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2020 MIPS Measure #238: Use of High-Risk Medications in the Elderly

Quality ID 238
eMeasure ID CMS156v8
NQF 0022
High Priority Measure Yes
Specifications EHR Registry
Measure Type Process
Specialty Allergy/Immunology Cardiology Family Medicine Geriatrics Internal Medicine Pulmonology Rheumatology

Measure Description

Percentage of patients 65 years of age and older who were ordered high-risk medications. Two rates are submitted.

1) Percentage of patients who were ordered at least one high-risk medication.
2) Percentage of patients who were ordered at least two of the same high-risk medication

 

Instructions

This measure is to be submitted a minimum of once per performance period for patients seen during the performance period. There is no diagnosis associated with this measure. This measure may be submitted by Merit-based Incentive Payment System (MIPS) eligible clinicians who perform the quality actions described in the measure based on the services provided and the measure-specific denominator coding.

This measure will be calculated with 2 performance rates:

1) Percentage of patients who were ordered at least one high-risk medication
2) Percentage of patients who were ordered at least two of the same high-risk medication

MIPS eligible clinicians should continue to submit the measure as specified, with no additional steps needed to account for multiple performance rates.

Measure Submission Type:

Measure data may be submitted by individual MIPS eligible clinicians, groups, or third party intermediaries. The listed denominator criteria are used to identify the intended patient population. The numerator options included in this specification are used to submit the quality actions as allowed by the measure. The quality-data codes listed do not need to be submitted by MIPS eligible clinicians, groups, or third party intermediaries that utilize this modality for submissions; however, these codes may be submitted for those third party intermediaries that utilize Medicare Part B claims data. For more information regarding Application Programming Interface (API), please refer to the Quality Payment Program (QPP) website.

 

THERE ARE TWO SUBMISSION CRITERIA FOR THIS MEASURE:

1) Percentage of patients who were ordered at least one high-risk medication

OR

2) Percentage of patients who were ordered at least two of the same high-risk medications

 

SUBMISSION CRITERIA 1: PERCENTAGE OF PATIENTS WHO WERE ORDERED AT LEAST ONE HIGH-RISK MEDICATION

Denominator (Submission Criteria 1)

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

Denominator Criteria (Eligible Cases) 1:

Patients aged ≥ 65 years on date of encounter

AND

Patient encounter during performance period (CPT or HCPCS): 99201, 99202, 99203, 99204, 99205, 99212, 99213, 99214, 99215, 99341, 99342, 99343, 99344, 99345, 99347, 99348, 99349, 99350, G0438, G0439

AND NOT

DENOMINATOR EXCLUSION:

Patients who use hospice services any time during the measurement period: G9741

 

Numerator (Submission Criteria 1)

Patients with an order for at least one high-risk medication during the measurement period

Definitions:

The intent of Numerator 1 is to assess if the patient has been prescribed at least one high-risk medication.

Cumulative Medication Duration - an individual’s total number of medication days over a specific period; the period counts multiple prescriptions with gaps in between, but does not count the gaps during which a medication was not dispensed.

To determine the cumulative medication duration, determine first the number of the Medication Days for each prescription in the period: the number of doses divided by the dose frequency per day. Then add the Medication Days for each prescription without counting any days between the prescriptions.

Table 1 – High-Risk Medications at any dose or duration

Description

Prescription

 

Anticholinergics, first-generation antihistamines

Brompheniramine
Carbinoxamine
Chlorpheniramine
Clemastine
Cyproheptadine
Dexbrompheniramine
Dexchlorpheniramine

Dimenhydrinate
Diphenhydramine (oral)
Doxylamine
Hydroxyzine
Meclizine
Promethazine
Triprolidine

Anticholinergics, anti-Parkinson agents

Benztropine (oral)

Trihexyphenidy

Antispasmodics

Atropine (exclude ophthalmic)
Belladonna alkaloids
Clidinium-chloradiazepoxide
Dicyclomide

Hyoscyamine
Propantheline
Scopolamine

Antithrombotics

Dipyridamole, oral short-acting (does not apply to the combination with aspirin)

