of Encounter, Performed: Face-to-Face Interaction"
      - OR:
        
        AND: "Occurrence A of Physical Exam, Finding: Heart Rate (result < 50 bpm)" during "Occurrence A of Encounter, Performed: Discharge Services - Hospital Inpatient"
        
        AND: "Occurrence B of Physical Exam, Finding: Heart Rate (result < 50 bpm)" during "Occurrence A of Encounter, Performed: Discharge Services - Hospital Inpatient"
  - OR:
    - OR: "Medication, Order not done: Medical Reason" for "Beta Blocker Therapy Ingredient"
    - OR: "Medication, Order not done: Patient Reason" for "Beta Blocker Therapy Ingredient"
    - OR: "Medication, Order not done: System Reason" for "Beta Blocker Therapy Ingredient"
    - starts during
      - OR: "Occurrence A of Encounter, Performed: Care Services in Long-Term Residential Facility"
      - OR: "Occurrence A of Encounter, Performed: Home Healthcare Services"
      - OR: "Occurrence A of Encounter, Performed: Nursing Facility Visit"
      - OR: "Occurrence A of Encounter, Performed: Office Visit"
      - OR: "Occurrence A of Encounter, Performed: Outpatient Consultation"
      - OR: "Occurrence A of Encounter, Performed: Face-to-Face Interaction"
      - OR: "Occurrence A of Encounter, Performed: Discharge Services - Hospital Inpatient"
  - OR:
    - OR:
      - AND: "Occurrence A of Diagnosis, Active: Arrhythmia" starts before or during "Occurrence A of Encounter, Performed: Care Services in Long-Term Residential Facility"
      - AND NOT: "Occurrence A of Diagnosis, Active: Arrhythmia" ends before start of "Occurrence A of Encounter, Performed: Care Services in Long-Term Residential Facility"
    - OR:
      - AND: "Occurrence A of Diagnosis, Active: Arrhythmia" starts before or during "Occurrence A of Encounter, Performed: Home Healthcare Services"
      - AND NOT: "Occurrence A of Diagnosis, Active: Arrhythmia" ends before start of "Occurrence A of Encounter, Performed: Home Healthcare Services"
    - OR:
      - AND: "Occurrence A of Diagnosis, Active: Arrhythmia" starts before or during "Occurrence A of Encounter, Performed: Nursing Facility Visit"
      - AND NOT: "Occurrence A of Diagnosis, Active: Arrhythmia" ends before start of "Occurrence A of Encounter, Performed: Nursing Facility Visit"
    - OR:
      - AND: "Occurrence A of Diagnosis, Active: Arrhythmia" starts before or during "Occurrence A of Encounter, Performed: Office Visit"
      - AND NOT: "Occurrence A of Diagnosis, Active: Arrhythmia" ends before start of "Occurrence A of Encounter, Performed: Office Visit"
    - OR:
      - AND: "Occurrence A of Diagnosis, Active: Arrhythmia" starts before or during "Occurrence A of Encounter, Performed: Outpatient Consultation"
      - AND NOT: "Occurrence A of Diagnosis, Active: Arrhythmia" ends before start of "Occurrence A of Encounter, Performed: Outpatient Consultation"
    - OR:
      - AND: "Occurrence A of Diagnosis, Active: Arrhythmia" starts before or during "Occurrence A of Encounter, Performed: Face-to-Face Interaction"
      - AND NOT: "Occurrence A of Diagnosis, Active: Arrhythmia" ends before start of "Occurrence A of Encounter, Performed: Face-to-Face Interaction"
    - OR:
      - AND: "Occurrence A of Diagnosis, Active: Arrhythmia" starts before or during "Occurrence A of Encounter, Performed: Discharge Services - Hospital Inpatient"
      - AND NOT: "Occurrence A of Diagnosis, Active: Arrhythmia" ends before start of "Occurrence A of Encounter, Performed: Discharge Services - Hospital Inpatient"
  - OR:
    - OR:
