Use of High-Risk Medications in Older Adults
Compare Versions of: "Use of High-Risk Medications in Older Adults"
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| Measure Information | 2022 Performance Period | 2023 Performance Period | 2024 Performance Period |
|---|---|---|---|
| Title | Use of High-Risk Medications in Older Adults | Use of High-Risk Medications in Older Adults | Use of High-Risk Medications in Older Adults |
| CMS eCQM ID | CMS156v10 | CMS156v11 | CMS156v12 |
| CBE ID | Not Applicable | Not Applicable | Not Applicable |
| MIPS Quality ID | 238 | 238 | 238 |
| Description |
Percentage of patients 65 years of age and older who were ordered at least two high-risk medications from the same drug class. Three rates are reported. 1. Percentage of patients 65 years of age and older who were ordered at least two high-risk medications from the same drug class. 2. Percentage of patients 65 years of age and older who were ordered at least two high-risk medications from the same drug class, except for appropriate diagnoses. 3. Total rate (the sum of the two numerators divided by the denominator, deduplicating for patients in both numerators). |
Percentage of patients 65 years of age and older who were ordered at least two high-risk medications from the same drug class. Three rates are reported. 1. Percentage of patients 65 years of age and older who were ordered at least two high-risk medications from the same drug class. 2. Percentage of patients 65 years of age and older who were ordered at least two high-risk medications from the same drug class, except for appropriate diagnoses. 3. Total rate (the sum of the two numerators divided by the denominator, deduplicating for patients in both numerators). |
Percentage of patients 65 years of age and older who were ordered at least two high-risk medications from the same drug class. Three rates are reported. 1. Percentage of patients 65 years of age and older who were ordered at least two high-risk medications from the same drug class. 2. Percentage of patients 65 years of age and older who were ordered at least two high-risk medications from the same drug class, except for appropriate diagnoses. 3. Total rate (the sum of the two numerators divided by the denominator, deduplicating for patients in both numerators). |
| Definition | *See CMS156v10.html | *See CMS156v11-v2.html |
Index Prescription Start Date (IPSD). The start date of the earliest prescription ordered for a high-risk medication during the measurement period. A high-risk medication is identified by any one of the following: a. A prescription for medications classified as high risk at any dose and for any duration. b. A prescription for medications classified as high risk at any dose with greater than a 90 day supply. c. A prescription for medications classified as high risk exceeding average daily dose criteria. An order is identified by either a prescription order or a prescription refill. |
| Initial Population |
Patients 65 years and older who had a visit during the measurement period |
Patients 65 years and older at the end of the measurement period who had a visit during the measurement period |
Patients 65 years and older at the end of the measurement period who had a visit during the measurement period |
| Numerator |
Rate 1 : Patients with at least two orders of high-risk medications from the same drug class. Rate 2: Patients with at least two orders of high-risk medications from the same drug class (i.e., antipsychotics and benzodiazepines). Total rate (the sum of the two previous numerators, deduplicated). |
Rate 1: Patients with at least two orders of high-risk medications from the same drug class on different days. a. At least two orders of high-risk medications from the same drug class. b. At least two orders of high-risk medications from the same drug class with summed days supply greater than 90 days. c. At least two orders of high-risk medications from the same drug class each exceeding average daily dose criteria. Rate 2: Patients with at least two orders of high-risk medications from the same drug class (i.e., antipsychotics and benzodiazepines) on different days. Total rate (the sum of the two previous numerators, deduplicated). |
Rate 1: Patients with at least two orders of high-risk medications from the same drug class on different days. a. At least two orders of high-risk medications from the same drug class. b. At least two orders of high-risk medications from the same drug class with summed days supply greater than 90 days. c. At least two orders of high-risk medications from the same drug class each exceeding average daily dose criteria. Rate 2: Patients with at least two orders of high-risk medications from the same drug class (i.e., antipsychotics and benzodiazepines) on different days except for appropriate diagnoses. a. Patients with two or more antipsychotic prescriptions ordered on different days, and who did not have a diagnosis of schizophrenia, schizoaffective disorder, or bipolar disorder on or between January 1 of the year prior to the measurement period and the IPSD for antipsychotics. b. Patients with two or more benzodiazepine prescriptions ordered on different days, and who did not have a diagnosis of seizure disorders, rapid eye movement sleep behavior disorder, benzodiazepine withdrawal, ethanol withdrawal, or severe generalized anxiety disorder on or between January 1 of the year prior to the measurement period and the IPSD for benzodiazepines. Total rate (the sum of the two previous numerators, deduplicated). |
