Specifications Manual for Joint Commission National Quality Measures (v2018A)
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Release Notes:
Data Element
Version 2018A

Data Element Name: Reason for No ACEI and No ARB Prescribed for LVSD in Outpatient Setting
Collected For: ACHFOP-02
Definition:Reasons for not prescribing either an angiotensin converting enzyme inhibitor (ACEI) or angiotensin receptor blocker (ARB) for LVSD in the outpatient setting:
  • ACEI allergy AND ARB allergy
  • Moderate or severe aortic stenosis
  • Other reasons documented by physician/advanced practice nurse/physician assistant (physician/APN/PA) or pharmacist for not prescribing an ACEI AND not prescribing an ARB for this patient.
    Note: Documentation of a reason for not prescribing one class (either ACEI or ARB) should be considered implicit documentation of a reason for not prescribing the other class for the following five conditions only:
    • Angioedema
    • Hyperkalemia
    • Hypotension
    • Renal artery stenosis
    • Worsening renal function/renal disease/dysfunction
  • Reason documented by physician/APN/PA or pharmacist for not prescribing an ARB AND an ACEI allergy
  • Reason documented by physician/APN/PA or pharmacist for not prescribing an ACEI AND an ARB allergy

ACEIs and ARBs widen or dilate blood vessels, lowering blood pressure and making it easier for the heart to pump blood. They also inhibit the adverse effects of neurohormonal activation on the heart. These effects help reduce the risk of adverse outcomes such as death or hospitalization.
Suggested Data Collection Question:Is there documentation of BOTH a reason for not prescribing an ACEI AND a reason for not prescribing an ARB for LVSD in the outpatient setting?
Format:
Length:1
Type:Alphanumeric
Occurs:1
Allowable Values:

Y (Yes) There is documentation of BOTH a reason for not prescribing an ACEI AND a reason for not prescribing an ARB for LVSD in the outpatient setting.

N (No) There is no documentation of BOTH a reason for not prescribing an ACEI AND a reason for not prescribing an ARB for LVSD in the outpatient setting, or unable to determine from medical record documentation.
Notes for Abstraction:
  • An “allergy” or “sensitivity” documented counts as an allergy regardless of what type of reaction might be noted (e.g., “Allergies: ACEIs — Cough” — consider as ACEI allergy).
  • Documentation of an allergy/sensitivity to one particular ACEI is acceptable to take as an allergy to the entire class of ACEIs. Same for ARBs (e.g., “Allergic to Valsartan”- consider as ARB allergy).
  • When conflicting information is documented in a medical record, select “Yes”.
  • In the absence of explicit documentation that the patient has current moderate/severe aortic stenosis, this should be inferred when there is documentation of a history of moderate/severe aortic stenosis without mention of repair or replacement, valvuloplasty, or commissurotomy.
  • When determining whether there is a reason documented by a physician/APN/PA or pharmacist for not prescribing an ACEI or an ARB:
    • Documentation of a reason for not prescribing one class (either ACEI or ARB) should be considered implicit documentation of a reason for not prescribing the other class for the following five conditions ONLY:
      • Angioedema
      • Hyperkalemia
      • Hypotension
      • Renal artery stenosis
      • Worsening renal function/renal disease/dysfunction
    • Examples of statements that count as a reason for not prescribing ACEI and a reason for not prescribing ARB:
      • “Creatinine high. Hold losartan.”
      • “Hx angioedema with ACEIs.”
      • “No ACEI. Bilateral renal artery stenosis.”
      • “BPs running low. Discontinue losartan.”
      • “Potassium 5.5 — No ACEI.”
      • “Severe hypotension with ACEIs in past.”
      • “Add ARB if hyperkalemia resolves.”
  • Reasons for no ACEIs and reasons for no ARBs must be explicitly documented (e.g., “POTASSIUM 5.5 — No ACEI”) or clearly implied (e.g., “Severe hypotension with ACEIs in past,” “Hx ACEI-induced cough,” “ARBs contraindicated,” “Pt. refusing all medications,” “Supportive care only — no medications,” “ACEI therapy not indicated,” ACEI on pre-printed order form is crossed out, “No ACEI/ARB” [reason not given]). If reasons are not mentioned in the context of ACEIs/ARBs, do not make inferences (e.g., Do not assume that an ACEI/ARB is not prescribed because of the patient's chronic renal disease alone).
    • Deferral of an ACEI from one physician/APN/PA or pharmacist to another does NOT count as a reason for not prescribing an ACEI unless the problem underlying the deferral is also noted. Same for ARBs. Examples:
      • “Consulting cardiologist to evaluate pt. for ACEI therapy” - select “No” (Do NOT consider as reason for not prescribing ACEI).
      • “Pt. hypotensive. Start ARB if OK with cardiology.” - select "Yes" (Consider as reason for not prescribing ACEI and reason for not prescribing ARB ).
    • If there is documentation of a plan to initiate/restart an ACEI, and the reason/problem underlying the delay in starting/restarting the ACEI is also noted, this constitutes a “clearly implied” reason for not prescribing ACEI. Same for ARBs. Acceptable examples (select "Yes"):
      • "Pt. hemodynamically unstable. May start ACEI/ARB as outpatient.”
      • “Add ARB if hyperkalemia resolves”
    • ACEIs/ARBs are sometimes described as RAS (renin-angiotensin system) or RAAS (renin-angiotensin-aldosterone system) blockers/inhibitors. Documentation of a reason for not prescribing "RAS" or "RAAS" blockers or inhibitors should be considered implicit documentation of a reason for no ACEI and no ARB (e.g., "Hold all RAS blockers").
Suggested Data Sources:

