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  • Measure Summary
  • NQMC:010801
  • Apr 2016
  • NQF-Endorsed Measure

Heart failure: percentage of patients aged 18 years and older with a diagnosis of heart failure with a current or prior LVEF less than 40% who were prescribed beta-blocker therapy either within a 12 month period when seen in the outpatient setting or at each hospital discharge.

American College of Cardiology Foundation (ACCF), American Heart Association (AHA), Physician Consortium for Performance Improvement® (PCPI®). Heart failure performance measurement set. Chicago (IL): American Medical Association (AMA); 2016 Apr. 48 p. [29 references]

View the original measure documentation External Web Site Policy

This is the current release of the measure.

This measure updates a previous version: American College of Cardiology Foundation, American Heart Association, Physician Consortium for Performance Improvement®. Heart failure performance measurement set. Chicago (IL): American Medical Association; 2011 Jan. 85 p. [51 references].

Primary Measure Domain

Clinical Quality Measures: Process

Secondary Measure Domain

Does not apply to this measure

Description

This measure is used to assess the percentage of patients aged 18 years and older with a diagnosis of heart failure with a current or prior left ventricular ejection fraction (LVEF) less than 40% who were prescribed beta-blocker therapy either within a 12 month period when seen in the outpatient setting or at each hospital discharge.

Note: This measure and the Angiotensin-converting enzyme (ACE) Inhibitor or Angiotensin Receptor Blocker (ARB) Therapy for Left Ventricular Systolic Dysfunction measure (see the related National Quality Measures Clearinghouse [NQMC] summary of the Physician Consortium for Performance Improvement [PCPI] measure Heart failure: percentage of patients aged 18 years and older with a diagnosis of heart failure with a current or prior LVEF less than 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) address related aspects of care for effective treatment for patients with heart failure and should be measured concurrently. Both ACE inhibitors and beta-blockers have been shown to reduce mortality and hospitalizations and improve a patient's clinical status. ARBs can be considered a reasonable alternative for ACE inhibitors. Combined treatment with these agents produces additive benefits and is required for optimal management of heart failure. It is not recommended that either of these measures be used independently. The pairing of these measures is not intended to suggest the use of any particular scoring methodology (i.e., a composite score), nor does it imply either equality of or difference in the relative "weights" of the two measures. A performance score for each measure should be reported individually to provide actionable information upon which to focus quality improvement efforts.

Rationale

Heart failure is a chronic condition that poses a major and growing threat to the public's health. Improving the effectiveness of care and optimizing patient outcomes will become increasingly important as the population of the United States ages.

Beta-blockers are recommended for all patients with stable heart failure and left ventricular systolic dysfunction (LVSD), unless contraindicated. Treatment should be initiated as soon as a patient is diagnosed with LVSD 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 (Yancy et al., 2013).

The following evidence statements are quoted verbatim from the referenced clinical guidelines:

7.3.2.4. Beta Blockers: Recommendation

Class I

  1. Use of 1 of the 3 beta-blockers proven to reduce mortality (e.g., bisoprolol, carvedilol, and sustained release metoprolol succinate) is recommended for all patients with current or prior symptoms of heart failure with reduced ejection fraction (HFrEF), unless contraindicated, to reduce morbidity and mortality (Yancy et al., 2013).

7.3.2.4.2. Beta Blockers: Initiation and Maintenance. 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.

Beta-blockers Commonly Used for the Treatment of Patients with [Heart Failure] with Low Ejection Fraction

Drug Initial Daily Dose(s) Maximum Dose(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
Carvedilol CR 10 mg once 80 mg once
Metoprolol succinate extended release (metoprolol CR/XL) 12.5 to 25 mg once 200 mg once

For the hospitalized patient:

Class I

  • In patients with HFrEF experiencing a symptomatic exacerbation of heart failure (HF) requiring hospitalization during chronic maintenance treatment with guideline-directed medical therapy (GDMT), it is recommended that GDMT be continued in the absence of hemodynamic instability or contraindications (Yancy et al., 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 (Yancy et al., 2013).

