Measure Description
Percentage of isolated Coronary Artery Bypass Graft (CABG) surgeries for patients aged 18 years and older who received a beta-blocker within 24 hours prior to surgical incision.
Instructions
This measure is to be submitted each time an isolated CABG procedure is performed during the performance period. It is anticipated that Merit-based Incentive Payment System (MIPS) eligible clinicians who provide services for isolated CABG will submit this measure. The timeframe for this measure includes the entire 24 hour period prior to the surgical incision time.
Measure Submission Type:
Measure data may be submitted by individual MIPS eligible clinicians, groups, or third-party intermediaries. The listed denominator criteria are used to identify the intended patient population. The numerator options included in this specification are used to submit the quality actions as allowed by the measure. The quality-data codes listed do not need to be submitted by MIPS eligible clinicians, groups, or third-party intermediaries that utilize this modality for submissions; however, these codes may be submitted for those third-party intermediaries that utilize Medicare Part B claims data. For more information regarding Application Programming Interface (API), please refer to the Quality Payment Program (QPP) website.
Denominator
Isolated CABG surgeries for patients aged 18 years and older.
Definition:
Isolated CABG – Refers to CABG using arterial and/or venous grafts only
Denominator Criteria (Eligible Cases):
Patients aged ≥ 18 years on date of encounter
AND
Patient procedure during the performance period (CPT): 00566, 00567, 33510, 33511, 33512, 33513, 33514, 33516, 33533, 33534, 3535, 33536
OR
Patient procedure during the performance period (CPT): 33510, 33511, 33512, 33513, 33514, 33516, 33533, 33534, 33535, 33536
AND
Patient procedure during the performance period (CPT): 33530
Numerator
Patients who received a beta-blocker within 24 hours prior to surgical incision of isolated CABG surgeries
Definition:
Medical Reason – MIPS Eligible clinician must document specific reason(s) for not administering beta- blockers.
NUMERATOR NOTE: Denominator Exception(s) are determined on the date of the denominator eligible encounter.
Numerator Options:
Performance Met: Beta blocker administered within 24 hours prior to surgical incision (4115F)
OR
Denominator Exception: Documentation of medical reason(s) for not administering beta blocker within 24 hours prior to surgical incision (e.g., not indicated, contraindicated, other medical reason) (4115F with 1P)
OR
Performance Not Met: Beta blocker not administered within 24 hours prior to surgical incision, reason not otherwise specified (4115F with 8P)
Rationale
“Continued adherence to the current ACC/AHA guidelines regarding preoperative beta-blockade in CABG surgery, together with good medical judgement, is advisable. Important considerations include perioperative continuation of beta- blockade in patients receiving long term therapy and administration and titration of beta-blockers to optimal heart rate and blood pressure in beta-blocker naïve patients, initiated as long before surgery as possible (preferably weeks before in elective patients)” (JAMA Internal Medicine, August 2014, Volume 174, Number 8).
“Despite significant developments in PCI, CABG remains the most commonly used treatment option for patients with complex CAD and high-risk patients” (El Bardissi et al., 2012, p.274).
Postoperative atrial fibrillation (POAF) is a common complication following cardiac surgery, occurring in 25-40% of patients (Crystal, 2004, Burgess, 2006). POAF has been associated with increased rates of post-operative morbidity such as cerebrovascular accidents (CVA), infections (e.g. septicemia, pneumonia, and mediastinitis), renal failure and mortality and consequently, increased costs (Mariscalco, 2008, Crystal, 2004, Bramer, 2010).
“Postoperative AF after cardiac operations is associated with postoperative morbidities such as cerebrovascular accidents (CVA), infections (e.g., septicemia, pneumonia and mediastinitis), and renal failure. Previous studies have suggested that POAF after CABG is related to early and late mortality” (Bramer et al., 2010, p.443). “Development of AF immediately after coronary artery bypass surgery (CABG) results in a longer stay in the intensive care unit and in hospital, together with a significantly higher (two-to three-fold) risk of post-operative stroke” (Burgess et al., 2006, p.2846).
Prophylactic administration of beta-blockers has been shown to reduce the risk of POAF and mortality following isolated coronary artery bypass graft surgery (Connolly, 2003, Mariscalco, 2008, Ferguson, 2002). Khan’s meta-analysis of RCTs (2013) found that "Preoperative beta-blocker prophylaxis initiation resulted in 51% reduction in the incidence of AF as compared to controls, however these results were not statistically significant” (p.62-63). Thaper and Kulik’s systemic review (2018) found that “prophylactic beta-blocker therapy reduces the risk of new-onset atrial fibrillation in the postoperative period by 50%, justifying their administration to nearly all patients undergoing CABG.”
"According to our findings, perioperative application of beta-blockers still plays a pivotal role in cardiac surgery, as they can substantially reduce the high burden of supraventricular and ventricular arrhythmias in the aftermath of surgery. Their influence on mortality, AMI, stroke, congestive heart failure, hypotension and bradycardia in this setting remains unclear” (Blessberger et al., 2014, p.3). Recent studies (Kohsaka et al. 2016, Brinkman et al. 2014) researched the use of preoperative beta-blockers and concluded the use of beta-blockers did not improve outcomes.
The Brinkman study concluded “Preoperative beta-blocker use among patients undergoing nonemergent CABG surgery who have not had a recent myocardial infarction was not associated with improved perioperative outcomes” (p.1320). The Kohsaka research concluded “in a propensity-matched, balanced cohort of CABG patients, the use of betablockers was not associated with decreased mortality or in-hospital complications, regardless of the patient’s preoperative risk profile. The present findings suggest that preoperative β-blocker use in patients undergoing CABG is not associated with improved short-term outcomes” (p.53).
A scientific statement by the AHA in 2015 continues to support the use of perioperative beta-blockers in patients undergoing CABG surgery. See Clinical Recommendation Statements for recommendation and grade.
Clinical Recommendation Statements
Secondary Prevention After Coronary Artery Bypass Graft Surgery: A Scientific Statement From the American Heart Association (2015)
Beta-Blocker Therapy Recommendations
1. All CABG patients should be prescribed perioperative beta-blocker therapy to prevent postoperative AF, ideally starting before surgery, unless contraindicated (i.e., bradycardia, severe reactive airway disease) (Class I; Level of Evidence A).
Preoperative Beta-blockers (ACCF/AHA, 2011):
Class I
1) Beta-blockers should be administered as soon as possible, and for at least 24 hours before CABG to all patients without contraindications to reduce the incidence or clinical sequelae of postoperative AF. (Level of Evidence: B), (ACCF/AHA, 2011, p.e152)
Class IIa
1) “Preoperative use of beta-blockers in patients without contraindications, particularly in those with an LV ejection fraction (LVEF) greater than 30%, can be effective in reducing the risk of in-hospital mortality.” (Level of Evidence: B), (ACCF/AHA, 2011, p.e152)
2) “Beta-blockers can be effective in reducing the incidence of perioperative myocardial ischemia.” (Level of Evidence: B), (ACCF/AHA, 2011, p.e152)
Class IIb
1) “The effectiveness of preoperative beta-blockers in reducing in-hospital mortality rate in patients with LVEF less than 30% is uncertain.” (Level of Evidence: B), (ACCF/AHA, 2011, p.e152)
Treatment of arrhythmias after revascularization (ESC/EACTS, 2014)
Class I
1) “Beta-blockers are recommended to decrease the incidence of atrial fibrillation after CABG in the absence of contraindications.” (Level of Evidence: A), (ESC/EACTS, 2014, p.146)