      - AND: "Occurrence A of Diagnosis, Active: Hypotension" starts before or during "Occurrence A of Encounter, Performed: Care Services in Long-Term Residential Facility"
      - AND NOT: "Occurrence A of Diagnosis, Active: Hypotension" ends before start of "Occurrence A of Encounter, Performed: Care Services in Long-Term Residential Facility"
    - OR:
      - AND: "Occurrence A of Diagnosis, Active: Hypotension" starts before or during "Occurrence A of Encounter, Performed: Home Healthcare Services"
      - AND NOT: "Occurrence A of Diagnosis, Active: Hypotension" ends before start of "Occurrence A of Encounter, Performed: Home Healthcare Services"
    - OR:
      - AND: "Occurrence A of Diagnosis, Active: Hypotension" starts before or during "Occurrence A of Encounter, Performed: Nursing Facility Visit"
      - AND NOT: "Occurrence A of Diagnosis, Active: Hypotension" ends before start of "Occurrence A of Encounter, Performed: Nursing Facility Visit"
    - OR:
      - AND: "Occurrence A of Diagnosis, Active: Hypotension" starts before or during "Occurrence A of Encounter, Performed: Office Visit"
      - AND NOT: "Occurrence A of Diagnosis, Active: Hypotension" ends before start of "Occurrence A of Encounter, Performed: Office Visit"
    - OR:
      - AND: "Occurrence A of Diagnosis, Active: Hypotension" starts before or during "Occurrence A of Encounter, Performed: Outpatient Consultation"
      - AND NOT: "Occurrence A of Diagnosis, Active: Hypotension" ends before start of "Occurrence A of Encounter, Performed: Outpatient Consultation"
    - OR:
      - AND: "Occurrence A of Diagnosis, Active: Hypotension" starts before or during "Occurrence A of Encounter, Performed: Face-to-Face Interaction"
      - AND NOT: "Occurrence A of Diagnosis, Active: Hypotension" ends before start of "Occurrence A of Encounter, Performed: Face-to-Face Interaction"
    - OR:
      - AND: "Occurrence A of Diagnosis, Active: Hypotension" starts before or during "Occurrence A of Encounter, Performed: Discharge Services - Hospital Inpatient"
      - AND NOT: "Occurrence A of Diagnosis, Active: Hypotension" ends before start of "Occurrence A of Encounter, Performed: Discharge Services - Hospital Inpatient"
  - OR:
    - OR:
      - AND: "Occurrence A of Diagnosis, Active: Asthma" starts before or during "Occurrence A of Encounter, Performed: Care Services in Long-Term Residential Facility"
      - AND NOT: "Occurrence A of Diagnosis, Active: Asthma" ends before start of "Occurrence A of Encounter, Performed: Care Services in Long-Term Residential Facility"
    - OR:
      - AND: "Occurrence A of Diagnosis, Active: Asthma" starts before or during "Occurrence A of Encounter, Performed: Home Healthcare Services"
      - AND NOT: "Occurrence A of Diagnosis, Active: Asthma" ends before start of "Occurrence A of Encounter, Performed: Home Healthcare Services"
    - OR:
      - AND: "Occurrence A of Diagnosis, Active: Asthma" starts before or during "Occurrence A of Encounter, Performed: Nursing Facility Visit"
      - AND NOT: "Occurrence A of Diagnosis, Active: Asthma" ends before start of "Occurrence A of Encounter, Performed: Nursing Facility Visit"
    - OR:
      - AND: "Occurrence A of Diagnosis, Active: Asthma" starts before or during "Occurrence A of Encounter, Performed: Office Visit"
      - AND NOT: "Occurrence A of Diagnosis, Active: Asthma" ends before start of "Occurrence A of Encounter, Performed: Office Visit"
    - OR:
      - AND: "Occurrence A of Diagnosis, Active: Asthma" starts before or during "Occurrence A of Encounter, Performed: Outpatient Consultation"