Evidence for Rationale

American College of Cardiology Foundation (ACCF), American Heart Association (AHA), Physician Consortium for Performance Improvement® (PCPI®). Heart failure performance measurement set. Chicago (IL): American Medical Association (AMA); 2016 Apr. 48 p. [29 references]

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 JJ, Mitchell JE, Peterson PN, Riegel B, Sam F, Stevenson LW, Tang WH, 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 Oct 15;62(16):e147-239. [924 references] PubMed External Web Site Policy

Primary Health Components

Heart failure; left ventricular systolic dysfunction (left ventricular ejection fraction [LVEF] less than 40%); beta-blocker therapy

Denominator Description

All patients aged 18 years and older with a diagnosis of heart failure with a current or prior left ventricular ejection fraction (LVEF) less than 40% (see the related "Denominator Inclusions/Exclusions" field)

Numerator Description

Patients who were prescribed beta-blocker therapy either within a 12 month period when seen in the outpatient setting or at each hospital discharge (see the related "Numerator Inclusions/Exclusions" field)

Type of Evidence Supporting the Criterion of Quality for the Measure

  • A clinical practice guideline or other peer-reviewed synthesis of the clinical research evidence
  • One or more research studies published in a National Library of Medicine (NLM) indexed, peer-reviewed journal

Additional Information Supporting Need for the Measure

Importance of Topic

Prevalence and Incidence

  • 5.7 million Americans are living with heart failure - 2.6% of men and 2.1% of women.
  • Heart failure was the most common cardiac condition for adults 85 years and older in 1997–2006 (Levit et al., 2008).
  • Over 670,000 patients are diagnosed with heart failure for the first time each year.
  • Heart failure incidence approaches 10 per 1000 population after 65 years of age.
  • At 40 years of age, the lifetime risk of developing heart failure for both men and women is 1 in 5. At 80 years of age, remaining lifetime risk for development of new heart failure remains at 20% for men and women, even in the face of a much shorter life expectancy.
  • Data has indicated an increase in the incidence of heart failure and improved survival rate among the elderly, with both of these effects being greater in men.

Mortality

  • In 2005, 1 in 8 death certificates (292,214 deaths) in the United States mentioned heart failure. Heart failure was selected as the "underlying cause" in 58,933 of those deaths.
  • 80% of men and 70% of women less than 65 years of age who have heart failure will die within 8 years.
  • The 30-day, 1-year, and 5-year case fatality rates after hospitalization for heart failure were 10.4%, 22%, and 42.3%, respectively.
  • After heart failure is diagnosed, the survival rate is lower in men than in women, but less than 15% of women survive more than 8 to 12 years. The 1-year mortality rate is high, with 1 in 5 dying.
  • In people diagnosed with heart failure, sudden cardiac death occurs at 6 to 9 times the rate of the general population.

Office Visits and Hospital Stays

  • 2006 data found that the number of ambulatory care visits for heart failure was 3,390,000.
  • Hospital discharges for heart failure rose from 877,000 in 1996 to 1,106,000 in 2006.
  • In 2006, heart failure (534,000 stays for males and 565,000 for females) occurred equally often in hospitalizations for males and females.
  • Fonarow and colleagues (2005) assessed length of stay and in-hospital mortality rates and the variation among hospitals. The "median inpatient length of stay [was found to be] 4.0 days (range, 2.3-9.5 days), with an approximately 2-day difference between hospitals at the 10th (3.1 days) and 90th (5.0 days) percentiles. Median in-hospital mortality was 3.5%, with substantial variation between hospitals. There was a 2-fold difference in mortality between the 25th and 75th percentiles (2.4% vs 4.8%) and a 4.4-fold difference in mortality between the 10th and 90th percentiles (1.4% vs 6.1%)."
  • Within 1 year of hospitalization for heart failure, more than 1 in 3 Medicare beneficiaries died, and two-thirds were readmitted to the hospital. Nearly 40% of patients were admitted at least twice.
  • Among patients enrolled in Medicare, the rate of 30-day readmission following hospital discharge with a heart failure diagnosis is 26.9% (Jencks, Williams, & Coleman, 2009).

Cost

  • For 2009, the estimated direct and indirect cost of heart failure in the United States is $37.2 billion (Lloyd-Jones et al., 2010).
  • U.S. hospital costs for treating patients with heart failure increased from $6.6 billion in 1997 to $11.2 billion in 2006 (a 6.1% annual increase).
  • More Medicare dollars are spent for the diagnosis and treatment of heart failure than for any other diagnosis (Jessup et al., 2009).

