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

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

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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.

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)

Higher score indicates better quality

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.

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

LVEF < 40% corresponds to qualitative documentation of moderate dysfunction or severe dysfunction.

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 of Encounter, Performed" is to establish that the eligible professional has an existing relationship with the patient.

TBD

All patients aged 18 years and older with a diagnosis of heart failure

Equals Initial Population with a current or prior LVEF < 40%

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

Not Applicable

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)

For every patient evaluated by this measure also identify payer, race, ethnicity and sex

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