2020 ACC/AHA Clinical Performance and Quality Measures for Adults With Heart Failure

Abstract

HomeCirculation: Cardiovascular Quality and OutcomesVol. 13, No. 112020 ACC/AHA Clinical Performance and Quality Measures for Adults With Heart Failure Free AccessReview ArticlePDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyRedditDiggEmail Jump toSupplementary MaterialsFree AccessReview ArticlePDF/EPUB2020 ACC/AHA Clinical Performance and Quality Measures for Adults With Heart FailureA Report of the American College of Cardiology/American Heart Association Task Force on Performance Measures Paul A. Heidenreich, MD, MS, FACC, FAHA, Chair, Gregg C. Fonarow, MD, FACC, FAHA, FHFSA, Vice Chair, Khadijah Breathett, MD, MS, FACC, FAHA, FHFSA, Corrine Y. Jurgens, PhD, RN, ANP, FAHA, FHFSA, Barbara A. Pisani, DO, FACC, FAHA, Bunny J. Pozehl, PhD, APRN-NP, FAHA, FHFSA, John A. Spertus, MD, MPH, FACC, FAHA, Kenneth G. Taylor, MD, FACC, FHFSA, Jennifer T. Thibodeau, MD, MSCS, FACC, FHFSA, Clyde W. Yancy, MD, MSc, MACC, FAHA, FHFSA and Boback Ziaeian, MD, PhD, FACC, FAHA Paul A. HeidenreichPaul A. Heidenreich Search for more papers by this author , Gregg C. FonarowGregg C. Fonarow *ACC/AHA Task Force on Performance Measure Liaison. Search for more papers by this author , Khadijah BreathettKhadijah Breathett Search for more papers by this author , Corrine Y. JurgensCorrine Y. Jurgens Search for more papers by this author , Barbara A. PisaniBarbara A. Pisani Search for more papers by this author , Bunny J. PozehlBunny J. Pozehl Search for more papers by this author , John A. SpertusJohn A. Spertus Search for more papers by this author , Kenneth G. TaylorKenneth G. Taylor †Heart Failure Society of America Representative. Search for more papers by this author , Jennifer T. ThibodeauJennifer T. Thibodeau Search for more papers by this author , Clyde W. YancyClyde W. Yancy Search for more papers by this author and Boback ZiaeianBoback Ziaeian Search for more papers by this author Originally published2 Nov 2020https://doi.org/10.1161/HCQ.0000000000000099Circulation: Cardiovascular Quality and Outcomes. 2020;13:e000099Table of ContentsTop 10 Take-Home Messages 920Preamble 9211. Introduction 9211.1. Scope of the Problem 9241.2. Disclosure of Relationships With Industry and Other Entities 9242. Methodology 9242.1. Literature Review 9242.2. Definition and Selection of Measures 9243. ACC/AHA Heart Failure Measure Set 9243.1. Discussion of Changes to 2011 Heart Failure Measure Set 9243.1.1. Retired Measures 9253.1.2. Revised Measures 9253.1.3. New Measures 9254. Areas for Further Research 925References 927Appendix A. Heart Failure Measure Set 931Performance Measures for Heart Failure 931Short Title: PM-1: Left Ventricular Ejection Fraction Assessment (Outpatient Setting) 931Short Title: PM-2: Symptom and Activity Assessment (Outpatient Setting) 932Short Title: PM-3: Symptom Management (Outpatient Setting) 933Short Title: PM-4: Beta-Blocker Therapy for Heart Failure With Reduced Ejection Fraction (Outpatient and Inpatient Setting) 934Short Title: PM-5: Angiotensin-Converting Enzyme Inhibitor or Angiotensin Receptor Blocker or Angiotensin Receptor-Neprilysin Inhibitor Therapy for Heart Failure With Reduced Ejection Fraction (Outpatient and Inpatient Setting) 935Short Title: PM-6: Angiotensin Receptor-Neprilysin Inhibitor Therapy for Heart Failure With Reduced Ejection Fraction (Outpatient and Inpatient Setting) 936Short Title: PM-7: Dose of Beta-Blocker Therapy for Heart Failure With Reduced Ejection Fraction (Outpatient Setting) 937Short Title: PM-8: Dose of Angiotensin-Converting Enzyme Inhibitor, Angiotensin Receptor Blocker, or Angiotensin Receptor-Neprilysin Inhibitor Therapy for Heart Failure With Reduced Ejection Fraction (Outpatient Setting) 939Short Title: PM-9: Mineralocorticoid Receptor Antagonist Therapy for Heart Failure With Reduced Ejection Fraction (Outpatient and Inpatient Setting) 940Short Title: PM-10: Laboratory Monitoring in New Mineralocorticoid Receptor Antagonist Therapy (Outpatient and Inpatient Setting) 941Short Title: PM-11: Hydralazine/Isosorbide Dinitrate Therapy for Heart Failure With Reduced Ejection Fraction in Those Self-Identified as Black or African American (Outpatient and Inpatient