Opportunity for Improvement

  • According to a study analyzing the quality of health care in the U.S., on average, patients with heart failure received the recommended quality of care only about 63.9% of the time (McGlynn et al., 2003). Quality of care was assessed by analysis of clinician performance on 36 heart failure quality indicators. Quality of care varied significantly by indicator with average rates of adherence ranging from 16.12% for the provision of dietary counseling within one month of the start of medical treatment to 100% for blood pressure assessment at the time of presentation ("Appendix," 2003).
  • Using baseline data from the Registry to Improve the Use of Evidence-Based Heart Failure Therapies in the Outpatient Setting (IMPROVE HF), Fonarow and colleagues (2008) assessed contemporary care patterns for heart failure in the outpatient setting among 167 outpatient cardiology practices in the United States. The authors found that a median 27% of patients received all heart failure therapies for which they were potentially eligible and use of guideline-recommended therapies by practices varied widely. To quantify use of therapies, 7 individual metrics were assessed.
  • In another study, Fonarow and colleagues (2005) analyzed data from 81,142 admissions occurring between July 2002, and December 2003, at 223 hospitals in the United States to determine rates of conformity with the 4 Joint Commission core heart failure performance measures. Across all hospitals, median rates of conformity with HF-1 (discharge instructions), HF-2 (assessment of left ventricular function), HF-3 (use of angiotensin-converting enzyme [ACE] inhibitors in patients with left ventricular systolic dysfunction [LVSD]), and HF-4 (smoking cessation counseling) were 24.0%, 86.2%, 72.0%, and 43.2%, respectively. Rates of conformity at individual hospitals varied from 0% to 100%.
  • More recent national data available for the aforementioned core performance measures from the Joint Commission's Quality Check Web site indicates higher rates of adherence. From October 2007 through September 2008, performance was as follows (Joint Commission on Accreditation of Healthcare Organizations, 2009):
Joint Commission Core Heart Failure Performance Measures Mean
HF-1 Discharge instructions 82.03%
HF-2 Assessment of left ventricular function 96.62%
HF-3 Use of ACE inhibitors in patients with LVSD 92.28%
HF-4 Smoking cessation counseling 97.25%

Geographic Variations in Care

The 2008 Dartmouth Atlas of Health Care identified geographic differences in the care of patients with chronic illness.

  • Among the 306 hospital referral regions, the frequency of hospitalizations for heart failure varied by a factor of more than four.
  • Patients with heart failure saw a physician 99.3 times in the last six months of life at the highest ranked hospital and 15.2 times at the lowest ranked (rankings based on U.S. News and World Report 2001) (Wennberg et al., 2008).

Disparities

The 2009 National Healthcare Disparities Report showed that disparities in care for heart failure exist across populations (Agency for Healthcare Research and Quality [AHRQ], 2010). Although the quality of hospital care for heart failure has improved overall, "care for whites continues to improve at a higher rate than for minority populations. Thus, quality improvement has not necessarily translated to disparities reduction, which is critical for high-quality care." Recommended hospital care for heart failure was characterized by evaluation of the patient's left ventricular ejection fraction (LVEF) and patient's receipt of an ACE inhibitor for left ventricular systolic dysfunction. Separately, to analyze patient centered care, a measure was included to identify adult hospital patients with heart failure who were given complete written discharge instructions.

  • In 2006, the proportion of Medicare patients with heart failure who received recommended hospital care was higher for blacks than for whites (91.4% compared with 90%) (AHRQ, 2009).
  • In 2006, the proportion of Medicare patients with heart failure who received recommended hospital care was lower for American Indians (AI) or Alaska Natives (AN) (86.3%) and Hispanics (89.3%) compared with whites (90%) (AHRQ, 2009).
  • From 2005 to 2007, disparities in hospital care for heart failure for AI/ANs have been worsening at a rate of 12.4% per year.
  • In all years (2005 to 2007), Hispanics and AI/ANs were less likely than whites to receive complete written discharge instructions.
  • Rates of implantable cardioverter defibrillator (ICD) therapy in eligible patients hospitalized for heart failure are lower among eligible women and black patients than among white men (Hernandez et al., 2007; Curtis et al., 2007).
  • Both patient age and sex are associated with reduced rates of some heart failure therapies: ICDs, anticoagulation for atrial fibrillation, and the provision of heart failure education (Yancy et al., 2009).
  • An analysis of the American Heart Association's (AHA) Get With The Guidelines (GWTG)–Heart Failure quality improvement program (Yancy, Fonarow, & LaBresh, 2007) identified differences in heart failure in black, white, and Hispanic patients. Black patients were younger, had lower ejection fraction, lower risk of in-patient death and similar length of stay as whites and Hispanics. While overall quality of care was similar, there were some differences in the quality of care received by black, white and Hispanic patients. Performance on all performance measures under study were either similar or higher in black heart failure patients compared to white and Hispanic patients.

