Use of High-Risk Medications in Older Adults

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).

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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 (PIM) 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 & Paauw, 2017). Long-term use of benzodiazepines in older adults has been associated with increased risk of dementia (Zhong, Wang, Zhang, & Zhao, 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). Among Medicare beneficiaries it is estimated that the prevalence of PIM use was 77% among long-stay nursing home residents (defined as >101 consecutive days in a nursing home). The most common PIMs were benzodiazepines, antipsychotics, and insulin (Riester et al., 2023).

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).

The measure is based on recommendations from the American Geriatrics Society Beers Criteria[R] for Potentially Inappropriate Medication Use in Older Adults (2023). The criteria were developed through key clinical expert consensus processes by Beers in 1997, Zhan in 2001, Fick et al. in 2003, 2012, 2015, and 2019 and, most recently the American Geriatrics Society Beers Criteria Update Expert Panel in 2023. 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.

Lower score indicates better quality

Reference Type: CITATION

Reference Text: 'Agrawal, R. (2020). Careful Prescribing of Benzodiazepines during COVID-19 Pandemic: A Review. Journal of Mental Health & Clinical Psychology, 4(4). Retrieved from https://www.mentalhealthjournal.org/articles/careful-prescribing-of-benzodiazepines-during-covid-19-pandemic-a-review.html'

Reference Type: CITATION

Reference Text: 'Fick, D. M., Semla, T., Beizer, J., et al. (2015). American Geriatrics Society 2015 Updated Beers Criteria for Potentially Inappropriate Medication Use in Older Adults. Journal of the American Geriatrics Society, 63(11), 2227-2246.'

Reference Type: CITATION

Reference Text: 'Beers, M. H. (1997). Explicit criteria for determining potentially inappropriate medication use by the elderly. Archives of Internal Medicine, 157, 1531-1536.'

Reference Type: CITATION

Reference Text: 'Fick, D., Semla, T., Beizer, J., et al. (2012). American Geriatrics Society updated Beers criteria for potentially inappropriate medication use in older adults: The American Geriatrics Society 2012 Beers Criteria Update Expert Panel. Journal of the American Geriatrics Society, 60(4), 616.'

Reference Type: CITATION

Reference Text: 'Fick, D. M., Cooper, J. W., Wade, W. E., et al. (2003). Updating the Beers criteria for potentially inappropriate medication use in older adults. Archives of Internal Medicine, 163(22), 2716-2724.'

Reference Type: CITATION

Reference Text: 'Fick, D. M., Mion, L. C., Beers, M. H., et al. (2008). Health outcomes associated with potentially inappropriate medication use in older adults. Research in Nursing & Health, 31(1), 42-51.'

Reference Type: CITATION

Reference Text: 'Fu, A. Z., Liu, G. G., & Christensen, D. B. (2004). Inappropriate medication use and health outcomes in the elderly. Journal of the American Geriatrics Society, 52(11), 1934-1939.'

Reference Type: CITATION

Reference Text: 'Fu, A. Z., Jiang, J. Z., Reeves, J. H., Fincham, J. E., Liu, G. G., & Perri, M. (2007). Potentially Inappropriate Medication Use and Healthcare Expenditures in the US Community-Dwelling Elderly. Medical Care, 45(5), 472–476. Retrieved from http://www.jstor.org/stable/40221449'

Reference Type: CITATION

Reference Text: 'Gray, C. L., & Gardner, C. (2009). Adverse drug events in the elderly: An ongoing problem. Journal of Managed Care & Specialty Pharmacy, 15(7), 568-571.'

Reference Type: CITATION

Reference Text: 'Hagstrom, K., Nailor, M., Lindberg, M., Hobbs, L., & Sobieraj, D. M. (2015). Association Between Potentially Inappropriate Medication Use in Elderly Adults and Hospital-Related Outcomes. Journal of the American Geriatrics Society, 63(1), 185-186.'