      - AND NOT: "Occurrence A of Diagnosis, Active: Asthma" ends before start of "Occurrence A of Encounter, Performed: Outpatient Consultation"
    - OR:
      - AND: "Occurrence A of Diagnosis, Active: Asthma" starts before or during "Occurrence A of Encounter, Performed: Face-to-Face Interaction"
      - AND NOT: "Occurrence A of Diagnosis, Active: Asthma" ends before start of "Occurrence A of Encounter, Performed: Face-to-Face Interaction"
    - OR:
      - AND: "Occurrence A of Diagnosis, Active: Asthma" starts before or during "Occurrence A of Encounter, Performed: Discharge Services - Hospital Inpatient"
      - AND NOT: "Occurrence A of Diagnosis, Active: Asthma" ends before start of "Occurrence A of Encounter, Performed: Discharge Services - Hospital Inpatient"
  - OR:
    - OR:
      - AND: "Occurrence A of Diagnosis, Active: Allergy to Beta Blocker Therapy" starts before or during "Occurrence A of Encounter, Performed: Care Services in Long-Term Residential Facility"
      - AND NOT: "Occurrence A of Diagnosis, Active: Allergy to Beta Blocker Therapy" ends before start of "Occurrence A of Encounter, Performed: Care Services in Long-Term Residential Facility"
    - OR:
      - AND: "Occurrence A of Diagnosis, Active: Allergy to Beta Blocker Therapy" starts before or during "Occurrence A of Encounter, Performed: Home Healthcare Services"
      - AND NOT: "Occurrence A of Diagnosis, Active: Allergy to Beta Blocker Therapy" ends before start of "Occurrence A of Encounter, Performed: Home Healthcare Services"
    - OR:
      - AND: "Occurrence A of Diagnosis, Active: Allergy to Beta Blocker Therapy" starts before or during "Occurrence A of Encounter, Performed: Nursing Facility Visit"
      - AND NOT: "Occurrence A of Diagnosis, Active: Allergy to Beta Blocker Therapy" ends before start of "Occurrence A of Encounter, Performed: Nursing Facility Visit"
    - OR:
      - AND: "Occurrence A of Diagnosis, Active: Allergy to Beta Blocker Therapy" starts before or during "Occurrence A of Encounter, Performed: Office Visit"
      - AND NOT: "Occurrence A of Diagnosis, Active: Allergy to Beta Blocker Therapy" ends before start of "Occurrence A of Encounter, Performed: Office Visit"
    - OR:
      - AND: "Occurrence A of Diagnosis, Active: Allergy to Beta Blocker Therapy" starts before or during "Occurrence A of Encounter, Performed: Outpatient Consultation"
      - AND NOT: "Occurrence A of Diagnosis, Active: Allergy to Beta Blocker Therapy" ends before start of "Occurrence A of Encounter, Performed: Outpatient Consultation"
    - OR:
      - AND: "Occurrence A of Diagnosis, Active: Allergy to Beta Blocker Therapy" starts before or during "Occurrence A of Encounter, Performed: Face-to-Face Interaction"
      - AND NOT: "Occurrence A of Diagnosis, Active: Allergy to Beta Blocker Therapy" ends before start of "Occurrence A of Encounter, Performed: Face-to-Face Interaction"
    - OR:
      - AND: "Occurrence A of Diagnosis, Active: Allergy to Beta Blocker Therapy" starts before or during "Occurrence A of Encounter, Performed: Discharge Services - Hospital Inpatient"
      - AND NOT: "Occurrence A of Diagnosis, Active: Allergy to Beta Blocker Therapy" ends before start of "Occurrence A of Encounter, Performed: Discharge Services - Hospital Inpatient"
  - OR:
    - OR:
      - AND: "Occurrence A of Medication, Intolerance: Beta Blocker Therapy" starts before or during "Occurrence A of Encounter, Performed: Care Services in Long-Term Residential Facility"
      - AND NOT: "Occurrence A of Medication, Intolerance: Beta Blocker Therapy" ends before start of "Occurrence A of Encounter, Performed: Care Services in Long-Term Residential Facility"