The Physician Consortium for Performance Improvement (PCPI) believes that performance measure data should be stratified by race, ethnicity, and primary written and spoken language to assess disparities and initiate subsequent quality improvement activities addressing identified disparities. These categories are consistent with recent national efforts to standardize the collection of race and ethnicity data. A 2008 National Quality Forum (NQF) report endorsed 45 practices including stratification by the aforementioned variables (NQF, 2008). A 2009 Institute of Medicine (IOM) report "recommends collection of the existing Office of Management and Budget (OMB) race and Hispanic ethnicity categories as well as more fine-grained categories of ethnicity (referred to as granular ethnicity and based on one's ancestry) and language need (a rating of spoken English language proficiency of less than very well and one's preferred language for health-related encounters)" ("Race," 2010).

Measure Importance

Opportunity for Improvement

Registry data from IMPROVE HF indicates that beta-blockers were prescribed to 86% of eligible outpatients without documented contraindications or intolerance. More importantly, use of beta-blockers varied widely with practices reporting rates of adherence as low as 8.6% and as high as 100%.

From March 1, 2003, through December 31, 2004, Fonarow and colleagues analyzed data from the 259 U.S. hospitals (48,612 patients) participating in the Organized Program to Initiate Lifesaving Treatment in Hospitalized Patients With Heart Failure (OPTIMIZE-HF) to determine the effect of a quality improvement initiative. Baseline data indicated that 78% of eligible patients were prescribed a beta-blocker at discharge. Use of any of the three recommended, evidence-based beta-blockers (bisoprolol fumarate, carvedilol, metoprolol succinate) was significantly lower with 56% of eligible patients (Fonarow et al., 2007).

Evidence for Additional Information Supporting Need for the Measure

Agency for Healthcare Research and Quality (AHRQ). 2009 National Healthcare Disparities Report. Rockville (MD): Agency for Healthcare Research and Quality (AHRQ); 2010 Mar. 296 p.

Agency for Healthcare Research and Quality. NHQRDRnet data query system. [internet]. [accessed 2009 May 25].

American College of Cardiology Foundation (ACCF), American Heart Association (AHA), Physician Consortium for Performance Improvement® (PCPI®). Heart failure performance measurement set. Chicago (IL): American Medical Association (AMA); 2016 Apr. 48 p. [29 references]

Appendix to McGlynn EA, Asch SM, Adams J, et al. The quality of health care delivered to adults in the United States. N Engl J Med. 2003;348:2635-45.

Curtis LH, Al-Khatib SM, Shea AM, Hammill BG, Hernandez AF, Schulman KA. Sex differences in the use of implantable cardioverter-defibrillators for primary and secondary prevention of sudden cardiac death. JAMA. 2007 Oct 3;298(13):1517-24. PubMed External Web Site Policy

Fonarow GC, Abraham WT, Albert NM, Gattis Stough W, Gheorghiade M, Greenberg BH, O'Connor CM, Pieper K, Sun JL, Yancy CW, Young JB, OPTIMIZE-HF Investigators and Hospitals. Influence of a performance-improvement initiative on quality of care for patients hospitalized with heart failure: results of the Organized Program to Initiate Lifesaving Treatment in Hospitalized Patients With Heart Failure (OPTIMIZE-HF). Arch Intern Med. 2007 Jul 23;167(14):1493-502. PubMed External Web Site Policy

Fonarow GC, Yancy CW, Albert NM, Curtis AB, Stough WG, Gheorghiade M, Heywood JT, McBride ML, Mehra MR, O'Connor CM, Reynolds D, Walsh MN. Heart failure care in the outpatient cardiology practice setting: findings from IMPROVE HF. Circ Heart Fail. 2008 Jul;1(2):98-106. PubMed External Web Site Policy

Fonarow GC, Yancy CW, Heywood JT, ADHERE Scientific Advisory Committee, Study Group, and Investigators. Adherence to heart failure quality-of-care indicators in US hospitals: analysis of the ADHERE Registry. Arch Intern Med. 2005 Jul 11;165(13):1469-77. PubMed External Web Site Policy

Hernandez AF, Fonarow GC, Liang L, Al-Khatib SM, Curtis LH, LaBresh KA, Yancy CW, Albert NM, Peterson ED. Sex and racial differences in the use of implantable cardioverter-defibrillators among patients hospitalized with heart failure. JAMA. 2007 Oct 3;298(13):1525-32. PubMed External Web Site Policy

Jencks SF, Williams MV, Coleman EA. Rehospitalizations among patients in the Medicare fee-for-service program. N Engl J Med. 2009 Apr 2;360(14):1418-28. PubMed External Web Site Policy

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.