| Numerator Exclusions |
Rate 2: For patients with two or more antipsychotic prescriptions ordered, exclude patients who have a diagnosis of schizophrenia, schizoaffective disorder, or bipolar disorder on or between January 1 of the year prior to the measurement period and the Index Prescription Start Date (IPSD) for antipsychotics. For patients with two or more benzodiazepine prescriptions ordered, exclude patients who have a diagnosis of seizure disorders, rapid eye movement sleep behavior disorder, benzodiazepine withdrawal, ethanol withdrawal, or severe generalized anxiety disorder on or between January 1 of the year prior to the measurement period and the IPSD for benzodiazepines. |
Rate 2: For patients with two or more antipsychotic prescriptions ordered, exclude patients who have a diagnosis of schizophrenia, schizoaffective disorder, or bipolar disorder on or between January 1 of the year prior to the measurement period and the IPSD for antipsychotics. For patients with two or more benzodiazepine prescriptions ordered, exclude patients who have a diagnosis of seizure disorders, rapid eye movement sleep behavior disorder, benzodiazepine withdrawal, ethanol withdrawal, or severe generalized anxiety disorder on or between January 1 of the year prior to the measurement period and the IPSD for benzodiazepines. |
Not Applicable |
| Denominator |
Equals Initial Population |
Equals Initial Population |
Equals Initial Population |
| Denominator Exclusions |
Exclude patients who are in hospice care for any part of the measurement period. Exclude patients receiving palliative care during the measurement period. |
Exclude patients who are in hospice care for any part of the measurement period. Exclude patients receiving palliative care for any part of the measurement period. |
Exclude patients who are in hospice care for any part of the measurement period. Exclude patients receiving palliative care for any part of the measurement period. |
| Denominator Exceptions |
None |
None |
None |
| Measure Steward | National Committee for Quality Assurance | National Committee for Quality Assurance | National Committee for Quality Assurance |
| Measure Scoring | Proportion measure | Proportion measure | Proportion measure |
| Measure Type | Process measure | Process measure | Process measure |
| Improvement Notation |
Lower score indicates better quality |
Lower score indicates better quality |
Lower score indicates better quality |
| Guidance |
The intent of the measure is to assess if the patient has been ordered at least two of the same high-risk medication prescriptions from the same medication class on different days. The intent of the measure is to assess if the reporting provider ordered the high-risk medication(s). If the patient had a high-risk medication previously prescribed by another provider, they would not be counted towards the numerator unless the reporting provider also ordered a high-risk medication for them. This eCQM is a patient-based measure.
This version of the eCQM uses QDM version 5.5. Please refer to the eCQI resource center for more information on the QDM. |
The intent of the measure is to assess if the patient has been ordered at least two high-risk medication prescriptions from the same drug class on different days. The intent of the measure is to assess if the reporting provider ordered the high-risk medication(s). If the patient had a high-risk medication previously prescribed by another provider, they would not be counted towards the numerator unless the reporting provider also ordered a high-risk medication from the same drug class for them. Calculate average daily dose for each prescription event. To calculate average daily dose, multiply the quantity of pills prescribed by the dose of each pill and divide by the days supply. For example, a prescription for the 30-days supply of digoxin containing 15 pills, 0.25 mg each pill, has an average daily dose of 0.125 mg. To calculate average daily dose for elixirs and concentrates, multiply the volume prescribed by daily dose and divide by the days supply. Do not round when calculating average daily dose. This eCQM is a patient-based measure.
This version of the eCQM uses QDM version 5.6. Please refer to the QDM page for more information on the QDM. |
The intent of the measure is to assess if the patient has been ordered at least two high-risk medication prescriptions from the same drug class on different days. The intent of the measure is to assess if the reporting provider ordered the high-risk medication(s). If the patient had a high-risk medication previously prescribed by another provider, they would not be counted towards the numerator unless the reporting provider also ordered a high-risk medication from the same drug class for them. Calculate average daily dose for each prescription event. To calculate average daily dose, multiply the quantity of pills prescribed by the dose of each pill and divide by the days supply. For example, a prescription for the 30-days supply of digoxin containing 15 pills, 0.25 mg each pill, has an average daily dose of 0.125 mg. To calculate average daily dose for elixirs and concentrates, multiply the volume prescribed by daily dose and divide by the days supply. Do not round when calculating average daily dose. This eCQM is a patient-based measure.
