Brief Description of Measure:

CMS135: Heart Failure (HF): Angiotensin-Converting Enzyme (ACE) Inhibitor or Angiotensin Receptor Blocker (ARB) or Angiotensin Receptor-Neprilysin Inhibitor (ARNI) 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 ACE inhibitor or ARB or ARNI therapy either within a 12-month period when seen in the outpatient setting OR at each hospital discharge
CMS144: 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

Description of Issue:

Upon review of the clinical treatment trials for low LVEF heart failure found in the literature, cited below, the technical expert panel (TEP) determined that two groups of patients were not included: patients post-heart transplant and patients with a left ventricular assist device.
 
(Greene SJ, Butler J, Albert NM, et al. Medical therapy for heart failure with reduced ejection fraction: the CHAMP-HF registry. J Am Coll Cardiol.  2018;72:351–66).
 
Therefore, the TEP recommended adding a denominator exclusion for patients with a history of heart transplant or with a Left Ventricular Assist Device (LVAD)

Proposed Solution:

ADD DENOMINATOR EXCLUSION TO HEADER FOR CMS 135 AND CMS 144:
Patients with a history of heart transplant or with Left Ventricular Assist Device (LVAD)
 
PROPOSED LOGIC ADDITIONS TO CMS 135 AND 144
Population 1:
Has Heart Transplant Outpatient
   exists ["Procedure, Performed": "Heart Transplant"] HeartTransplant
     with "Heart Failure Outpatient Encounter with Moderate or Severe LVSD" ModerateOrSevereLVSDHFOutpatientEncounter
       such that ( Global."NormalizeInterval" ( HeartTransplant.relevantDatetime, HeartTransplant.relevantPeriod ) ) before end of ModerateOrSevereLVSDHFOutpatientEncounter.relevantPeriod
 
Has Left Ventricular Assist Device Implanted Outpatient
   exists ["Procedure, Performed": "Left ventricular assist device (physical object)"] LVADOutpatient
     with "Heart Failure Outpatient Encounter with Moderate or Severe LVSD" ModerateOrSevereLVSDHFOutpatientEncounter
       such that (Global."NormalizeInterval"(LVADOutpatient.relevantDatetime, LVADOutpatient.relevantPeriod))  before end of ModerateOrSevereLVSDHFOutpatientEncounter.relevantPeriod
 
Denominator Exclusions 1
   “Has Heart Transplant Outpatient”
      or “Has Left Ventricular Assist Device Implanted Outpatient”
 

Population 2:
Has Heart Transplant Inpatient
   exists ["Procedure, Performed": "Heart Transplant"] HeartTransplant
   with "Heart Failure Inpatient Encounter with Moderate or Severe LVSD" ModerateOrSevereLVSDHFInpatientEncounter
   such that (Global."NormalizeInterval"(HeartTransplant.relevantDatetime, HeartTransplant.relevantPeriod)) before end of ModerateOrSevereLVSDHFInpatientEncounter.relevantPeriod
 
Has Left Ventricular Assist Device Implanted Inpatient
   exists ["Procedure, Performed": "Left ventricular assist device (physical object)"] LVADInpatient
     with "Heart Failure Inpatient Encounter with Moderate or Severe LVSD" ModerateOrSevereLVSDHFInpatientEncounter
       such that (Global."NormalizeInterval"(LVADInpatient.relevantDatetime, LVADInpatient.relevantPeriod))  before end of ModerateOrSevereLVSDHFInpatientEncounter.relevantPeriod
 
Denominator Exclusions 2
   “Has Heart Transplant Inpatient”
      or “Has Left Ventricular Assist Device Implanted Inpatient”
 
 
PROPOSED CODING ADDITIONS:
Heart Transplant Value Set: Grouping (SNOMEDCT/ICD10PCS) 2.16.840.1.113762.1.4.1178.33
Left Ventricular Assist Device direct reference code: SNOMEDCT 232967006: Implantation of left ventricular assist device (procedure)

Rationale for Change:

​Patients post-heart transplant or with an LVAD will be excluded, because these patients were excluded from clinical treatment trials for low LVEF heart failure.