Joint Commission on Accreditation of Healthcare Organizations. Quality check. [internet]. [accessed 2009 Jun 03].

Levit K, Stranges E, Ryan K, Elixhauser A. HCUP facts and figures, 2006: statistics on hospital-based care in the United States. [internet]. Rockville (MD): Agency for Healthcare Research and Quality; 2008 [accessed 2009 May 06].

Lloyd-Jones D, Adams RJ, Brown TM, Carnethon M, Dai S, De Simone G, Ferguson TB, Ford E, Furie K, Gillespie C, Go A, Greenlund K, Haase N, Hailpern S, Ho PM, Howard V, Kissela B, Kittner S, Lackland D, Lisabeth L, Marelli A, McDermott MM, Meigs J, Mozaffarian D, Mussolino M, Nichol G, Roger VL, Rosamond W, Sacco R, Sorlie P, Roger VL, Thom T, Wasserthiel-Smoller S, Wong ND, Wylie-Rosett J, American Heart Association Statistics Committee and Stroke Statistics, Writing Group Members. Heart disease and stroke statistics--2010 update: a report from the American Heart Association. Circulation. 2010 Feb 23;121(7):e46-e215. PubMed External Web Site Policy

McGlynn EA, Asch SM, Adams J, Keesey J, Hicks J, DeCristofaro A, Kerr EA. The quality of health care delivered to adults in the United States. N Engl J Med. 2003 Jun 26;348(26):2635-45. PubMed External Web Site Policy

National Quality Forum. Closing the disparities gap in healthcare quality with performance measurement and public reporting. Washington (DC): National Quality Forum; 2008 Aug.  (Issue brief; no. 10). 

Race, ethnicity, and language data: standardization for health care quality improvement. AHRQ publication no. 10-0058-EF. [internet]. Rockville (MD): Agency for Healthcare Research and Quality; 2010 Mar [accessed 2011 May 16].

Wennberg JE, Fisher ES, Goodman D, Skinner J. Tracking the care of patients with severe chronic illness: The Dartmouth atlas of health care. [internet]. 2008 [accessed 2009 May 06].

Yancy CW, Fonarow GC, Albert NM, Curtis AB, Stough WG, Gheorghiade M, Heywood JT, McBride ML, Mehra MR, O'Connor CM, Reynolds D, Walsh MN. Influence of patient age and sex on delivery of guideline-recommended heart failure care in the outpatient cardiology practice setting: findings from IMPROVE HF. Am Heart J. 2009 Apr;157(4):754-62.e2. PubMed External Web Site Policy

Yancy CW, Fonarow GC, LaBresh KA. Disparate quality of care for Black and Hispanic heart failure (HF) patients: a report from Get with the Guidelines Heart Failure (GWTG-HF). J Card Fail. 2007;13:S157-S157.

Extent of Measure Testing

Several of the American College of Cardiology/American Heart Association/Physician Consortium for Performance Improvement (ACC/AHA/PCPI) heart failure measures presented here represent updates to existing inpatient and outpatient measures for heart failure. They have therefore been utilized, in their previous specifications, in several national performance measurement projects, including the Centers for Medicare & Medicaid Services (CMS) Physician Group Practice (PGP) Demonstration Project ("Medicare," 2009), the Doctor's Office Quality (DOQ) Project ("DOQ," 2009; "Doctor's," 2005), the DOQ-Information Technology (IT) Project ("DOQ," 2009), and the CMS Physician Quality Reporting Initiative (PQRI) Project (CMS, 2009). These projects have shown varying levels of feasibility, reliability, and performance, dependent upon the venue and modality of data collection. In addition, specific research projects have been conducted to test the reliability of these measures in various settings. Results of these testing projects have been considered and resulted in modifications to the measures, where appropriate.

Feasibility Testing

The CMS DOQ Project ("DOQ," 2009; "Doctor's," 2005) revealed that 4 of the 7 measures studied from the heart failure set are feasible to collect, as previously specified. As part of the DOQ Project, reviewers assessed the feasibility of use of the ACCF/AHA/PCPI measures in offices by performing retrospective audits of paper medical records and electronic health records (EHRs). A study by Baker et al. (2006) utilizing an EHR system found that all 4 measures studied were feasible to collect, though automated review was found to be less accurate than manual review. Implementation in the PQRI (CMS, 2009) program allowed for tracking of denominator mismatch rates. It is important to note that physicians participating in PQRI for heart failure measures in 2007 represented a small proportion of the eligible physicians (4.77%-4.88%) and therefore the measure performance rates may not accurately reflect the ability of the general physician population to attain quality performance.

