Measure Description: Percentage of patients age ≥18 y with a diagnosis of heart failure with a current or prior LVEF ≤40% who were prescribed a guideline-recommended beta blocker (e.g., bisoprolol, carvedilol, or sustained-release metoprolol succinate) at a dose that is at least 50% of the target dose (see Table A for target doses)
Numerator	Patients who were prescribed a guideline-recommended beta blocker at a dose that is at least 50% of the target dose (see Table A for target doses)
Denominator	All patients age ≥18 y with a diagnosis of heart failure with a current or prior LVEF ≤40% who were prescribed a recommended beta blocker
Denominator Exclusions	Heart transplant LVAD
Denominator Exceptions	Documentation of intolerance of higher dose or medical reason(s) for not prescribing higher dose of beta blocker Documentation of patient reason(s) for not prescribing higher dose of beta blocker Documentation of system reason(s) for not prescribing higher dose of beta blocker
Measurement Period	Annually
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
Use of guideline-recommended beta blockers has been proven to reduce morbidity and mortality in patients with HFrEF, and studies have supported a dose-response relationship of beta blockers with improved outcomes (59–64). These findings suggest that, among HFrEF patients in whom target doses might be well tolerated, treating at less than the target dose may result in worse clinical outcomes. Despite guideline recommendations for clinicians to achieve target doses of beta blockers shown to be effective in major clinical trials, the percentage of patients achieving these doses is low and remains low over time (20,65,66). Treatment with a beta blocker should be initiated at very low doses, followed by gradual incremental increases in dose if lower doses have been well tolerated. Clinicians should make every effort to achieve the target doses of the beta blockers shown to be effective in major clinical trials (7).
Clinical Recommendation(s)
2013 ACCF/AHA heart failure clinical practice guideline (7) 1. Use of 1 of the 3 beta blockers proven to reduce mortality (e.g., bisoprolol, carvedilol, and sustained-release metoprolol succinate) is recommended for all patients with current or prior symptoms of HFrEF, unless contraindicated, to reduce morbidity and mortality (32–37). (Class 1, Level of Evidence: A) 2017 ACC expert consensus decision pathway for optimization of heart failure treatment (10) 1. After a diagnosis of heart failure is made, GDMT should be initiated and therapies should be adjusted no more frequently than every 2 weeks to target doses (or maximally tolerated doses). 2. To achieve the maximal benefits of GDMT in patients with chronic HFrEF, therapies must be initiated and titrated to maximally tolerated doses (33,45,60,67).

ACC indicates American College of Cardiology; ACCF, American College of Cardiology Foundation; AHA, American Heart Association; EHR, electronic health record; GDMT, guideline-directed medical therapy; HFrEF, heart failure reduced ejection fraction; LVAD, left ventricular assist device; LVEF, left ventricular ejection fraction; and PM, performance measure.