Welcome to Lesson 3 of this learning activity titled Understanding Metrics. The content in this lesson was developed by Denise Pond and Beth Denton. I'm Veronica Wilson and I will be narrating this lesson. The 2017 ACC AHA HFSA Focused Update of the 2013 ACCF AHA Guidelines for the Management of Heart Failure evaluates the current recommendations and identifies what is beneficial. It was determined the use of ACE inhibitors is still beneficial for patients with prior or current symptoms of chronic heart failure with a reduced ejection fraction. The Focused Update reviews new clinical trial data and identifies what is beneficial, such as the use of renin-angiotensin system inhibitor with ACE inhibitor, or ARB or ARNI, in select patients with chronic heart failure and a reduced ejection fraction. It identifies new clinical trial data, such as the use of ivabradine, a Class IIa indication, for the treatment of a specific classification of heart failure, as it may be beneficial. In addition, the Focused Update identifies Class III indications which may be harmful or not recommended when a patient has a history of angioedema. To review the complete document, select Resources from the left navigation bar, then Documents. Then scroll to Quality Tools and Reference Documents. Here you will find the 2017 update. Now let's review the Reports Companion Guide as it applies to ACE inhibitors and ARBs. This is one example of how the companion guide will display the metric criteria. The numerator and denominator are well defined. The numerator will be the count of patients for whom ACE inhibitor or ARB were coded as yes, no medical reason, or no patient reason. The denominator will be the count of patients who had an initial generator implant, generator change, or generator explant, who had an LVEF of less than 40%. The clinical rationale or guideline recommendation will be provided. In addition, if a metric is NQF endorsed, the measure number will be displayed. When evaluating metric data, it is important to become familiar with the data elements that make up the metric. In metric number 4, either ACE inhibitor or ARB is required to be prescribed for LV dysfunction which is defined as LVEF of less than 40. The possible selections are yes, no no reason, no medical reason, or no patient reason. The denominator will include all generator procedures when the patient has an LVEF of less than 40. There are no denominator exclusions. Let's examine how some examples of this may work. If yes is coded for either ACE1 or ARB, regardless of what is coded for the other, the metric is met and the patient will appear as a yes in the numerator. In our example, ACE1 is coded yes with ARB coded as no medical reason. The metric criteria are met and yes will appear in the numerator. No in the numerator indicates the patient did not meet the requirements for metric number 4. In our example, ACE1 is coded as no, no reason with ARB coded as no medical reason. The metric criteria are not met, thus no will appear in the numerator. When both ACE1 and ARB are coded as no medical reason, the clinician is given credit for addressing the medication, therefore, the metric criteria are resulting in a yes in the numerator. Now, let's put this into practice by looking at a case scenario. A 65-year-old female with a history of non ischemic cardiomyopathy since 2012 is admitted for ICD generator change for primary prevention. The echo performed two months ago revealed an LVEF of 30%. The clinician documents the patient's heart failure is being appropriately managed on Toprol, Excel, and Lasix, however, she is allergic to ACE inhibitors. Based on the documentation in the medical record, the abstractor codes an LVEF of 30%, ACE inhibitor as no medical reason, and ARB as no, no reason. The question is, how will the abstractor's coding of ACE1 and ARB in Sequence 10-205 impact metric number 4? The coding will result in 1. No in the numerator of metric number 4 or 2. Yes in the numerator of metric number 4. Please take a minute to review what is coded by the abstractor and the question presented. The answer is number one. No in the numerator of metric number four as the allergy applies to the ACE inhibitor only. Please review the medical record for documentation regarding why the ARB was not prescribed. If no documentation is found, please consult with a clinician as there are no implied exclusions for discharge medications. This concludes lesson three of Understanding Metrics. And thank you for your participation.

Understanding Metrics

ACE inhibitors

ARBs

heart failure

reduced ejection fraction