eCQM Title

Use of High-Risk Medications in the Elderly

eCQM Identifier (Measure Authoring Tool) 156 eCQM Version number 8.3.000
NQF Number Not Applicable GUID a3837ff8-1abc-4ba9-800e-fd4e7953adbd
Measurement Period January 1, 20XX through December 31, 20XX
Measure Steward National Committee for Quality Assurance
Measure Developer National Committee for Quality Assurance
Endorsed By None
Description
Percentage of patients 65 years of age and older who were ordered high-risk medications. Two rates are reported.
a. Percentage of patients who were ordered at least one high-risk medication. 
b. Percentage of patients who were ordered at least two of the same high-risk medications.
Copyright
This Physician Performance Measure (Measure) and related data specifications are owned and stewarded by the Centers for Medicare & Medicaid Services (CMS). CMS contracted (Contract HHSM-500-2011-00079C) with the National Committee for Quality Assurance (NCQA) to develop this electronic measure. NCQA is not responsible for any use of the Measure. NCQA makes no representations, warranties, or endorsement about the quality of any organization or physician that uses or reports performance measures and NCQA has no liability to anyone who relies on such measures or specifications.

Limited proprietary coding is contained in the Measure specifications for user convenience. Users of proprietary code sets should obtain all necessary licenses from the owners of the code sets. NCQA disclaims all liability for use or accuracy of any third party codes contained in the specifications.

CPT(R) contained in the Measure specifications is copyright 2004-2018 American Medical Association. LOINC(R) copyright 2004-2018 Regenstrief Institute, Inc. This material contains SNOMED Clinical Terms(R) (SNOMED CT[R]) copyright 2004-2018 International Health Terminology Standards Development Organisation. ICD-10 copyright 2018 World Health Organization. All Rights Reserved.
Disclaimer
The performance Measure is not a clinical guideline and does not establish a standard of medical care, and has not been tested for all potential applications. THE MEASURE AND SPECIFICATIONS ARE PROVIDED "AS IS" WITHOUT WARRANTY OF ANY KIND.
 
Due to technical limitations, registered trademarks are indicated by (R) or [R] and unregistered trademarks are indicated by (TM) or [TM].
Measure Scoring Proportion
Measure Type Process
Stratification
None
Risk Adjustment
None
Rate Aggregation
None
Rationale
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 the elderly (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).

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 are not preventable, studies estimate that between 30 and 80 percent of adverse drug events in the elderly are preventable (MacKinnon & Hepler, 2003).

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 the elderly 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 adverse drug events (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 in number 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 elderly population continues to grow, the number of older adults who present with multiple medical conditions for which several medications are prescribed continues to increase, resulting in polypharmacy (Gray & Gardner, 2009).
Clinical Recommendation Statement
The measure is based on recommendations from the American Geriatrics Society Beers Criteria for Potentially Inappropriate Medication Use in Older Adults. 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 and 2015. The Beers Criteria identifies lists of drugs that are potentially inappropriate for all older adults and drugs that are potentially inappropriate in the elderly based on various high-risk factors such as dosage, days supply and underlying diseases or conditions. NCQA's Geriatric Measurement Advisory Panel selected a subset of drugs that should be used with caution in the elderly for inclusion in the proposed measure based upon the recommendations in the Beers Criteria.
Improvement Notation
Lower score indicates better quality
Reference
American Geriatrics Society 2015 Beers Criteria Update Expert Panel. (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
Beers, M. H. (1997). Explicit criteria for determining potentially inappropriate medication use by the elderly. Archives of Internal Medicine, 157, 1531-1536.
Reference
Campanelli, C. M. (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
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
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
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
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
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
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
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
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): 1257-76.
Reference
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
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
Zhan, C., Sangl, J., Bierman, A. S., et al. (2001). Potentially inappropriate medication use in the community-dwelling elderly. JAMA, 286(22), 2823-2868.
Definition
A high-risk medication is identified by either of the following:
     a. A prescription for medications classified as high risk at any dose and for any duration
     b. Prescriptions for medications classified as high risk at any dose with greater than a 90 day supply
Guidance
The intent of Numerator 1 of the measure is to assess if the patient has been prescribed at least one high-risk medication.  The intent of Numerator 2 of the measure is to assess if the patient has been prescribed at least two of the same high-risk medications 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.
Transmission Format
TBD
Initial Population
Patients 65 years and older who had a visit during the measurement period
Denominator
Equals Initial Population
Denominator Exclusions
Exclude patients whose hospice care overlaps the measurement period
Numerator
Numerator 1: Patients with an order for at least one high-risk medication during the measurement period

Numerator  2: Patients with at least two orders for the same high-risk medication on different days during the measurement period
Numerator Exclusions
Not Applicable
Denominator Exceptions
None
Supplemental Data Elements
For every patient evaluated by this measure also identify payer, race, ethnicity and sex

Table of Contents


Population Criteria

Definitions

Functions

Terminology

Data Criteria (QDM Data Elements)

Supplemental Data Elements

Risk Adjustment Variables


Measure Set
None