Measure Description: Percentage of patients age ≥18 y with a diagnosis of heart failure with current LVEF ≤35% despite ACE inhibitor, ARB, or ARNI and beta-blocker therapy for at least 3 mo who were counseled regarding ICD implantation as a treatment option for the prophylaxis of sudden death
Numerator	Patients who were counseled* regarding ICD implantation as a treatment option for the prophylaxis of sudden death *Counseling should be specific to each individual patient and include documentation of a discussion regarding the risk of sudden and non-sudden death and the efficacy, safety, and risks of an ICD. This will allow patients to be informed of the risks and benefits of ICD implantation and better able to make decisions based on the valuation of sudden cardiac death versus other risks.
Denominator	All patients age ≥18 y with a diagnosis of heart failure with current LVEF ≤35% despite ACE inhibitor, ARB, or ARNI and beta-blocker therapy for at least 3 mo
Denominator Exclusions	Functional ICD in situ Heart transplant LVAD
Denominator Exceptions	Documentation of medical reason(s) for not providing counseling regarding ICD implantation as a treatment option for the prophylaxis of sudden death (e.g., significant comorbidities, limited life expectancy, up titration of medical therapy is ongoing with anticipated LVEF improvement)
Measurement Period	12 mo
Sources of Data	EHR data Administrative data/claims (inpatient or outpatient claims) Administrative data/claims expanded (multiple sources) Paper medical record
Attribution	Individual practitioner Facility
Care Setting	Outpatient
Rationale
ICDs prevent sudden death due to ventricular tachyarrhythmias in select patients with HFrEF (7). However, frequent or inappropriate shocks from an ICD can lead to reduced quality of life. Patients may differ in the willingness to have an ICD implanted based on their preferences for quality and length of life. Given the significant risks and benefits of ICD implantation, eligible patients should be fully informed of this treatment option (7). Among 21,059 patients from 236 sites in the GWTG Registry, 23% received predischarge ICD counseling. Women were counseled less frequently than men, and racial and ethnic minorities were less likely to receive counseling than White patients (80).
Clinical Recommendation(s)
2013 ACCF/AHA heart failure clinical practice guideline (7) 1. ICD therapy is recommended for primary prevention of SCD to reduce total mortality in selected patients with nonischemic DCM or ischemic heart disease at least 40 days post-MI with LVEF of 35% or less and NYHA class II or III symptoms on chronic GDMT, who have reasonable expectation of meaningful survival for more than 1 year (81,82).† (Class 1, Level of Evidence: A) †Counseling should be specific to each individual patient and should include documentation of a discussion about the potential for sudden death and non-sudden death from HF or noncardiac conditions. Information should be provided about the efficacy, safety, and potential complications of an ICD and the potential for defibrillation to be inactivated if desired in the future, notably when a patient is approaching end of life. This will facilitate shared decision-making among patients, families, and the medical care team about ICDs (83). 2017 AHA/ACC/HRS ventricular arrhythmias and prevention of sudden cardiac death guideline (9) 1. Patients considering implantation of a new ICD or replacement of an existing ICD for a low battery should be informed of their individual risk of SCD and non-sudden death from HF or noncardiac conditions and the effectiveness, safety, and potential complications of the ICD in light of their health goals, preferences, and values (84–88). (Class 1, Level of Evidence: B-NR)

ACC indicates American College of Cardiology; ACCF, American College of Cardiology Foundation; ACE, angiotensin–converting enzyme; AHA, American Heart Association; ARB, angiotensin receptor blocker; ARNI, angiotensin receptor–neprilysin inhibitor; DCM, dilated cardiomyopathy; EHR, electronic health record; GWTG, Get With The Guidelines; GDMT, guideline-directed medical therapy; HF, heart failure; HFrEF, heart failure reduced ejection fraction; HRS, Heart Rhythm Society; ICD, implantable cardioverter-defibrillator; LVAD, left ventricular assist device; LVEF, left ventricular ejection fraction; MI, myocardial infarction; NYHA, New York Heart Association; PM, performance measure; and SCD, sudden cardiac death.