Measure Information Form
Version 2020A2
Advanced Certification Heart Failure Outpatient (ACHFOP)
Set Measures
| Set Measure ID | Measure Short Name |
|---|---|
| ACHFOP-01 | Hospital Outpatient Beta-Blocker Therapy (i.e., Bisoprolol, Carvedilol, or Sustained-Release Metoprolol Succinate Prescribed for LVSD) |
| ACHFOP-02 | Hospital Outpatient ACEI or ARB Prescribed for LVSD |
| ACHFOP-03 | Hospital Outpatient Aldosterone Receptor Antagonists |
| ACHFOP-04 | Hosptial Outpatient New York Heart Association (NYHA Classification Assessment) |
| ACHFOP-05 | Hospital Outpatient Activity Recommendations |
| ACHFOP-06 | Hospital Outpatient Discussion of Advance Directives/Advance Care Planning |
| ACHFOP-07 | Hospital Outpatient Advance Directive Executed |
General Data Elements
| Element Name | Collected For |
|---|---|
| Birthdate | All Records, |
| ICD-10-CM Principal Diagnosis Code | All Records, Optional for HBIPS-2, HBIPS-3 |
| ICD-10-PCS Other Procedure Codes | All Records, Optional for All HBIPS Records |
| ICD-10-PCS Principal Procedure Code | All Records, Optional for All HBIPS Records |
| ICD-10-PCS Principal Procedure Date | All Records, Optional for All HBIPS Records |
Measure Set Specific Data Elements
Related Materials
Initial Patient Population Algorithm
ACHF Sample Size Requirements
Hospitals that choose to sample have the option of sampling quarterly or sampling monthly. A hospital may choose to use a larger sample size than is required. Hospitals whose Initial Patient Population size is less than the minimum number of cases per quarter for the measure set cannot sample.
Regardless of the option used, hospital samples must be monitored to ensure that sampling procedures consistently produce statistically valid and useful data. Due to exclusions, hospitals selecting sample cases MUST submit AT LEAST the minimum required sample size.
The following sample size tables for each option automatically build in the number of cases needed to obtain the required sample sizes. For information concerning how to perform sampling, refer to the Population and Sampling Specifications section in this manual.
Quarterly Sampling
Hospitals performing quarterly sampling for ACHF must ensure that its Initial Patient Population and sample size meet the following conditions:Based on Initial Patient Population Size for the ACHF Measure Set
Hospital's Measure
| Average Quarterly Initial Patient Population Size “N” |
Minimum Required Sample Size “n” |
|---|---|
| ≥ 1516 | 304 |
| 381 — 1515 | 20% of Initial Patient Population size |
| 76 — 380 | 76 |
| 0 — 75 | No sampling; 100% Initial Patient Population required |
Monthly Sampling
Hospitals performing monthly sampling for ACHF must ensure that its Initial Patient Population and sample size meet the following conditions:Based on Initial Patient Population Size for the ACHF Measure Set
Hospital's Measure
| Average Monthly Initial Patient Population Size “N” |
Minimum Required Sample Size “n” |
|---|---|
| ≥ 506 | 102 |
| 131 — 505 | 20% of Initial Patient Population size |
| 26 — 130 | 26 |
| <26 | No sampling; 100% Initial Patient Population required |
Sample Size Examples
- Quarterly sampling:
- The ACHF Initial Patient Population size for a hospital has been 500 patients per quarter during the past year. The required quarterly sample size would be 100 (twenty percent of 500) heart failure patients per quarter -- as this number is smaller than the maximum condition (i.e., 304 cases) and larger than the minimum condition (i.e., 76 cases).
- A hospital's ACHF Initial Patient Population size is 1,482 patients during the third quarter. The required sample size is 20% of the patient population or 297 cases for the quarter (twenty percent of 1,482 equals 296.4 rounded to the next highest whole number equals 297).
- Monthly sampling:
- A hospital's ACHF Initial Patient Population size is 25 patients during March. Since this is less than the minimum condition (i.e., 26 cases), no sampling is allowed or 100% of the patient population of 25 cases is required.
- A hospital's ACHF Initial Patient Population size is 503 patients during July. The required sample size is 20% of the patient population or 101 cases for the month (twenty percent of 503 equals 100.6 rounded to the next highest whole number equals 101).
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