    - OR:
      - AND: "Occurrence A of Medication, Intolerance: Beta Blocker Therapy" starts before or during "Occurrence A of Encounter, Performed: Home Healthcare Services"
      - AND NOT: "Occurrence A of Medication, Intolerance: Beta Blocker Therapy" ends before start of "Occurrence A of Encounter, Performed: Home Healthcare Services"
    - OR:
      - AND: "Occurrence A of Medication, Intolerance: Beta Blocker Therapy" starts before or during "Occurrence A of Encounter, Performed: Nursing Facility Visit"
      - AND NOT: "Occurrence A of Medication, Intolerance: Beta Blocker Therapy" ends before start of "Occurrence A of Encounter, Performed: Nursing Facility Visit"
    - OR:
      - AND: "Occurrence A of Medication, Intolerance: Beta Blocker Therapy" starts before or during "Occurrence A of Encounter, Performed: Office Visit"
      - AND NOT: "Occurrence A of Medication, Intolerance: Beta Blocker Therapy" ends before start of "Occurrence A of Encounter, Performed: Office Visit"
    - OR:
      - AND: "Occurrence A of Medication, Intolerance: Beta Blocker Therapy" starts before or during "Occurrence A of Encounter, Performed: Outpatient Consultation"
      - AND NOT: "Occurrence A of Medication, Intolerance: Beta Blocker Therapy" ends before start of "Occurrence A of Encounter, Performed: Outpatient Consultation"
    - OR:
      - AND: "Occurrence A of Medication, Intolerance: Beta Blocker Therapy" starts before or during "Occurrence A of Encounter, Performed: Face-to-Face Interaction"
      - AND NOT: "Occurrence A of Medication, Intolerance: Beta Blocker Therapy" ends before start of "Occurrence A of Encounter, Performed: Face-to-Face Interaction"
    - OR:
      - AND: "Occurrence A of Medication, Intolerance: Beta Blocker Therapy" starts before or during "Occurrence A of Encounter, Performed: Discharge Services - Hospital Inpatient"
      - AND NOT: "Occurrence A of Medication, Intolerance: Beta Blocker Therapy" ends before start of "Occurrence A of Encounter, Performed: Discharge Services - Hospital Inpatient"
  - OR:
    - OR:
      - AND: "Occurrence A of Diagnosis, Active: Intolerance to Beta Blocker Therapy" starts before or during "Occurrence A of Encounter, Performed: Care Services in Long-Term Residential Facility"
      - AND NOT: "Occurrence A of Diagnosis, Active: Intolerance to Beta Blocker Therapy" ends before start of "Occurrence A of Encounter, Performed: Care Services in Long-Term Residential Facility"
    - OR:
      - AND: "Occurrence A of Diagnosis, Active: Intolerance to Beta Blocker Therapy" starts before or during "Occurrence A of Encounter, Performed: Home Healthcare Services"
      - AND NOT: "Occurrence A of Diagnosis, Active: Intolerance to Beta Blocker Therapy" ends before start of "Occurrence A of Encounter, Performed: Home Healthcare Services"
    - OR:
      - AND: "Occurrence A of Diagnosis, Active: Intolerance to Beta Blocker Therapy" starts before or during "Occurrence A of Encounter, Performed: Nursing Facility Visit"
      - AND NOT: "Occurrence A of Diagnosis, Active: Intolerance to Beta Blocker Therapy" ends before start of "Occurrence A of Encounter, Performed: Nursing Facility Visit"
    - OR:
      - AND: "Occurrence A of Diagnosis, Active: Intolerance to Beta Blocker Therapy" starts before or during "Occurrence A of Encounter, Performed: Office Visit"
      - AND NOT: "Occurrence A of Diagnosis, Active: Intolerance to Beta Blocker Therapy" ends before start of "Occurrence A of Encounter, Performed: Office Visit"
    - OR:
      - AND: "Occurrence A of Diagnosis, Active: Intolerance to Beta Blocker Therapy" starts before or during "Occurrence A of Encounter, Performed: Outpatient Consultation"
      - AND NOT: "Occurrence A of Diagnosis, Active: Intolerance to Beta Blocker Therapy" ends before start of "Occurrence A of Encounter, Performed: Outpatient Consultation"
    - OR:
      - AND: "Occurrence A of Diagnosis, Active: Intolerance to Beta Blocker Therapy" starts before or during "Occurrence A of Encounter, Performed: Face-to-Face Interaction"
      - AND NOT: "Occurrence A of Diagnosis, Active: Intolerance to Beta Blocker Therapy" ends before start of "Occurrence A of Encounter, Performed: Face-to-Face Interaction"
    - OR:
      - AND: "Occurrence A of Diagnosis, Active: Intolerance to Beta Blocker Therapy" starts before or during "Occurrence A of Encounter, Performed: Discharge Services - Hospital Inpatient"
      - AND NOT: "Occurrence A of Diagnosis, Active: Intolerance to Beta Blocker Therapy" ends before start of "Occurrence A of Encounter, Performed: Discharge Services - Hospital Inpatient"
  - OR:
    - OR:
      - AND: "Occurrence A of Diagnosis, Active: Bradycardia" starts before or during "Occurrence A of Encounter, Performed: Care Services in Long-Term Residential Facility"
      - AND NOT: "Occurrence A of Diagnosis, Active: Bradycardia" ends before start of "Occurrence A of Encounter, Performed: Care Services in Long-Term Residential Facility"
    - OR:
      - AND: "Occurrence A of Diagnosis, Active: Bradycardia" starts before or during "Occurrence A of Encounter, Performed: Home Healthcare Services"
      - AND NOT: "Occurrence A of Diagnosis, Active: Bradycardia" ends before start of "Occurrence A of Encounter, Performed: Home Healthcare Services"
    - OR:
      - AND: "Occurrence A of Diagnosis, Active: Bradycardia" starts before or during "Occurrence A of Encounter, Performed: Nursing Facility Visit"
      - AND NOT: "Occurrence A of Diagnosis, Active: Bradycardia" ends before start of "Occurrence A of Encounter, Performed: Nursing Facility Visit"
    - OR:
      - AND: "Occurrence A of Diagnosis, Active: Bradycardia" starts before or during "Occurrence A of Encounter, Performed: Office Visit"
      - AND NOT: "Occurrence A of Diagnosis, Active: Bradycardia" ends before start of "Occurrence A of Encounter, Performed: Office Visit"
    - OR:
      - AND: "Occurrence A of Diagnosis, Active: Bradycardia" starts before or during "Occurrence A of Encounter, Performed: Outpatient Consultation"
      - AND NOT: "Occurrence A of Diagnosis, Active: Bradycardia" ends before start of "Occurrence A of Encounter, Performed: Outpatient Consultation"
    - OR:
      - AND: "Occurrence A of Diagnosis, Active: Bradycardia" starts before or during "Occurrence A of Encounter, Performed: Face-to-Face Interaction"
      - AND NOT: "Occurrence A of Diagnosis, Active: Bradycardia" ends before start of "Occurrence A of Encounter, Performed: Face-to-Face Interaction"
    - OR:
      - AND: "Occurrence A of Diagnosis, Active: Bradycardia" starts before or during "Occurrence A of Encounter, Performed: Discharge Services - Hospital Inpatient"
      - AND NOT: "Occurrence A of Diagnosis, Active: Bradycardia" ends before start of "Occurrence A of Encounter, Performed: Discharge Services - Hospital Inpatient"
  - OR:
    - OR:
      - AND: "Occurrence A of Medication, Allergy: Beta Blocker Therapy Ingredient" starts before or during "Occurrence A of Encounter, Performed: Care Services in Long-Term Residential Facility"