Setting) 942Short Title: PM-12: Counseling Regarding Implantable Cardioverter-Defibrillator Implantation for Patients With Heart Failure With Reduced Ejection Fraction on Guideline-Directed Medical Therapy (Outpatient Setting) 943Short Title: PM-13: Cardiac Resynchronization Therapy Implantation for Patients With Heart Failure With Reduced Ejection Fraction on Guideline-Directed Medical Therapy (Outpatient Setting) 944Quality Measures for Heart Failure 945Short Title: QM-1: Patient Self-Care Education (Outpatient Setting) 945Short Title: QM-2: Measurement of Patient-Reported Outcome-Health Status (Outpatient Setting) 946Short Title: QM-3: Sustained or Improved Health Status in Heart Failure (Outcome) 947Short Title: QM-4: Postdischarge Appointment for Patients With Heart Failure (Inpatient Setting) 948Structural Measure for Heart Failure 949Short Title: SM-1: Heart Failure Registry Participation 949Rehabilitation Performance Measures Related to Heart Failure 950Short Title: PM-2: Exercise Training Referral for HFrEF From Inpatient Setting 950Short Title: PM-4: Exercise Training Referral for HFrEF From Outpatient Setting 951Appendix B. Author Relationships With Industry and Other Entities (Relevant) 952Appendix C. Reviewer Relationships With Industry and Other Entities (Comprehensive)954Top 10 Take-Home Messages for Adults With Heart FailureThis document describes performance measures for heart failure that are appropriate for public reporting or pay-for-performance programs.The performance measures are from the 2017 American College of Cardiology/American Heart Association/Heart Failure Society of America heart failure guideline update and are selected from the strongest recommendations (Class 1 or 3).Quality measures are also provided that are not yet ready for public reporting or pay for performance but might be useful for clinicians and healthcare organizations for quality improvement.A new safety measure (laboratory monitoring for patients treated with mineralocorticoid receptor antagonists) is paired with a new treatment measure (mineralocorticoid receptor antagonists in patients with heart failure with reduced left ventricular ejection fraction).Other additions to the performance measures include the new medication sacubitril/valsartan and use of cardiac resynchronization therapy.To address frequent lack of titration of heart failure medications, 2 new performance measures are included based on dose, either reaching 50% of the recommended dose (eg, beta blocker or angiotensin-converting enzyme inhibitor/angiotensin receptor antagonist/angiotensin receptor neprilysin inhibitor) or documenting that such a dose was not tolerated or otherwise inappropriate.For all measures, if the clinician determines the care is inappropriate for the patient, that patient is excluded from the measure.For all measures, patients who decline treatment or care are excluded.A patient-centered discussion of the benefits and risks of implantable cardioverter-defibrillator treatment remains a performance measure.To reflect the increasing importance of patient-reported outcome measures, 2 patient-reported outcomes quality measures were added that use heart failure patient-reported outcomes questionnaires currently accepted by the US Food and Drug Administration.PreambleThe American College of Cardiology (ACC)/American Heart Association (AHA) performance measurement sets serve as vehicles to accelerate translation of scientific evidence into clinical practice. Measure sets developed by the ACC/AHA are intended to provide practitioners and institutions that deliver cardiovascular services with tools to measure the quality of care provided and identify opportunities for improvement.Writing committees are instructed to consider the methodology of performance measure development1,2 and to ensure that the measures developed are aligned with ACC/AHA clinical practice guidelines. The writing committees also are charged with constructing measures that maximally capture important aspects of care quality, including timeliness, safety, effectiveness, efficiency, equity, and patient-centeredness, while minimizing, when possible, the reporting burden imposed on hospitals, practices, and practitioners.Potential challenges from measure