Description:

HEART FAILURE DATA COLLECTION Version 1.1.4 Revised October 31st, 2017 www.ichom.org Notice: This work was conducted using resources from ICHOM, the International Consortium for Health Outcomes Measurement (www.ICHOM.org). The content is solely the responsibility of the authors and does not necessarily represent the official views of ICHOM. Conditions: Heart Failure Treatment Approaches: Pharmacotherapy | Invasive Therapy | Rehabilitation This ODM-file contains baseline characteristics. It should be filled in at the time of the index event. The index event represents the entry into the set. This could either be after diagnosis/first encounter in an outpatient setting, or at discharge from hospital if the initial presentation was severe enough to require admission. Use of the following Scores for this standard set: KCCQ-12: Kansas City Cardiomyopathy Questionnaire-Short Version: You can obtain a license to use this instrument at your institution by visiting http://cvoutcomes.org/licenses NYHA – New York Heart Association Functional Classification: The NYHA is free for all health care organizations, and a license is not needed. PROMIS Physical Function Short Form 4a – Patient-Reported Outcome Measurement Information System: PROMIS Physical Function is free for all health care organizations, and a license is not needed. For more information, please visit http://www.healthmeasures.net/explore-measurement-systems/promis/obtain-administer-measures . As http://www.nihpromis.org/ is the official distribution site for PROMIS questionnaires and translations, only the total score will be included in this version of the standard set. Patient Health Questionnaire (PHQ-2): Copyright by Pfizer: "content found on the PHQ Screeners site is free for download and use as stated within the PHQ Screeners site, please visit http://www.phqscreeners.com/ for more information. ICHOM was supported for the Heart Failure Standard Set by GIG Cymru NHS Wales, American Heart Association, British Heart Foundation, Heart Failure Association of the ESC and European Society of Cardiology. Publication: Burns DJP, Arora J, Okunade O, Beltrame JF, Bernardez-Pereira S, Crespo-Leiro MG, et al. International Consortium for Health Outcomes Measurement (ICHOM): Standardized Patient-Centered Outcomes Measurement Set for Heart Failure Patients. JACC: Heart Failure. 2020 Mar 1;8(3):212–22. For this version of the standard set, semantic annotation with UMLS CUIs has been added.

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www.ichom.org

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Versions (2) ▾
  1. 11/16/18
  2. 4/30/20
Copyright Holder:
ICHOM
Uploaded on:

April 30, 2020

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License:
Creative Commons BY-NC 4.0
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Baseline Characteristics, at time of index event

Patient ID
Demographic Factors
DD/MM/YYYY
Please provide the patient's sex at birth
What is your ethnicity (Select all that apply) 0 = American Indian or Alaska Native
What is your ethnicity (Select all that apply) 1 = Asian
What is your ethnicity (Select all that apply) 2 = Black or African American
What is your ethnicity (Select all that apply) 3 = Hispanic or Latino
What is your ethnicity (Select all that apply) 4 = Native Hawaiian or Other Pacific Islander
What is your ethnicity (Select all that apply) 5 = White
What is your ethnicity (Select all that apply) 6 = other or 999=unknown (only fill out, if none of the above)
Baseline health status
Indicate units of height
Indicate units of weight
Have you ever been told by your doctor that you have atrial fibrillation?
Have you ever been told by your doctor that you've had a heart attack (this is sometimes called a myocardial infarction, or MI)?
Do you currently smoke, or have you smoked cigarettes or tobacco over the past year?
Do you drink more than one alcoholic drink a day?
Indicate whether the patient has a documented history of hypertension, diagnosed and treated with medication and/or diet and/or exercise
Have you ever been told by your doctor that you have diabetes?
Indicate whether the patient has a chronic lung disease
Indicate whether the patient has a diagnosis of renal dysfunction
Indicate whether an echocardiogram was performed to assess ejection fraction
If "1 = yes" to ECHOPERF, please state range of patient’s ejection fraction:
Please indicate diagnostic categories: 1 = Ischaemic
Please indicate diagnostic categories: 2 = Hypertensive
Please indicate diagnostic categories: 3 = Valvular
Please indicate diagnostic categories: 4 = Familial
Please indicate diagnostic categories: 5 = Peripartum
Please indicate diagnostic categories: 6 = Myocarditis/Inflammatory
Please indicate diagnostic categories: 7 = Infiltrative
Please indicate diagnostic categories: 8 = Stress/Takotsubo
Please indicate diagnostic categories: 9 = Chagas Disease
Please indicate diagnostic categories: 10 = Idiopathic/Other
Please indicate diagnostic categories: 999 = Unknown
Treatment variables
Indicate whether the patient is currently being prescribed medication for heart failure
Indicate whether ACE inhibitors are currently prescribed for heart failure
Indicate whether Angiotensin Receptor II Blockers are currently prescribed for heart failure
Indicate whether an Angiotensin Receptor Blocker/Neprilysin Inhibitor combination is currently prescribed for heart failure
Indicate whether Beta Blockers are currently prescribed for heart failure
Indicate whether Calcium Channel Blockers are currently prescribed for heart failure
Indicate whether Digoxin is currently prescribed for heart failure
Indicate whether Diuretics are currently prescribed for heart failure
Indicate whether Hydralazine and Isosorbide Dinitrate are currently prescribed for heart failure
Indicate whether Ivabradine is currently prescribed for heart failure
Indicate whether Mineralocorticoid Receptor Antagonists are currently prescribed for heart failure
Indicate whether other medications are currently prescribed for heart failure
Did the patient receive a cardiac device to treat heart failure?
Indicate the device type
DD/MM/YYYY
Did the patient undergo cardiac surgery?
Indicate the cardiac surgery type
DD/MM/YYYY
Has cardiac rehabilitation been initiated?
Burden of Care
Did the patient’s appointment or admission have any complications which were related to a device for Heart Failure including, but not exclusively: active bleeding requiring exploration and/or transfusion, abscess related to the device, minor infection (localized, treated with antibiotics and surgical drainage) related to the device, major infection (systemic, requiring device explant) related to the device, minor malfunction (requiring follow-up appointment/reprogramming), and/or major malfunction (requiring explant or revision)?
DD/MM/YYYY
Did the patient have a major healthcare-associated infection (requiring IV antibiotics and/or prolonged hospital stay – 14 days or more) during this admission?
DD/MM/YYYY
Did the patient have a major adverse event related to Heart Failure medication during this admission, and/or as a cause of this admission?
DD/MM/YYYY