      - AND NOT: "Occurrence A of Medication, Allergy: Beta Blocker Therapy Ingredient" ends before start of "Occurrence A of Encounter, Performed: Care Services in Long-Term Residential Facility"
    - OR:
      - AND: "Occurrence A of Medication, Allergy: Beta Blocker Therapy Ingredient" starts before or during "Occurrence A of Encounter, Performed: Home Healthcare Services"
      - AND NOT: "Occurrence A of Medication, Allergy: Beta Blocker Therapy Ingredient" ends before start of "Occurrence A of Encounter, Performed: Home Healthcare Services"
    - OR:
      - AND: "Occurrence A of Medication, Allergy: Beta Blocker Therapy Ingredient" starts before or during "Occurrence A of Encounter, Performed: Nursing Facility Visit"
      - AND NOT: "Occurrence A of Medication, Allergy: Beta Blocker Therapy Ingredient" ends before start of "Occurrence A of Encounter, Performed: Nursing Facility Visit"
    - OR:
      - AND: "Occurrence A of Medication, Allergy: Beta Blocker Therapy Ingredient" starts before or during "Occurrence A of Encounter, Performed: Office Visit"
      - AND NOT: "Occurrence A of Medication, Allergy: Beta Blocker Therapy Ingredient" ends before start of "Occurrence A of Encounter, Performed: Office Visit"
    - OR:
      - AND: "Occurrence A of Medication, Allergy: Beta Blocker Therapy Ingredient" starts before or during "Occurrence A of Encounter, Performed: Outpatient Consultation"
      - AND NOT: "Occurrence A of Medication, Allergy: Beta Blocker Therapy Ingredient" ends before start of "Occurrence A of Encounter, Performed: Outpatient Consultation"
    - OR:
      - AND: "Occurrence A of Medication, Allergy: Beta Blocker Therapy Ingredient" starts before or during "Occurrence A of Encounter, Performed: Face-to-Face Interaction"
      - AND NOT: "Occurrence A of Medication, Allergy: Beta Blocker Therapy Ingredient" ends before start of "Occurrence A of Encounter, Performed: Face-to-Face Interaction"
    - OR:
      - AND: "Occurrence A of Medication, Allergy: Beta Blocker Therapy Ingredient" starts before or during "Occurrence A of Encounter, Performed: Discharge Services - Hospital Inpatient"
      - AND NOT: "Occurrence A of Medication, Allergy: Beta Blocker Therapy Ingredient" ends before start of "Occurrence A of Encounter, Performed: Discharge Services - Hospital Inpatient"
  - OR:
    - AND NOT: "Diagnosis, Active: Cardiac Pacer in Situ" starts before or during
      - OR: "Occurrence A of Encounter, Performed: Care Services in Long-Term Residential Facility"
      - OR: "Occurrence A of Encounter, Performed: Home Healthcare Services"
      - OR: "Occurrence A of Encounter, Performed: Nursing Facility Visit"
      - OR: "Occurrence A of Encounter, Performed: Office Visit"
      - OR: "Occurrence A of Encounter, Performed: Outpatient Consultation"
      - OR: "Occurrence A of Encounter, Performed: Face-to-Face Interaction"
      - OR: "Occurrence A of Encounter, Performed: Discharge Services - Hospital Inpatient"
    - AND NOT: "Device, Applied: Cardiac Pacer" starts before or during
      - OR: "Occurrence A of Encounter, Performed: Care Services in Long-Term Residential Facility"
      - OR: "Occurrence A of Encounter, Performed: Home Healthcare Services"
      - OR: "Occurrence A of Encounter, Performed: Nursing Facility Visit"
      - OR: "Occurrence A of Encounter, Performed: Office Visit"
      - OR: "Occurrence A of Encounter, Performed: Outpatient Consultation"
      - OR: "Occurrence A of Encounter, Performed: Face-to-Face Interaction"
      - OR: "Occurrence A of Encounter, Performed: Discharge Services - Hospital Inpatient"
    - AND:
      - OR:
        
