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Angiotensin Converting Enzyme (ACE) Inhibitor or Angiotensin Receptor Blocker (ARB) Therapy

CBE ID
1662
Endorsement Status
E&M Committee Rationale/Justification
  • Evaluate why the measure is not widely used and develop implementation guidance to support use of the measure. 
  • Conduct empirical validity testing at the entity level for both reliability and validity.
1.0 New or Maintenance
Previous Endorsement Cycle
Is Under Review
No
Next Maintenance Cycle
Fall 2028
1.6 Measure Description

Percentage of patients aged 18 years and older with a diagnosis of chronic kidney disease (CKD) (Stages 1-5, not receiving Renal Replacement Therapy (RRT)) and proteinuria who were prescribed ACE inhibitor or ARB therapy within a 12-month period.

 

This measure is NQF Measure 1662/MIPS Measure 489.

Measure Specs
General Information
1.7 Measure Type
1.7 Composite Measure
No
1.3 Electronic Clinical Quality Measure (eCQM)
1.8 Level of Analysis
1.9 Care Setting
1.10 Measure Rationale

This measure is aimed at increasing the number of patients with CKD and proteinuria who are prescribed ACE inhibitor or ARB therapy. ACE inhibitors and ARBs are preferred agents for diabetic kidney disease and nondiabetic kidney diseases with proteinuria (albuminuria), even in the absence of hypertension. In these diseases, ACE inhibitors and ARBs lower blood pressure, reduce proteinuria (albuminuria), slow the progression of kidney disease, and likely reduce cardiovascular disease risk by mechanisms in addition to lowering blood pressure. These benefits have been shown across high quality, multi-center, randomized controlled trials such as RENAAL (Reduction of Endpoints in NIDDM with the Angiotensin II Antagonist Losartan) (Brenner et al., New England Journal of Medicine, 2001). A meta-analysis of randomized trials showed that ACEi/ARB therapy lowered the odds of kidney failure (also known as end-stage renal disease [ESRD]) by 30-39 percent and of cardiovascular disease events by 18 percent-24 percent (Xie et al., Am J Kidney Dis, 2016). In a meta-analysis including primarily diabetic patients with proteinuria, use of ACEi/ARB therapy had a 0.36 to 0.78 odds of incident kidney failure (Cai et al., Nephrology, dialysis, transplantation, 2018). Similarly, in a Cochrane meta-analysis, patients with early (stage 1 to 3) non-diabetic CKD who were treated versus not treated with ACEi/ARB had 31 percent lower risk of kidney failure (Jafar et al., Annals of internal medicine, 2001). Based upon this robust evidence, ACE inhibitors and ARBs are recommended for patients with CKD and proteinuria by the Kidney Disease: Improving Global Outcomes (KDIGO) international guidelines and the Kidney Disease Outcomes Quality Initiative.

 

CKD is a major public health problem; a total of 37 million Americans have CKD. There is a clear performance gap in ACE inhibitor and ARB usage among patients with CKD, with only 40 percent of CKD patients receiving an ACEi/ARB in NHANES data (Murphy et al., JASN, 2019). Population health efforts to increase the use of ACEi/ARB in American Indians and Alaska Natives have been associated with a decrease in incident kidney failure related to diabetic kidney disease (Bullock et al., MMWR Morbidity and mortality weekly report, 2017). In summary, this measure is a central component of high-quality nephrology care, as ACE inhibitors and ARBs decrease the rate of kidney failure, cardiovascular outcomes, and mortality in patients with CKD and proteinuria.

 

References:

Brenner BM, Cooper ME, de Zeeuw D, Keane WF, Mitch WE, Parving HH, Remuzzi G, Snapinn SM, Zhang Z, Shahinfar S, et al. Effects of losartan on renal and cardiovascular outcomes in patients with type 2 diabetes and nephropathy. N Engl J Med. 2001;345(12):861–9.

 

Xie X, Liu Y, Perkovic V, Li X, Ninomiya T, Hou W, Zhao N, Liu L, Lv J, Zhang H, Wang H. Renin-Angiotensin System Inhibitors and Kidney and Cardiovascular Outcomes in Patients With CKD: A Bayesian Network Meta-analysis of Randomized Clinical Trials. Am J Kidney Dis. 2016 May;67(5):728-41. doi: 10.1053/j.ajkd.2015.10.011. Epub 2015 Nov 18. PMID: 26597926.

 

Cai J, Huang X, Zheng Z, Lin Q, Peng M, Shen D. Comparative efficacy of individual renin–angiotensin system inhibitors on major renal outcomes in diabetic kidney disease: a network meta-analysis. Nephrol Dial Transplant. 2018; 33(11):1968–1976.  doi: 10.1093/ndt/gfy001

 

Jafar TH, Schmid CH, Landa M, et al. Angiotensin-Converting Enzyme Inhibitors and Progression of Nondiabetic Renal Disease: A Meta-Analysis of Patient-Level Data. Ann Intern Med. 2001;135:73-87. [Epub 17 July 2001]. doi:10.7326/0003-4819-135-2-200107170-00007

 

Murphy DP, Drawz PE, Foley RN. Trends in Angiotensin-Converting Enzyme Inhibitor and Angiotensin II Receptor Blocker Use among Those with Impaired Kidney Function in the United States. J Am Soc Nephrol. 2019 Jul;30(7):1314-1321. doi: 10.1681/ASN.2018100971.

 

Bullock A, Burrows NR, Narva AS, et al. Vital Signs: Decrease in Incidence of Diabetes-Related End-Stage Renal Disease among American Indians/Alaska Natives — United States, 1996–2013. MMWR Morb Mortal Wkly Rep 2017;66:26-32. DOI: 10.15585/mmwr.mm6601e1.

 

1.20 Types of Data Sources
1.25 Data Source Details

Data is contained in patient chart; no specialized collection instrument is needed. Entity will review CPT codes, ICD-10 codes and lab values to calculate the measure.