Reliability Testing

The DOQ Project ("DOQ," 2009; "Doctor's," 2005) tested inter-rater reliability twice during the project. The agreement rate for the heart failure measures was 92.9%.

An observational study by Baker et al. (2006) compared automated review of EHR data with automated review followed by manual review of electronic notes for patients with apparent quality deficits (hybrid review). Performance based on automated review of EHR data was similar to that based on hybrid review for 3 of the 4 measures studied, though performance was better in the hybrid review for all cases. Overall, failure to recognize contraindications to medications documented only in provider notes caused performance on medication-based quality measures to be underestimated.

The Cardio-HIT study is in progress ("Preliminary," n.d.) testing heart failure measures in 6 physician offices with 5 different EHRs, in use for at least 5 years at time of project. As part of the project, the integrated measure specifications were translated to data fields within the practice EHR. Records for 46,737 eligible patients were reviewed. Final results from this project are expected to be available soon. The results regarding exception rate reporting will be analyzed to determine if any changes to the measures are required.

Testing of the Measurement Set

The American Medical Association (AMA)-convened PCPI collaborated on several measure testing projects in 2007, 2009 and 2015 to ensure two Heart Failure measures are reliable and were evaluated for accuracy of the measure denominator, numerator and exception case identification. The testing projects were conducted utilizing EHR and registry data. Parallel forms reliability and signal-to-noise reliability were tested.

One site participated in the parallel forms testing of the measures. The site was an academic, general internal medicine clinic.

Signal-to-noise reliability was assessed using 2013 data acquired from the CMS Physician Quality Reporting System Group Practice Reporting Option (GPRO) database.

Measures Tested

  • Heart Failure – Beta Blocker Therapy for Left Ventricular Systolic Dysfunction (LVSD)
  • Heart Failure – Angiotensin-Converting Enzyme (ACE) Inhibitor or Angiotensin Receptor Blocker (ARB) for LVSD

Reliability Testing

The purpose of reliability testing was to evaluate whether the measure definitions and specifications, as prepared by the PCPI, yield stable, consistent measures. Data abstracted from electronic health records were used to calculate parallel forms reliability and data acquired from the GPRO database were used to perform signal-to-noise reliability testing for the measures.

Heart Failure – Beta Blocker Therapy for LVSD

Parallel Forms Reliability Testing

There were 254 observations from Site A included as part of the analysis. Of the 254 patients sampled, automated EHR review detected 219 (86.2%) with an active electronic prescription for a beta blocker. Of the remaining 35 patients, 13 (37.1%) met one or more of the exclusion criteria. Performance was 90.9% by automated EHR review. The automated quality assessment had a sensitivity of 100.0% for identifying patients with heart failure, taking a beta-blocker. The automated quality assessment captured 12 of 18 patients with valid exclusion criteria (sensitivity, 66.7%), and 1 of 13 patients who met exclusion criteria were judged not to have a true exclusion.

GPRO EHR Web-Interface

The reliability at the minimum level of quality reporting events (10) was 0.44. The average number of quality reporting events for physicians included is 90.1. The reliability at the average number of quality reporting events was 0.87. This measure has moderate reliability when evaluated at the minimum level of quality reporting events and high reliability at the average number of quality events.

GPRO Registry

The reliability at the minimum level of quality reporting events (10) was 0.86. The average number of quality reporting events for physicians included is 33.9. The reliability at the average number of quality reporting events was 0.96. This measure has high reliability when evaluated at the minimum level of quality reporting events and high reliability at the average number of quality events.

Evidence for Extent of Measure Testing

American College of Cardiology Foundation (ACCF), American Heart Association (AHA), Physician Consortium for Performance Improvement® (PCPI®). Heart failure performance measurement set. Chicago (IL): American Medical Association (AMA); 2016 Apr. 48 p. [29 references]

Baker DW, Persell SD, Thompson JA, Soman NS, Burgner KM, Liss D, Kmetik KS. Automated review of electronic health records to assess quality of care for outpatients with heart failure. Ann Intern Med. 2007 Feb 20;146(4):270-7. PubMed External Web Site Policy

Centers for Medicare and Medicaid Services. Measures Codes Physician Quality Reporting Initiative. [internet]. [accessed 2009 Mar 12].

Doctor's office quality final report. Project 2002-2005 coordinating QIO. Iowa Foundation for Medical Care; 2005 Dec.

DOQ and DOQ-IT measure specifications. [internet]. Baltimore (MD): Centers for Medicare and Medicaid Services; [accessed 2009 Mar 12].

