Measure Description: Percentage of patient visits for those patients age ≥18 y with a diagnosis of heart failure with quantitative results of an evaluation of both current level of activity and clinical symptoms documented
Numerator	Patient visits with quantitative results of an evaluation of both current level of activity and clinical symptoms documented* *Evaluation and quantitative results documented can include: Documentation of NYHA class or Documentation of completion of a valid, reliable, disease-specific instrument (e.g., KCCQ or MLHFQ) Numerator Definitions/Instructions: The NYHA functional classification reflects a subjective assessment by a healthcare provider of the severity of a patient’s symptoms. Patients are assigned to one of the following classes: Class I: Patients with cardiac disease but without resulting limitation of physical activity. Ordinary physical activity does not cause undue fatigue, palpitation, dyspnea, or anginal pain. Class II: Patients with cardiac disease resulting in slight limitation of physical activity. They are comfortable at rest. Ordinary physical activity results in fatigue, palpitation, dyspnea, or anginal pain. Class III: Patients with marked limitation of physical activity. They are comfortable at rest. Less than ordinary activity causes fatigue, palpitation, dyspnea, or anginal pain. Class IV: Patients with cardiac disease resulting in inability to carry on any physical activity without discomfort. Symptoms of heart failure or of the anginal syndrome may be present even at rest. If any physical activity is undertaken, discomfort is increased. Patient-reported health status as assessed by a structured survey/questionnaire instrument offers another, more patient-centric approach to assessing and summarizing the patient’s overall heart failure symptom burden. These instruments serve as important constructs for delivering and evaluating heart failure care.
Denominator	All patient visits for those patients age ≥18 y with a diagnosis of heart failure
Denominator Exclusions	Heart transplant LVAD
Denominator Exceptions	Documentation of medical reason(s) for not evaluating both current level of activity and clinical symptoms (e.g., severe cognitive or functional impairment) Documentation of patient reason(s) for not evaluating both current level of activity and clinical symptoms
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
Initial and ongoing evaluations of patients with heart failure should include an assessment of symptoms and their functional consequences. These assessments serve as the basis for making treatment decisions, monitoring the effects of treatment, and modifying treatment as appropriate. Decreasing symptoms and improving function are 2 of the primary goals of heart failure treatment and represent important patient-centric outcomes for heart failure care. The ACC/AHA have not addressed PRO tool selection. However, the FDA has provided guidelines for an appropriate PRO tool (16) and, currently, 2 heart failure survey tools–the MLHFQ (15) and the KCCQ (14)–are considered qualified tools for FDA device use in heart failure (17).
Clinical Recommendation(s)
2013 ACCF/AHA heart failure clinical practice guideline (7) 1. A thorough history and physical examination should be obtained/performed in patients presenting with HF to identify cardiac and noncardiac disorders or behaviors that might cause or accelerate the development or progression of HF. (Class 1, Level of Evidence: C) 2. The NYHA functional classification gauges the severity of symptoms in those with structural heart disease. Although reproducibility and validity may be problematic (18), the NYHA functional classification is an independent predictor of mortality (19). It is widely used in clinical practice and research and for determining the eligibility of patients for certain healthcare services (7). However, NYHA functional class assessment is not reported in a significant number of patients in contemporary HF practices in the United States (20). 3. Evaluate general health status (see Figure 2, 2013 ACCF/AHA guideline) (7). Although no specific 2013 ACCF/AHA guideline recommendation is made regarding collection of NYHA or other quantitative result, knowledge of symptom status is needed to determine candidacy for appropriate HF treatments (7).

ACC indicates American College of Cardiology; ACCF, American College of Cardiology Foundation; AHA, American Heart Association; EHR, electronic health record; FDA, U.S. Food and Drug Administration; HF, heart failure; KCCQ, Kansas City Cardiomyopathy Questionnaire; LVAD, left ventricular assist device; MLHFQ, Minnesota Living with Heart Failure Questionnaire; NYHA, New York Heart Association; PM, performance measure; and PRO, patient-reported outcome.