implementation may lead to unintended consequences. The manner in which challenges are addressed is dependent on several factors, including the measure design, data collection method, performance attribution, baseline performance rates, reporting methods, and incentives linked to these reports.The ACC/AHA Task Force on Performance Measures (Task Force) distinguishes quality measures from performance measures. Quality measures are those metrics that may be useful for local quality improvement but are not yet appropriate for public reporting or pay for performance programs (uses of performance measures). New measures are initially evaluated for potential inclusion as performance measures. In some cases, a measure is insufficiently supported by the guidelines. In other instances, when the guidelines support a measure, the writing committee may feel it is necessary to have the measure tested to identify the consequences of measure implementation. Quality measures may then be promoted to the status of performance measures as supporting evidence becomes available.P. Michael Ho, MD, PhD, FACC, FAHAChair, ACC/AHA Task Force on Performance Measures1. IntroductionIn 2019, the Task Force convened the writing committee to begin the process of revising the existing performance measures set for heart failure that was released in 2011.3 The writing committee also was charged with the task of developing new measures to evaluate the care of patients in accordance with the 2017 ACC/AHA/HFSA heart failure guideline update.4This updated performance measure set addresses in-hospital and continuing care in the outpatient setting. All Class 1 (strong) and 3 (no benefit or harmful, process to be avoided) guideline-recommended processes were considered for inclusion as performance measures. The current Class of Recommendation and Level of Evidence guideline classification scheme used by the ACC and AHA in their clinical guidelines is shown in Table 1. The value (benefit and cost) of a process of care was also considered. If high-quality, published, cost-effectiveness studies indicate that a Class 1 guideline recommendation for a process of care is considered a poor value by ACC/AHA standards, then it was not included as a performance measure.5 There were no Class 1 recommended processes of care judged to be of poor value. All ACC/AHA clinical practice guideline recommendations (including Class 2) were considered as potential quality measures. Ultimately, we selected measures based on their importance for health, existing gaps in care, ease of implementation, potential duplication with other performance measure lists, and risk for unintended consequences.The writing committee developed a comprehensive heart failure measure set that includes 18 measures: 13 performance measures, 4 quality measures, 1 structural measure, and 2 rehabilitation performance measures (from the 2018 ACC/AHA performance measures for cardiac rehabilitation6), as reflected in Table 2 and Appendix A. The performance measures for heart failure included in the measure set are summarized in Table 2, which provides information on the measure number, measure title, and care setting. The measure specifications (Appendix A) provide information included in Table 2 and more detailed information including, the measure description, numerator, denominator (ie, denominator exclusions and exceptions), rationale for the measure, clinical practice guideline that supports the measure, measurement period, source of data, and attribution.Table 2. ACC/AHA 2020 Heart Failure Clinical Performance, Quality and Structural MeasuresMeasure No.Measure TitleCare SettingAttributionMeasure DomainCOR/LOEPerformance Measures PM-1LVEF assessmentOutpatientIndividual practitioner, FacilityDiagnosticCOR: 1, LOE: C; COR: 2a, LOE: C PM-2Symptom and activity assessmentOutpatientIndividual practitioner, FacilityMonitoringCOR: 1, LOE: C PM-3Symptom managementOutpatientIndividual practitioner, FacilityTreatmentSee measure rationale in Appendix A for details PM-4Beta-blocker therapy for HFrEFOutpatient, InpatientIndividual practitioner, FacilityTreatmentCOR: 1, LOE: A; COR: 1, LOE: B PM-5ACE inhibitor or ARB or ARNI therapy for HFrEFOutpatient, InpatientIndividual practitioner, FacilityTreatmentCOR: 