eMeasure Title

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

eMeasure Identifier (Measure Authoring Tool) 144 eMeasure Version number 6.0.000
NQF Number 0083 GUID 8439f671-2932-4d4c-88ca-ea5faeacc89a
Measurement Period January 1, 20XX through December 31, 20XX
Measure Steward PCPI(R) Foundation (PCPI[R])
Measure Developer American Medical Association (AMA)
Measure Developer PCPI(R) Foundation (PCPI[R])
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 2017 American College of Cardiology, American Heart Association and American Medical Association. All Rights Reserved.
Disclaimer
The Measures are not clinical guidelines, 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 American Medical Association (AMA), American College of Cardiology (ACC) or the American Heart Association (AHA). Neither the AMA, nor ACC, nor AHA, nor the PCPI (R) Foundation (PCPI[R]), nor their members shall be responsible for any use of the Measures. 

AMA and PCPI encourage use of the Measures by other health care professionals, where appropriate.

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 and former members of the AMA-PCPI 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 2004-2016 American Medical Association. LOINC(R) is copyright 2004-2016 Regenstrief Institute, Inc. This material contains SNOMED CLINICAL TERMS (SNOMED CT[R]) copyright 2004-2016 International Health Terminology Standards Development Organisation (IHTSDO). ICD-10 is copyright 2016 World Health Organization. All Rights Reserved.

Due to technical limitations, registered trademarks are indicated by (R) or [R].
Measure Scoring Proportion
Measure Type Process
Stratification
None
Risk Adjustment
None
Rate Aggregation
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
Use of 1 of the 3 beta blockers proven to reduce mortality (eg, 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 Doses(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)
Improvement Notation
Higher score indicates better quality
Reference
Yancy CW, Jessup M, Bozkurt B, Butler J, Casey DE Jr, Drazner MH, Fonarow GC, Geraci SA, Horwich T, Januzzi JL, Johnson MR, Kasper EK, Levy WC, Masoudi FA, McBride PE, McMurray JJV, Mitchell JE, Peterson PN, Riegel B, Sam F, Stevenson LW, Tang WHW, Tsai EJ, Wilkoff BL. 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. J Am Coll Cardiol 2013;62:e147-239.
Definition
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.
Guidance
LVEF < 40% corresponds to qualitative documentation of moderate dysfunction or severe dysfunction.

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. 

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.

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 Encounter, Performed" is to establish that the eligible professional or eligible clinician has an existing relationship with the patient.
Transmission Format
TBD
Initial Population
All patients aged 18 years and older with a diagnosis of heart failure
Denominator
Equals Initial 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).
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 Variables)

Data Criteria (QDM Data Elements)

Supplemental Data Elements

Risk Adjustment Variables


Measure Set
None