This version of the eCQM uses QDM version 5.6. Please refer to the QDM page for more information on the QDM. |
| Telehealth Eligible | Yes | Yes | Yes |
| Rationale | *See CMS156v10.html | *See CMS156v11-v2.html |
Certain medications (MacKinnon & Hepler, 2003) are associated with increased risk of harm from drug side-effects and drug toxicity and pose a concern for patient safety. There is clinical consensus that these drugs pose increased risks in older adults (Kaufman, Brodin, & Sarafian, 2005). Potentially inappropriate medication use in older adults has been connected to significantly longer hospital stay lengths and increased hospitalization costs (Hagstrom et al., 2015) as well as increased risk of death (Lau et al., 2004). Use of specific high-risk medications such as hypnotics, including benzodiazepine receptor agonists, and nonsteroidal anti-inflammatory drugs (NSAIDS) can result in increased risk of delirium, falls, fractures, gastrointestinal bleeding and acute kidney injury (Merel et al., 2017). Long-term use of benzodiazepines in older adults has been associated with increased risk of dementia (Zhong et al., 2015; Takada et al., 2016). Additionally, the use of antipsychotics can lead to increased risk of stroke and greater cognitive decline in older adults with dementia (Tampi et al., 2016). Older adults receiving inappropriate medications are more likely to report poorer health status at follow-up, compared to those who receive appropriate medications (Fu, Liu, & Christensen, 2004). A study of the prevalence of potentially inappropriate medication use in older adults found that 40 percent of individuals 65 and older filled at least one prescription for a potentially inappropriate medication and 13 percent filled two or more (Fick et al., 2008). While some adverse drug events (ADEs) are unavoidable, studies estimate that between 30 and 80 percent of ADEs in older adults are preventable (MacKinnon & Hepler, 2003). More recently with the onset of the COVID-19 pandemic, several studies have shown an increase in anxiety, insomnia and depression rates, which could result in an increase in the use of high-risk medications in order to treat these conditions (Agrawal, 2020). Reducing the number of inappropriate prescriptions can lead to improved patient safety and significant cost savings. Conservative estimates of extra costs due to potentially inappropriate medications in older adults average $7.2 billion a year (Fu et al., 2007). Medication use by older adults will likely increase further as the U.S. population ages, new drugs are developed, and new therapeutic and preventive uses for medications are discovered (Rothberg et al., 2008). The annual direct costs of preventable ADEs in the Medicare population have been estimated to exceed $800 million (Institute of Medicine, 2007). By the year 2030, nearly one in five U.S. residents is expected to be aged 65 years or older; this age group is projected to more than double from 38.7 million in 2008 to more than 88.5 million in 2050. Likewise, the population aged 85 years or older is expected to increase almost four-fold, from 5.4 million to 19 million between 2008 and 2050. As the older adult population continues to grow, the number of older adults who present with multiple medical conditions for which several medications are prescribed will likely continue to increase, resulting in polypharmacy concerns (Gray & Gardner, 2009). |
| Stratification | *See CMS156v10.html | *See CMS156v11-v2.html |
None |
| Risk Adjustment | *See CMS156v10.html | *See CMS156v11-v2.html |
None |
| Clinical Recommendation Statement | *See CMS156v10.html | *See CMS156v11-v2.html |
The measure is based on recommendations from the American Geriatrics Society Beers Criteria[R] for Potentially Inappropriate Medication Use in Older Adults (2019 Update). The criteria were developed through key clinical expert consensus processes by Beers in 1997, Zhan in 2001, and an updated process by Fick et al. in 2003, 2012, 2015, and 2019. The Beers Criteria identifies lists of drugs that are potentially inappropriate for all older adults, except for those with certain conditions for which some high-risk medications may be warranted, and drugs that are potentially inappropriate in older adults based on various high-risk factors such as dosage, days supply and underlying diseases or conditions. NCQA's Geriatric Measurement Advisory Panel recommended a subset of drugs that should be used with caution in older adults for inclusion in the measure based upon the recommendations in the Beers Criteria. |
| Notes |
*There is a known issue on CMS156v10. See issue EKI-17 on the ONC eCQM Known Issues Dashboard for details. |
*There is a known issue on CMS156v11. See issue EKI-17 on the ONC eCQM Known Issues Dashboard for details. |
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| Next Version | No Version Available | ||
| Previous Version | No Version Available |
Header
Updated copyright.
Measure Section: Copyright
Source of Change: Annual Update
Updated references.
