Release Notes:
Data Element
Version 2018A
Data Element Name: |
Reason for No Bisoprolol, Carvedilol, or Sustained-Release Metoprolol Prescribed for LVSD in the Outpatient Setting |
Collected For: |
ACHFOP-01 |
Definition: | Reasons for not prescribing bisoprolol, carvedilol, or sustained-release metoprolol succinate for LVSD in the outpatient setting:
- Beta-blocker allergy
- Second or third-degree heart block on ECG and does not have a pacemaker
- Other reasons documented by physician/advanced practice nurse/physician assistant (physician/APN/PA) or pharmacist
Bisoprolol, carvedilol, and sustained-release metoprolol succinate are agents which block beta-adrenergic receptors, thereby decreasing the rate and force of heart contractions, and reducing blood pressure. Over time beta-blockers improve the heart's pumping ability.
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Suggested Data Collection Question: | Is there documentation of a reason for not prescribing bisoprolol, carvedilol, or sustained-release metoprolol succinate for LVSD in the outpatient setting? |
Format: |
Length: | 1 |
Type: | Alphanumeric |
Occurs: | 1 |
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Allowable Values: |
Y (Yes) There is documentation of a reason for not prescribing bisoprolol, carvedilol, or sustained-release metoprolol succinate for LVSD in the outpatient setting.
N (No) There is no documentation of a reason for not prescribing bisoprolol, carvedilol, or sustained-release metoprolol succinate for LVSD in the outpatient setting, or unable to determine from medical record documentation.
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Notes for Abstraction: |
- A beta-blocker “allergy” or “sensitivity” documented counts as an allergy regardless of what type of reaction might be noted (e.g., “Allergies: Beta-blockers — Impotence” — select “Yes”).
- Documentation of an allergy/sensitivity to one particular beta-blocker is acceptable to take as an allergy to the entire class of beta-blockers (e.g., “Allergic to Toprol-XL”).
- When conflicting information is documented in a medical record, select “Yes”.
- When determining whether there is second or third-degree heart block on ECG in the outpatient setting AND does not have pacemaker:
- Consider this true if (1) there are findings of second or third-degree heart block on the ECG AND this same ECG does NOT show pacemaker findings, OR (2) There is documentation of a finding of second or third-degree heart block (not specifically referenced as an ECG finding) without mention of the presence of pacemaker findings (e.g., “Second-degree heart block” per ER report).
- Disregard pacemaker findings if documentation suggests the patient has a non-functioning pacemaker.
- Second or third-degree heart block and pacemaker ECG findings can be taken from unsigned ECG reports. Physician/APN/PA documentation is not required.
- Second or third-degree heart block findings and pacemaker findings from telemetry and rhythm strips are acceptable.
- In cases where ECG findings of second- or third-degree heart block are referenced and documentation does not address the presence or absence of pacemaker findings, infer no pacemaker findings. E.g., “ECG on arrival showed second-degree heart block” per H&P.
- When determining whether there is a reason documented by a physician/APN/PA or pharmacist for not prescribing bisoprolol, carvedilol, or sustained-release metoprolol succinate in the outpatient setting:
- Reasons must be explicitly documented (e.g., “COPD - No BBs”, “HR running in 50s. Hold off on beta-blocker therapy”) or clearly implied (e.g., “Severe hypotension with beta-blockers in past,” “BBs contraindicated,” “Pt. refusing all medications,” “Supportive care only — no medications,” “BBs not indicated,” beta-blocker on pre-printed order form is crossed out, “No beta-blockers” [no reason given]). If reasons are not mentioned in the context of beta-blockers, do not make inferences (e.g., Do not assume that bisoprolol, carvedilol, or sustained-release metoprolol succinate is not being prescribed because of the patient's history of Peripheral Vascular Disease alone).
- Discontinuation of bisoprolol, carvedilol, or sustained-release metoprolol succinate documented in combination with the start of a another one of these beta-blockers (i.e., switch from bisoprolol to carvedilol) does not count as a reason for not prescribing bisoprolol, carvedilol, or sustained-release metoprolol succinate in the outpatient setting. Examples:
- “Stop carvedilol” and “Start Coreg 12.5 mg po bid” in same physician order
- “Change metoprolol to Coreg” in progress note
- Discontinuation of bisoprolol, carvedilol, or sustained-release metoprolol succinate at a particular dose documented in combination with the start of a different dose of that beta-blocker (i.e., change in dosage) does not count as a reason for not prescribing bisoprolol, carvedilol, or sustained-release metoprolol succinate in the outpatient setting. Examples:
- “Stop metoprolol succinate 25 mg po” and “Start metoprolol succinate 50 mg po” in same physician order
- “Increase bisoprolol 5 mg to 10 mg” in progress note
- “Reason documentation which refers to a more general medication class is not acceptable (e.g., “Hold all BP meds”).
- Deferral from one physician/APN/PA or pharmacist to another does NOT count as a reason for not prescribing bisoprolol, carvedilol, or sustained-release metoprolol succinate in the outpatient setting unless the problem underlying the deferral is also noted. Examples:
- “Consulting cardiologist to evaluate pt. for beta-blocker treatment” - select “No”.
- “Pt. hypotensive. Start Coreg if OK with cardiology.” - select "Yes”.
- If there is documentation of a plan to initiate/restart bisoprolol, carvedilol, or sustained-release metoprolol succinate, and the reason/problem underlying the delay in starting/restarting the beta-blocker is also noted, this constitutes a “clearly implied” reason for not prescribing a beta-blocker in the outpatient setting.
- Acceptable examples (select “Yes”):
- “BPs running low. May start Zebeta as outpatient.”
- "Add Toprol-XL if HR stabilizes"
- Unacceptable examples (select “No”):
- “Consider starting Coreg next appointment .”
- “May add beta-blockers when pt. can tolerate”
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Suggested Data Sources: |
- Consultation notes
- Emergency department record
- History and physical
- Progress notes
- Physician orders
- Discharge summary
- Transfer sheet
- Outpatient medical record
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Additional Notes: |
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Guidelines for Abstraction: |
Inclusion |
Exclusion |
2nd/3rd degree heart block (HB)
Note: The following inclusive terms may stand alone or be modified by “variable” or “intermittent.”
- Atrioventricular (AV) block described as 2 to 1, 3 to 1, second-degree, or third-degree
- Atrioventicular (AV) dissociation
- Heart block (HB) described as 2 to 1, 3 to 1, complete (CHB), high degree, high grade, second-degree, or third-degree
- Mobitz Type 1 or 2
- Wenckebach
Pacemaker findings
- Paced rhythm
- Paced spikes
- Pacing described as atrial, AV, dual chamber, or ventricular
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Beta-blocker allergy
- Allergy to beta-blocker eye drops (e.g., Cosopt)
- Beta-blocker allergy described using one of the negative modifiers or qualifiers listed in Appendix H, Table 2.6, Qualifiers and Modifiers Table
2nd/3rd degree heart block (HB)
- 2nd/3rd degree heart block (HB), or any of the other 2nd/3rd degree heart block inclusion terms, described using one of the negative modifiers or qualifiers listed in Appendix H, Table 2.6, Qualifiers and Modifiers Table
- Atrial flutter
- Atrioventricular (AV) block or conduction block, type/degree not specified
- First-degree atrioventricular (AV) block
- First-degree heart block (HB)
- Heart block, type/degree not specified
- Intraventricular conduction delay (IVCD)
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Reason for No Bisoprolol, Carvedilol, or Sustained-Release Metoprolol Prescribed for LVSD in the 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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