1, LOE: A; COR: 1, LOE: B-R PM-6ARNI therapy for HFrEFOutpatient, InpatientIndividual practitioner, FacilityTreatmentCOR: 1, LOE: B-R PM-7Dose of beta-blocker therapy for HFrEFOutpatientIndividual practitioner, FacilityTreatmentCOR: 1, LOE: A PM-8Dose of ACE inhibitor, ARB, or ARNI therapy for HFrEFOutpatientIndividual practitioner, FacilityTreatmentCOR: 1, LOE: A; COR: 1, LOE: B-R PM-9MRA therapy for HFrEFOutpatient, InpatientIndividual practitioner, FacilityTreatmentCOR: 1, LOE: A; COR: 1, LOE: B PM-10Laboratory monitoring in new MRA therapyOutpatient, InpatientIndividual practitioner, FacilityMonitoringCOR: 1, LOE: A PM-11Hydralazine/isosorbide dinitrate therapy for HFrEF in those self-identified as Black or African AmericanOutpatient, InpatientIndividual practitioner, FacilityTreatmentCOR: 1, LOE: A PM-12Counseling regarding ICD implantation for patients with HFrEF on guideline-directed medical therapyOutpatientIndividual practitioner, FacilityTreatmentCOR: 1, LOE: A PM-13CRT implantation for patients with HFrEF on guideline-directed medical therapyOutpatientIndividual practitioner, FacilityTreatmentCOR: 1, LOE: A; COR: 1, LOE: BQuality Measures QM-1Patient self-care educationOutpatientIndividual practitioner, FacilitySelf-CareCOR: 1, LOE: B QM-2Measurement of patient-reported outcome-health statusOutpatientIndividual practitioner, FacilityMonitoringSee measure rationale in Appendix A for details QM-3Sustained or improved health status in heart failureOutpatientIndividual practitioner, FacilityOutcomeSee measure rationale in Appendix A for details QM-4Postdischarge appointment for patients with heart failureInpatientIndividual practitioner, FacilityTreatmentCOR: 2a, LOE: BStructural Measure SM-1Heart failure registry participationOutpatient, InpatientFacilityStructureCOR: 2a, LOE: BRehabilitation Performance Measures Related to Heart Failure (From the 2018 ACC/AHA performance measures for cardiac rehabilitation6 Rehab PM-2Exercise training referral for HF from inpatient settingInpatientFacilityProcessCOR: 1, LOE: A Rehab PM-4Exercise training referral for HF from outpatient settingOutpatientIndividual practitioner, FacilityProcessCOR: 1, LOE: AACC indicates American College of Cardiology; ACE, angiotensin–converting enzyme; AHA, American Heart Association; ARB, angiotensin receptor blocker; ARNI, angiotensin receptor–neprilysin inhibitor; COR, class of recommendation; CRT, cardiac resynchronization therapy; HF, heart failure; HFrEF, heart failure with reduced ejection fraction; ICD, implantable cardioverter-defibrillator; LOE, level of evidence; LVEF, left ventricular ejection fraction; MRA, mineralocorticoid receptor antagonists; PM, performance measure; QM, quality measure; and SM, structural measure.The writing committee recognized that the 2018 ACC/AHA performance measures for cardiac rehabilitation have been published that address heart failure.6 The cardiac rehabilitation measure set includes performance measures for exercise training referral for inpatients and outpatients with heart failure and reduced left ventricular ejection fraction (Table 2). These rehabilitation measures also should be considered heart failure–related ACC/AHA performance measures.A comprehensive list of contraindications to care is not provided. Instead, it is expected that clinical judgment will be used to determine if a contraindication exists. For example, certain patients with heart failure and congenital heart disease would not qualify for certain treatment measures and should be excluded from the denominator if documented by the clinician.Although the measures are published as a set, their implementation can be individualized. It is not expected that all measures will be adopted simultaneously. Although all the measures are considered valuable in improving care, we recognize that organizations may only be able to focus on a limited number of measures. When implementing any measure that involves patient input, it is important to consider the patient’s health literacy and adapt data collection accordingly. Performance measures are a critical step in addressing disproportionately lower quality of care and potentially worse health status and outcomes among an underserved population.1.1. Scope of the