        AND: "Occurrence A of Diagnosis, Active: Atrioventricular Block" starts before or during "Occurrence A of Encounter, Performed: Care Services in Long-Term Residential Facility"
        
        AND NOT: "Occurrence A of Diagnosis, Active: Atrioventricular Block" ends before start of "Occurrence A of Encounter, Performed: Care Services in Long-Term Residential Facility"
      - OR:
        
        AND: "Occurrence A of Diagnosis, Active: Atrioventricular Block" starts before or during "Occurrence A of Encounter, Performed: Home Healthcare Services"
        
        AND NOT: "Occurrence A of Diagnosis, Active: Atrioventricular Block" ends before start of "Occurrence A of Encounter, Performed: Home Healthcare Services"
      - OR:
        
        AND: "Occurrence A of Diagnosis, Active: Atrioventricular Block" starts before or during "Occurrence A of Encounter, Performed: Nursing Facility Visit"
        
        AND NOT: "Occurrence A of Diagnosis, Active: Atrioventricular Block" ends before start of "Occurrence A of Encounter, Performed: Nursing Facility Visit"
      - OR:
        
        AND: "Occurrence A of Diagnosis, Active: Atrioventricular Block" starts before or during "Occurrence A of Encounter, Performed: Office Visit"
        
        AND NOT: "Occurrence A of Diagnosis, Active: Atrioventricular Block" ends before start of "Occurrence A of Encounter, Performed: Office Visit"
      - OR:
        
        AND: "Occurrence A of Diagnosis, Active: Atrioventricular Block" starts before or during "Occurrence A of Encounter, Performed: Outpatient Consultation"
        
        AND NOT: "Occurrence A of Diagnosis, Active: Atrioventricular Block" ends before start of "Occurrence A of Encounter, Performed: Outpatient Consultation"
      - OR:
        
        AND: "Occurrence A of Diagnosis, Active: Atrioventricular Block" starts before or during "Occurrence A of Encounter, Performed: Face-to-Face Interaction"
        
        AND NOT: "Occurrence A of Diagnosis, Active: Atrioventricular Block" ends before start of "Occurrence A of Encounter, Performed: Face-to-Face Interaction"
      - OR:
        
        AND: "Occurrence A of Diagnosis, Active: Atrioventricular Block" starts before or during "Occurrence A of Encounter, Performed: Discharge Services - Hospital Inpatient"
        
        AND NOT: "Occurrence A of Diagnosis, Active: Atrioventricular Block" ends before start of "Occurrence A of Encounter, Performed: Discharge Services - Hospital Inpatient"

eMeasure Title	Heart Failure (HF): Beta-Blocker Therapy for Left Ventricular Systolic Dysfunction (LVSD)
eMeasure Identifier (Measure Authoring Tool)	144	eMeasure Version number	3
NQF Number	0083	GUID	8439f671-2932-4d4c-88ca-ea5faeacc89a
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 beta-blocker 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	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.
Clinical Recommendation Statement	Beta-blockers (using 1 of the 3 proven to reduce mortality, i.e., bisoprolol, carvedilol, and sustained release metoprolol succinate) are recommended for all stable 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 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… physicians, especially cardiologists and primary care physicians, should make every effort to achieve the target doses of the beta blockers shown to be effective in major clinical trials. (ACCF/AHA, 2009) Beta Blockers Commonly Used for the Treatment of Patients with [Heart Failure] with Low Ejection Fraction Drug Initial Daily Dose(s) Maximum Doses(s) Beta Blockers Bisoprolol 1.25 mg once 10 mg once Carvedilol 3.125 mg twice 25 mg twice 50 mg twice for patients >85 kg Metoprolol succinate 12.5 to 25 mg once 200 mg once extended release (metoprolol CR/XL) 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. (Class I, Level of Evidence: B) (ACCF/AHA, 2009) --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.
Definition	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 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
Guidance	LVEF < 40% corresponds to qualitative documentation of moderate dysfunction or severe dysfunction. 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. Beta-blocker therapy: -For patients with prior LVEF < 40%, beta-blocker therapy should include bisoprolol, carvedilol, or sustained release metoprolol succinate. 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 beta-blocker 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 beta-blocker therapy (eg, 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 (eg, patient declined, other patient reasons) Documentation of system reason(s) for not prescribing beta-blocker therapy (eg, other reasons attributable to the healthcare system)
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