  • Consultation notes
  • Emergency department record
  • History and physical
  • Progress notes
  • Physician orders
  • Discharge summary
  • Diagnostic test reports
  • Transfer sheet
  • Discharge instruction sheet
  • Outpatient medical record
Additional Notes:
Guidelines for Abstraction:
Inclusion Exclusion
Angioedema

  • Angioneurotic edema
  • Edema of the eyelid, glottis, larynx, nasopharynx, or pharynx
  • Periorbital edema described as acute

Hyperkalemia

  • Patient's potassium (K+) level noted (e.g., "Last Potassium 6.5. Will hold off on ACEI therapy”)
  • Potassium level described as elevated
  • References to potassium not specified or described as hyperkalemia (e.g., “Hold off on ACEI therapy. Check potassium.”, “Start candesartan once potassium improved”)

Hypotension

  • Blood pressure (BP) described as low
  • Patient's blood pressure measurement noted (e.g., "BP systolic running in 80s. Will not prescribe ARBs at this time”)
  • References to blood pressure not specified or described as hypotension (e.g., “Hold off on ACEI therapy. Check BP in a.m.”, “Start candesartan after BP normalizes”)
  • Shock

oderate/severe aortic stenosis (AS)

  • Aortic stenosis described as 3+, 4+, critical, or significant
  • Aortic stenosis, degree of severity not specified
  • Aortic valve area of less than 1.0 square cms
  • Subaortic stenosis, moderate/severe or degree of severity not specified

Worsening renal function/renal disease/dysfunction

  • Acute kidney injury (AKI)
  • Azotemia
  • Chronic kidney disease (CKD)
  • Dialysis
  • End stage renal disease (ESRD)
  • Nephritis
  • References to creatinine not specified or described as elevated (e.g., “Hold off on ACEI therapy. Check creatinine.”, “Start candesartan once creatinine improved”). References to renal/renal function not specified or described as renal dysfunction (e.g., “Hold on ACEI pending kidney function panel in a.m.”, “Start candesartan after nephrology sees”)
  • Renal failure, acute or chronic (ARF, RF, CRF)
  • Renal insufficiency (RI, CRI)
  • Renal/kidney transplant (RT, RTx, s/p renal transplant, KT)
  • Serum creatinine (Cr, Cre) level described as abnormal or elevated
  • Serum creatinine (Cr, Cre) noted (e.g., “No ACEIs. Creatinine 2.0”)

Refer to Appendix C, Table 1.2 for a comprehensive list of ACEIs and Table 1.7 for a comprehensive list of ARBs.

  • ACEI allergy
  • ACEI allergy described using one of the negative modifiers or qualifiers listed in Appendix H, Table 2.6, Qualifiers and Modifiers Table

Moderate/severe aortic stenosis (AS)

  • Aortic insufficiency only
  • Aortic regurgitation only
  • Aortic stenosis described as 1+ or 2+
  • Moderate/severe aortic stenosis, or any of the other moderate/severe aortic stenosis inclusion terms, described using one of the negative modifiers or qualifiers listed in Appendix H, Table 2.6, Qualifiers and Modifiers Table

Reason for No ACEI and No ARB Prescribed for LVSD in Outpatient Setting
Specifications Manual for Joint Commission National Quality Measures (v2018A)
Discharges 07-01-18 (3Q18) through 12-31-18 (4Q18)
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