ProblemHeart failure is a major and growing public health problem in the United States with significant morbidity, mortality, and associated cost. A detailed discussion of the scope of the problem and opportunities to improve the quality of care that is provided to patients with this condition is available in the ACCF/AHA 2013 heart failure clinical practice guideline7 and 2017 ACC/AHA/HFSA heart failure guideline update.41.2. Disclosure of Relationships With Industry and Other EntitiesThe Task Force makes every effort to avoid actual, potential, or perceived conflicts of interest that could arise as a result of relationships with industry or other entities (RWI). Information about the ACC/AHA policy on RWI can be found online. All members of the writing committee, as well as those selected to serve as peer reviewers of this document, were required to disclose all current relationships and those existing within the 12 months before the initiation of this writing effort. ACC/AHA policy also requires that the writing committee chair and at least 50% of the writing committee have no relevant RWI. Writing committee members are excluded from voting on sections to which their specific RWI may apply.Any writing committee member who develops new RWI during his or her tenure on the writing committee is required to notify staff in writing. These statements are reviewed periodically by the Task Force and by members of the writing committee. Writing committee member and peer reviewer RWI, which are pertinent to the document, are included in the appendixes: Appendix B for relevant writing committee RWI and Appendix C for comprehensive peer reviewer RWI. Additionally, to ensure complete transparency, the writing committee members’ comprehensive disclosure information, including RWI not relevant to the present document, is available online. Disclosure information for the Task Force is also available online.The work of the writing committee was supported exclusively by the ACC and the AHA without commercial support. Members of the writing committee volunteered their time for this effort. Meetings of the writing committee were confidential and attended only by writing committee members and staff from the ACC, AHA, and the Heart Failure Society of America, which served as a collaborator on this project.2. Methodology2.1. Literature ReviewIn developing the updated heart failure measure set, the writing committee reviewed evidence-based guidelines and statements that would potentially impact the construct of the measures. The clinical practice guidelines and scientific statements that most directly contributed to the development of these measures are shown in Table 3.Table 3. Associated ACC/AHA Clinical Practice Guidelines and Other Clinical Guidance DocumentsClinical Practice Guidelines 2017 ACC/AHA/HFSA heart failure guideline update4 2016 ESC heart failure diagnosis and treatment guidelines8 2013 ACCF/AHA heart failure clinical practice guideline7 2017 AHA/ACC/HRS ventricular arrhythmias and prevention of sudden cardiac death guideline9Performance Measures 2011 ACCF/AHA/PCPI heart failure performance measurement set3 2018 ACC/AHA performance measures for cardiac rehabilitation6 2017 ACC expert consensus decision pathway for optimization of heart failure treatment10ACC indicates American College of Cardiology; ACCF, American College of Cardiology Foundation; AHA, American Heart Association; ESC, European Society of Cardiology; HFSA, Heart Failure Society of America; HRS, Heart Rhythm Society; and PCPI, Physician Consortium for Performance Improvement.2.2. Definition and Selection of MeasuresThe writing committee considered a number of additional factors, which are listed in Table 4. The potential impact, appropriateness for public reporting and pay for performance, validity, reliability, and feasibility were considered. The writing committee examined available information on current gaps in care. The term “heart failure” refers to stage C or D heart failure unless otherwise stated.4Table 4. ACC/AHA Task Force on Performance Measures: Attributes for Performance Measures111. Evidence Based High-impact area that is useful in improving patient outcomesa) For structural measures, the structure should be closely linked