Medicare Physician Group Practice Demonstration fact sheet. [internet]. Baltimore (MD): Centers for Medicare & Medicaid Services; 2009 [accessed 2009 Mar 12].

Preliminary Cardio-HIT project data, provided by American Medical Association. [Not for distribution or publication].

State of Use

Current routine use

Current Use

Internal quality improvement

Pay-for-reporting

Professional certification

Public reporting

Measurement Setting

Ambulatory/Office-based Care

Hospital Inpatient

Hospital Outpatient

Professionals Involved in Delivery of Health Services

Advanced Practice Nurses

Physician Assistants

Physicians

Least Aggregated Level of Services Delivery Addressed

Individual Clinicians or Public Health Professionals

Statement of Acceptable Minimum Sample Size

Does not apply to this measure

Target Population Age

Age greater than or equal to 18 years

Target Population Gender

Either male or female

National Quality Strategy Aim

Better Care

National Quality Strategy Priority

Prevention and Treatment of Leading Causes of Mortality

IOM Care Need

Getting Better

Living with Illness

IOM Domain

Effectiveness

Equity

Case Finding Period

Unspecified

Denominator Sampling Frame

Patients associated with provider

Denominator (Index) Event or Characteristic

Clinical Condition

Encounter

Institutionalization

Patient/Individual (Consumer) Characteristic

Denominator Time Window

Does not apply to this measure

Denominator Inclusions/Exclusions

Inclusions
All patients aged 18 years and older with a diagnosis of heart failure with a current or prior left ventricular ejection fraction (LVEF) less than 40%

Eligible Population:

Age greater than or equal to 18 years

AND

  • Diagnosis for heart failure (refer to the original measure documentation for International Classification of Diseases, Ninth Revision, Clinical Modification [ICD-9-CM] codes [reportable through 9/30/2015])
  • Diagnosis for heart failure (refer to the original measure documentation for International Classification of Diseases, Tenth Revision, Clinical Modification [ICD-10-CM] codes [reportable beginning 10/1/2015])

AND

Current Procedural Terminology (CPT) codes for encounter (refer to the original measure documentation for CPT codes)

AND

Report Quality Data Code: G8923: LVEF less than 40% or documentation of moderately or severely depressed left ventricular systolic function

Note: LVEF less than 40% corresponds to qualitative documentation of moderate dysfunction or severe dysfunction.

Exclusions
None

Exceptions

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

Exclusions/Exceptions

Medical factors addressed

Patient factors addressed

System factors addressed

Numerator Inclusions/Exclusions

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

Note: Refer to the original measure documentation for administrative codes.

*Prescribed may include:

  • 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.

**Beta-blocker therapy should include bisoprolol, carvedilol, or sustained release metoprolol succinate. (See the original measure documentation for administrative codes and additional information on medications.)

Exclusions
None

Numerator Search Strategy

Fixed time period or point in time

Data Source

Administrative clinical data

Electronic health/medical record

Paper medical record

Type of Health State

Does not apply to this measure

Instruments Used and/or Associated with the Measure

None

Measure Specifies Disaggregation

Does not apply to this measure

Scoring

Rate/Proportion

Interpretation of Score

Desired value is a higher score

Allowance for Patient or Population Factors

Unspecified

Standard of Comparison

External comparison at a point in, or interval of, time

External comparison of time trends

Internal time comparison

Original Title

Measure #6: beta-blocker therapy for left ventricular systolic dysfunction (LVSD) (outpatient and inpatient setting).

Measure Collection Name

AMA/PCPI Heart Failure Performance Measurement Set

Submitter

American Medical Association - Medical Specialty Society

Developer

Physician Consortium for Performance Improvement® - Clinical Specialty Collaboration

Funding Source(s)