Reference Type: CITATION

Reference Text: 'Institute of Medicine, Committee on Identifying and Preventing Medication Errors. (2007). Preventing medication errors. Aspden, P., Wolcott, J. A., Bootman, J. L., & Cronenwatt, L. R. (Eds.). Washington, DC: National Academy Press.'

Reference Type: CITATION

Reference Text: 'Kaufman, M. B., Brodin, K. A., & Sarafian, A. (2005, April/May). Effect of prescriber education on the use of medications contraindicated in older adults in a managed Medicare population. Journal of Managed Care & Specialty Pharmacy, 11(3), 211-219.'

Reference Type: CITATION

Reference Text: 'Lau, D.T., J.D., Kasper, D.E., Potter, & A. Lyles. (2004). Potentially Inappropriate Medication Prescriptions Among Elderly Nursing Home Residents: Their Scope and Associated Resident and Facility Characteristics. Health Services Research, 39(5), 1257-1276.'

Reference Type: CITATION

Reference Text: 'MacKinnon, N. J., & Hepler, C. D. (2003). Indicators of preventable drug-related morbidity in older adults: Use within a managed care organization. Journal of Managed Care & Specialty Pharmacy, 9(2), 134-141.'

Reference Type: CITATION

Reference Text: 'Merel, S.E., & Paauw, D.S.  Paauw. (2017). Common Drug Side Effects and Drug-Drug Interactions in Elderly Adults in Primary Care. Journal of the American Geriatrics Society, 65(7), 1578-1585.'

Reference Type: CITATION

Reference Text: 'Rothberg, M. B., Perkow, P. S., Liu, F., et al. (2008). Potentially inappropriate medication use in hospitalized elders. Journal of Hospital Medicine, 3(2), 91-102.'

Reference Type: CITATION

Reference Text: 'Takada, M., M. Fujimoto, & K. Hosomi. (2016). Association between benzodiazepine use and dementia: data mining of different medical databases. International Journal of Medical Sciences, 13(11), 825-834.'

Reference Type: CITATION

Reference Text: 'Tampi, R.R., D.J. Tampi, S. Balachandran, & S. Srinivasan. (2016). Antipsychotic use in dementia: a systematic review of benefits and risks from meta-analyses. Therapeutic Advances in Chronic Disease, 7(5), 229-245.'

Reference Type: CITATION

Reference Text: 'Zhan, C., Sangl, J., Bierman, A. S., et al. (2001). Potentially inappropriate medication use in the community-dwelling elderly. JAMA, 286(22), 2823-2868.'

Reference Type: CITATION

Reference Text: 'Zhong, G., Wang, Y., Zhang, Y., & Zhao, Y. (2015). Association between benzodiazepine use and dementia: a meta-analysis. PLoS One, 10(5).'

Reference Type: CITATION

Reference Text: 'Fick, D. M., Semla, T. P., Steinman, M., et al. (2019). American Geriatrics Society 2019 Updated AGS Beers Criteria for Potentially Inappropriate Medication Use in Older Adults. Journal of the American Geriatrics Society, 67(4), 674-694.'

Reference Type: CITATION

Reference Text: 'Riester, M. R., Goyal, P., Steinman, M. A., et al. (2023). Prevalence of Potentially Inappropriate Medication Prescribing in US Nursing Homes, 2013–2017. Journal of General Internal Medicine, 38(6), 1563-1566.'

Reference Type: CITATION

Reference Text: 'The 2023 American Geriatrics Society Beers Criteria Update Expert Panel. (2023). American Geriatrics Society 2023 updated AGS Beers Criteria for potentially inappropriate medication use in older adults. Journal of the American Geriatrics Society, 71(7), 2052-2081.'

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.

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 eCQI resource center (https://ecqi.healthit.gov/qdm) for more information on the QDM.

TBD

Patients 65 years and older at the end of the measurement period who had a visit during the measurement period

Equals Initial Population

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.

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).

Not Applicable

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For every patient evaluated by this measure also identify payer, race, ethnicity and sex

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