to a meaningful process of care that, in turn, is linked to a meaningful patient outcome.b) For process measures, the scientific basis for the measure should be well established, and the process should be closely linked to a meaningful patient outcome.c) For outcome measures, the outcome should be clinically meaningful. If appropriate, performance measures based on outcomes should adjust for relevant clinical characteristics through the use of appropriate methodology and high-quality data sources.2. Measure Selection Measure definitiona) The patient group to whom the measure applies (denominator) and the patient group for whom conformance is achieved (numerator) are clearly defined and clinically meaningful. Measure exceptions and exclusionsb) Exceptions and exclusions are supported by evidence. Reliabilityc) The measure is reproducible across organizations and delivery settings. Face validityd) The measure appears to assess what it is intended to. Content validitye) The measure captures most meaningful aspects of care. Construct validityf)The measure correlates well with other measures of the same aspect of care.3. Measure Feasibility Reasonable effort and costa)The data required for the measure can be obtained with reasonable effort and cost. Reasonable time periodb)The data required for the measure can be obtained within the period allowed for data collection.4. Accountability Actionablea)Those held accountable can affect the care process or outcome. Unintended consequences avoidedb)The likelihood of negative, unintended consequences with the measure is low.Reproduced with permission from Thomas et al.6 Copyright © 2018, American Heart Association, Inc., and American College of Cardiology Foundation.ACC indicates American College of Cardiology; and AHA, American Heart Association.3. ACC/AHA Heart Failure Measure Set3.1. Discussion of Changes to 2011 Heart Failure Measure SetAfter reviewing the existing clinical practice guidelines, and the 2011 ACCF/AHA/PCPI heart failure performance measurement set,3 the writing committee discussed which measures required revision to reflect updated science related to heart failure and identified which guideline recommendations could serve as the basis for new performance or quality measures. The writing committee also reviewed existing publicly available measure sets.These subsections serve as a synopsis of the revisions that were made to previous measures and a description of why the new measures were created for both the inpatient and outpatient setting.3.1.1. Retired MeasuresThe writing committee decided to retire the left ventricular ejection fraction assessment measure used in the inpatient setting due to >97% of use12 (Table 5). Left ventricular ejection fraction assessment in the outpatient setting was retained.Table 5. Retired Heart Failure Measures From the 2011 Set3Measure No.Care SettingMeasure TitleRationale for Retiring the Measure2InpatientLVEF assessmentInpatient documentation of LVEF is at >97%.12LVEF indicates left ventricular ejection fraction.3.1.2. Revised MeasuresThe writing committee reviewed and made changes to the patient self-care education, angiotensin-converting enzyme inhibitor or angiotensin receptor blocker therapy for left ventricular systolic dysfunction, and postdischarge appointment measures, as summarized in Table 6. Table 6 provides information on the updated measures including the care setting, title, and a brief rationale for revisions made to the measures.Table 6. Revised Heart Failure MeasuresMeasure No.Measure TitleDescription of RevisionRationale for Revision5Patient self-care educationMoved from Performance Measure to Quality MeasureConcern regarding the accuracy of self-care education documentation; limited evidence of improved outcomes with better documentation.7ACE inhibitor or ARB therapy for LVSDAdded ARNI2017 ACC/AHA/HFSA heart failure guideline update4 made this revision to the recommendation.9Postdischarge appointmentMoved from Performance Measure to Quality Measure and included a time limit of 7 d2013 ACCF/AHA heart failure clinical practice guideline7 lists postdischarge appointment from 7-14 d as a Class 2a recommendation.ACC indicates American College of Cardiology; ACE, angiotensin–converting enzyme; AHA, American