Measure Section: Reference
Source of Change: Measure Lead
Removed the Numerator Exclusions criterion and converted to a Numerator negative inclusion criterion for the second population rate based on vendor feedback and measure intent.
Measure Section: Numerator
Source of Change: Measure Lead
Removed the Numerator Exclusions criterion and converted to a Numerator negative inclusion criterion for the second population rate based on vendor feedback and measure intent.
Measure Section: Numerator Exclusions
Source of Change: Measure Lead
Logic
Removed the Numerator Exclusions criterion and converted to a Numerator negative inclusion criterion for the second population rate based on vendor feedback and measure intent.
Measure Section: Numerator
Source of Change: Measure Lead
Removed the Numerator Exclusions criterion and converted to a Numerator negative inclusion criterion for the second population rate based on vendor feedback and measure intent.
Measure Section: Numerator Exclusions
Source of Change: Measure Lead
Updated the version number of the Palliative Care Exclusion ECQM Library to v3.0.000.
Measure Section: Definitions
Source of Change: Annual Update
Updated the version number of the Hospice Library to v5.0.000.
Measure Section: Definitions
Source of Change: Annual Update
Updated the version number of the Cumulative Medication Duration Library to v2.0.000.
Measure Section: Definitions
Source of Change: Annual Update
Replaced direct reference code 'Encounter with palliative care' with 'Palliative Care Diagnosis' value set in the PalliativeCare.Has Palliative Care in the Measurement Period definition to organize capture of patients receiving palliative care, per standards expert input.
Measure Section: Definitions
Source of Change: Measure Lead
Added QDM datatype 'Diagnosis' to the Hospice.'Has Hospice Services' definition referencing a new value set containing SNOMED finding codes to provide an additional approach for identifying patients receiving hospice care.
Measure Section: Definitions
Source of Change: Measure Lead
Added 'day of' specificity to the palliative care expressions for consistency.
Measure Section: Definitions
Source of Change: Measure Lead
Added 'day of' specificity to hospice expressions for consistency.
Measure Section: Definitions
Source of Change: Measure Lead
Condensed relevant definitions into 'First Antipsychotic Medication Ordered' and 'First Benzodiazepine Medication Ordered' for simplification and improved readability.
Measure Section: Definitions
Source of Change: Measure Lead
Updated the names of CQL definitions, functions, and/or aliases for clarification and to align with the CQL Style Guide.
Measure Section: Definitions
Source of Change: Standards/Technical Update
Updated the version number of the Palliative Care Exclusion ECQM Library to v3.0.000.
Measure Section: Functions
Source of Change: Annual Update
Updated the version number of the Hospice Library to v5.0.000.
Measure Section: Functions
Source of Change: Annual Update
Updated the version number of the Cumulative Medication Duration Library to v2.0.000.
Measure Section: Functions
Source of Change: Annual Update
Updated the 'CodeToDaily' function so that highest dose is calculated consistently.
Measure Section: Functions
Source of Change: Measure Lead
Updated numerator to capture patients with two orders of the same high-risk medication placed on the same day but with different start dates to meet measure intent.
Measure Section: Functions
Source of Change: Expert Work Group Review
Value Set
The VSAC is the source of truth for the value set content, please visit the VSAC for downloads of current value sets.
Replaced direct reference code ICD-10-CM code (Z51.5) with value set Palliative Care Diagnosis (2.16.840.1.113883.3.464.1003.1167) based on change in measure requirements/measure specification.
Measure Section: Terminology
Source of Change: Annual Update
Value set Anticholinergics, first generation antihistamines (2.16.840.1.113883.3.464.1003.1043): Added 13 RxNorm codes based on review by technical experts, SMEs, and/or public feedback. Deleted 4 RxNorm codes (1116173, 1245374, 359329, 860151) based on review by technical experts, SMEs, and/or public feedback.
Measure Section: Terminology
Source of Change: Measure Lead
Value set Antipsychotic (2.16.840.1.113883.3.464.1003.196.12.1523): Deleted 1 RxNorm code (1791691) based on review by technical experts, SMEs, and/or public feedback.
Measure Section: Terminology
Source of Change: Measure Lead
Value set Antispasmodics (2.16.840.1.113883.3.464.1003.1050): Deleted 2 RxNorm codes (1048147, 1598634) based on review by technical experts, SMEs, and/or public feedback.