Unspecified

Composition of the Group that Developed the Measure

Work Group Members - Heart Failure

Work Group Members

  • Robert O. Bonow, MD, MACC, FAHA, FACP (Co-Chair) (cardiology)
  • Theodore G. Ganiats, MD (Co-Chair) (family medicine, measure methodology)
  • Craig T. Beam, CRE (patient representative)
  • Kathleen Blake, MD (cardiac electrophysiology)
  • Donald E. Casey, Jr., MD, MPH, MBA, FACP, FAHA (internal medicine)
  • Sarah J. Goodlin, MD (geriatrics, palliative medicine)
  • Kathleen L. Grady, PhD, APN, FAAN, FAHA (cardiac surgery)
  • Randal F. Hundley, MD, FACC (cardiology, health plan representative)
  • Mariell Jessup, MD, FACC, FAHA, FESC (cardiology, heart failure)
  • Thomas E. Lynn, MD (family medicine, measure implementation)
  • Frederick A. Masoudi, MD, MSPH (cardiology)
  • David Nilasena, MD, MSPH, MS (general preventive medicine, public health, measure implementation)
  • Ileana L. Piña, MD, FACC (cardiology, heart failure)
  • Paul D. Rockswold, MD, MPH (family medicine)
  • Lawrence B. Sadwin (patient representative)
  • Joanna D. Sikkema, MSN, ANP-BC, FAHA (cardiology)
  • Carrie A. Sincak, PharmD, BCPS (pharmacy)
  • John Spertus, MD, MPH (cardiology)
  • Patrick J. Torcson, MD, FACP, MMM (hospital medicine)
  • Elizabeth Torres, MD (internal medicine)
  • Mark V. Williams, MD, FHM (hospital medicine)
  • John B Wong, MD (internal medicine)

Work Group Staff

American College of Cardiology Foundation

  • Charlene L. May
  • Melanie Shahriary, RN, BSN

American Heart Association

  • Cheryl Perkins, MD, RPh
  • Mark D. Stewart, MPH
  • Gayle Whitman, PhD, RN, FAHA, FAAN

American College of Cardiology Foundation/American Heart Association

  • Jensen S. Chiu, MHA

American Medical Association

  • Mark Antman, DDS, MBA
  • Heidi Bossley, MSN, MBA
  • Christopher Carlucci, MBA
  • Kerri Fei, MSN, RN
  • JoeAnn Jackson, MJ
  • Kendra Hanley, MS
  • Karen Kmetik, PhD
  • Pamela O'Neil, MPH
  • Samantha Tierney, MPH
  • Temaka Williams, MPH, MBA
  • Greg Wozniak, PhD

National Committee for Quality Assurance (NCQA) Liaison

  • Manasi Tirodkar, PhD, MS

The Joint Commission Liaison

  • Millie J. Perich, MS, RN

Financial Disclosures/Other Potential Conflicts of Interest

Conflicts, if any, are disclosed in accordance with the Physician Consortium for Performance Improvement® conflict of interest policy.

Endorser

National Quality Forum

NQF Number

0083

Date of Endorsement

2016 Feb 19

Core Quality Measures

Cardiology

Measure Initiative(s)

Physician Quality Reporting System

Adaptation

This measure was not adapted from another source.

Date of Most Current Version in NQMC

2016 Apr

Measure Maintenance

The Physician Consortium for Performance Improvement (PCPI) stipulates a regular review of measures (every 3-4 years) or when there is a major change in scientific evidence, results from testing or other issues noted that materially affect the integrity of the measure.

Date of Next Anticipated Revision

2017 Apr

Measure Status

This is the current release of the measure.

This measure updates a previous version: American College of Cardiology Foundation, American Heart Association, Physician Consortium for Performance Improvement®. Heart failure performance measurement set. Chicago (IL): American Medical Association; 2011 Jan. 85 p. [51 references].

Source(s)

American College of Cardiology Foundation (ACCF), American Heart Association (AHA), Physician Consortium for Performance Improvement® (PCPI®). Heart failure performance measurement set. Chicago (IL): American Medical Association (AMA); 2016 Apr. 48 p. [29 references]

Measure Availability

Source available from the American Medical Association (AMA)-convened Physician Consortium for Performance Improvement® Web site External Web Site Policy.

For further information, please contact AMA staff by e-mail at cqi@ama-assn.org.

NQMC Status

This NQMC summary was completed by ECRI on March 3, 2004. The information was verified by the measure developer on October 29, 2004.

This NQMC summary was updated by ECRI on December 19, 2011. The information was reaffirmed by the measure developer on November 17, 2010.

This NQMC summary was retrofitted into the new template on June 6, 2011.

This NQMC summary was updated by ECRI Institute on April 20, 2012. The information was not verified by the measure developer.

This NQMC summary was updated again by ECRI Institute on June 22, 2016. The information was verified by the measure developer on June 27, 2016.

Copyright Statement

This NQMC summary is based on the original measure, which is subject to the measure developer's copyright restrictions.

Complete Physician Performance Measurement Sets (PPMS) are published by the American Medical Association, on behalf of the Physician Consortium for Performance Improvement.

For more information, contact the American Medical Association, Clinical Performance Evaluation, 330 N. Wabash Ave, Chicago, IL 60611.

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