Heart Association; ARB, angiotensin receptor blocker; ARNI, angiotensin receptor–neprilysin inhibitor; HF, heart failure; and LVSD, left ventricular systolic dysfunction.3.1.3. New MeasuresThe writing committee created 7 new performance measures (PM 6-11, 13), 2 quality measures (QM 2, 3), and 1 structural measure (SM-1) (Table 7). Six of the new performance measures were based on Class 1 guideline recommendations for therapies known to prolong survival. An additional performance measure (PM-10, measurement of potassium after a mineralocorticoid receptor antagonist prescription) is also guideline recommended and included as a safety measure to accompany prescription for mineralocorticoid receptor antagonist (PM-9). Two new measures based on dose were created (PM-7 and PM-8). These were chosen because of the gap between doses used in practice and those shown to provide survival benefit in clinical trials. They were designed to apply only to those patients without demonstrated intolerance at higher doses.Table 7. New Heart Failure MeasuresMeasure No.Care SettingMeasure TitleRationale for Creating New MeasureRationale for Designating as a Quality Measure Versus a Performance MeasurePM-6Outpatient, InpatientARNI therapy for HFrEFImportant outcome benefit with large existing gap in careN/APM-7OutpatientDose of beta-blocker therapy for HFrEFImportant outcome benefit and large existing gap in careN/APM-8OutpatientDose of ACE inhibitor, ARB, or ARNI therapy for HFrEFImportant outcome benefit and large existing gap in careN/APM-9Outpatient, InpatientMRA therapy for HFrEFImportant outcome benefit and large existing gap in careN/APM-10Outpatient, InpatientLaboratory monitoring in new MRA therapyImportant outcome benefit and large existing gap in careN/APM-11Outpatient, InpatientHydralazine/isosorbide dinitrate therapy for HFrEF in those self-identified as Black or African AmericanImportant outcome benefit and large existing gap in careN/APM-13OutpatientCRT implantation for patients with HFrEF on guideline-directed medical therapyImportant outcome benefit and large existing gap in careN/AQM-2OutpatientMeasurement of patient-reported, outcome-health statusImportant outcome that is rarely measuredBest method of implementation is unclearQM-3OutpatientSustained or improved health status in heart failureImportant outcome that is rarely measuredNeeds validated risk-adjustmentSM-1Outpatient, InpatientHeart failure registry participationRegistries are a useful structure for measuring performanceAdditional data needed to determine the impact of registry participation on qualityACE indicates angiotensin–converting enzyme; ARB, angiotensin receptor blocker; ARNI, angiotensin receptor–neprilysin inhibitor; CRT, cardiac resynchronization therapy; HFrEF, heart failure with reduced ejection fraction; MRA, mineralocorticoid receptor antagonists; N/A, not applicable; PM, performance measure; QM, quality measure; and SM, structural measure.For more detailed information on each measure’s construct, refer to the specifications in Appendix A.4. Areas for Further ResearchThere are multiple ways that cardiac rehabilitation and exercise prescriptions can be implemented.13 Further studies are needed to determine if there are differences in the magnitude of outcome improvements by approach. Similarly, although patient-reported outcomes are considered an important metric, the best way to measure these needs additional research. Two surveys are well validated: The Kansas City Cardiomyopathy Questionnaire14 and the Minnesota Living with Heart Failure Questionnaire.15 However, risk-adjustment is required to fairly compare groups for use as an outcome measure. The collection of the measure (process of care) does not require risk-adjustment but will benefit from additional research to understand optimal timing of collection of patient-reported outcomes, including frequency and relation to the clinic visit. Finally, data supporting sodium-glucose cotransporter-2 inhibitors are emerging for heart failure treatment; however, with additional trials ongoing and having not been integrated into guideline recommendations at the time of generation of the measure set, the writing committee was unable to include them in the measure set.ACC