Measure Section: Terminology
Source of Change: Measure Lead
Value set Benzodiazepine (2.16.840.1.113883.3.464.1003.196.12.1522): Added 2 RxNorm codes (2594600, 2608698) based on review by technical experts, SMEs, and/or public feedback.
Measure Section: Terminology
Source of Change: Measure Lead
Value set Benzodiazepine Withdrawal (2.16.840.1.113883.3.464.1003.105.12.1208): Deleted 1 SNOMED CT code (361150008) based on review by technical experts, SMEs, and/or public feedback.
Measure Section: Terminology
Source of Change: Measure Lead
Replaced value set Bipolar Disorder (2.16.840.1.113883.3.464.1003.105.12.1157) with value set Bipolar Disorder (2.16.840.1.113883.3.67.1.101.1.128) based on review by technical experts, SMEs, and/or public feedback.
Measure Section: Terminology
Source of Change: Measure Lead
Value set Central nervous system, barbiturates (2.16.840.1.113883.3.464.1003.1055): Deleted 1 RxNorm code (1048147) based on review by technical experts, SMEs, and/or public feedback.
Measure Section: Terminology
Source of Change: Measure Lead
Value set Endocrine system, estrogens with or without progestins (2.16.840.1.113883.3.464.1003.1058): Deleted 1 RxNorm code (728118) based on review by technical experts, SMEs, and/or public feedback.
Measure Section: Terminology
Source of Change: Measure Lead
Value set Hospice Care Ambulatory (2.16.840.1.113883.3.526.3.1584): Deleted 3 SNOMED CT codes (170935008, 170936009, 305911006) based on review by technical experts, SMEs, and/or public feedback.
Measure Section: Terminology
Source of Change: Measure Lead
Added value set Hospice Diagnosis (2.16.840.1.113883.3.464.1003.1165) based on review by technical experts, SMEs, and/or public feedback.
Measure Section: Terminology
Source of Change: Measure Lead
Value set Hospice Encounter (2.16.840.1.113883.3.464.1003.1003): Added 2 SNOMED CT codes (305911006, 385765002) based on review by technical experts, SMEs, and/or public feedback.
Measure Section: Terminology
Source of Change: Measure Lead
Value set Online Assessments (2.16.840.1.113883.3.464.1003.101.12.1089): Added 4 CPT codes (98980, 98981, 99444, 99457) based on review by technical experts, SMEs, and/or public feedback. Added 3 HCPCS codes (G2250, G2251, G2252) based on review by technical experts, SMEs, and/or public feedback.
Measure Section: Terminology
Source of Change: Measure Lead
Replaced value set Ophthalmologic Services (2.16.840.1.113883.3.464.1003.101.11.1206) with value set Ophthalmological Services (2.16.840.1.113883.3.526.3.1285) based on review by technical experts, SMEs, and/or public feedback.
Measure Section: Terminology
Source of Change: Measure Lead
Removed value set Other Bipolar Disorder (2.16.840.1.113883.3.464.1003.105.12.1204) based on review by technical experts, SMEs, and/or public feedback.
Measure Section: Terminology
Source of Change: Measure Lead
Value set Pain medications, skeletal muscle relaxants (2.16.840.1.113883.3.464.1003.1062): Added 1 RxNorm code (2611794) based on review by technical experts, SMEs, and/or public feedback.
Measure Section: Terminology
Source of Change: Measure Lead
Value set Palliative Care Intervention (2.16.840.1.113883.3.464.1003.198.12.1135): Deleted 3 SNOMED CT codes (305686008, 305824005, 441874000) based on review by technical experts, SMEs, and/or public feedback.
Measure Section: Terminology
Source of Change: Measure Lead
Value set Payer (2.16.840.1.114222.4.11.3591): Added 5 SOP codes (1111, 1112, 142, 344, 141) based on review by technical experts, SMEs, and/or public feedback.
Measure Section: Terminology
Source of Change: Measure Lead
Value set Schizophrenia (2.16.840.1.113883.3.464.1003.105.12.1205): Added 1 SNOMED CT code (1204417003) based on review by technical experts, SMEs, and/or public feedback. Deleted 3 SNOMED CT codes (191530008, 191538001, 191539009) based on review by technical experts, SMEs, and/or public feedback.
Measure Section: Terminology
Source of Change: Measure Lead
Value set Seizure Disorder (2.16.840.1.113883.3.464.1003.105.12.1206): Added 21 SNOMED CT codes based on review by technical experts, SMEs, and/or public feedback.
Measure Section: Terminology
Source of Change: Measure Lead