Ticlopidine

Cardiovascular, alpha agonists, central

Methyldopa

Guanfacine

Cardiovascular, other

Disopyramide

Nifedipine, immediate release

Central nervous system, antidepressants

Amitriptyline
Clomipramine
Amoxapine
Desipramine

Imipramine
Trimipramine 
Nortriptyline
Paroxetine
Protriptyline

Central nervous system, barbiturates

Amobarbital
Butabarbital
Butalbital

Pentobarbital
Phenobarbital 
Secobarbital 

Central nervous system, vasodilators

Ergot mesylates

Isoxsuprine

Central nervous system, other

 

Meprobamate

Endocrine system, estrogens with or without progestins;
include only oral and topical patch products

Conjugated estrogen
Estropipate

Estradiol
Esterified estrogen

Endocrine system, sulfonylureas, long- duration

Chlorpropamide

Glyburide

Endocrine system, other

Desiccated thyroid

Megestrol

Pain medications, skeletal muscle relaxants

Carisoprodol
Chlorzoxazone
Cyclobenzaprine

Metaxalone
Methocarbamol 
Orphenadrine

Pain medications, other

Indomethacin
Meperidine

Ketorolac, includes parenteral
Pentazocine

Table 2 - High-Risk Medications With Days Supply Criteria

Description

Prescription

 

Days Supply Criteria

Anti-Infectives, other

Nitrofurantoin
Nitrofurantoin
macrocrystals

Nitrofurantoin
macrocrystals-
monohydrate

>90 days

Nonbenzodiazepine hypnotics

Eszopiclone
Zaleplon

Zolpidem

>90 days

NUMERATOR NOTE: Some high-risk medications are not included in this specific measure but should be avoided above a specified average daily dose. These medications are listed in Table 3. To calculate an average daily dose multiply the quantity of pills ordered by the dose of each pill and divide by the days supply. For example, a prescription for a 30-days supply of digoxin containing 15 pills, 0.250 mg each pill, has an average daily dose of 1.125 mg.

Table 3 - High-Risk Medications With Average Daily Dose Criteria

Description

Prescription

Average Daily Dose Criteria

Alpha agonists, central

Reserpine

>0.1 mg/day

Cardiovascular, other

Digoxin

>0.125 mg/day

Tertiary TCAs (as single agent or as part of combination products)

Doxepin

>6 mg/day

Numerator Instructions:

INVERSE MEASURE - A lower calculated performance rate for this measure indicates better clinical care or control. The “Performance Not Met” numerator option for this measure is the representation of the better clinical quality or control. Submitting that numerator option will produce a performance rate that trends closer to 0%, as quality increases. For inverse measures a rate of 100% means all of the denominator eligible patients did not receive the appropriate care or were not in proper control.

A high-risk medication is identified by either of the following:

• A prescription for medications classified as high risk at any dose and for any duration listed in Table 1
• Prescriptions for medications classified as high risk at any dose with greater than a 90 day cumulative medication duration listed in Table 2

Numerator Options:

Performance Met: One high-risk medication ordered (G9365)

OR

Performance Not Met: One high-risk medication not ordered (G9366)

 

SUBMISSION CRITERIA 2: PERCENTAGE OF PATIENTS with at least two ORDERs for the same HIGH-RISK MEDICATION

Denominator (Submission Criteria 2)

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

Denominator Criteria (Eligible Cases) 2:

Patients aged ≥ 65 years on date of encounter

AND

Patient encounter during performance period (CPT or HCPCS): 99201, 99202, 99203, 99204, 99205, 99212, 99213, 99214, 99215, 99341, 99342, 99343, 99344, 99345, 99347, 99348, 99349, 99350, G0438, G0439

AND NOT

DENOMINATOR EXCLUSION:

Patients who use hospice services any time during the measurement period: G9741

 

Numerator (Submission Criteria 2)

Patients with at least two orders for the same high-risk medication- on different days during the measurement period

Definitions:

The intent of Numerator 2 is to assess if the patient has either been prescribed at least two of the same high-risk medication in Table 4, received two or more prescriptions on different days, where the sum of days supply exceeds 90 days, for medications in the same medication class in Table 5 The intent of the measure is to assess if the submitting 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 submitting provider also ordered a high-risk medication for them.

Cumulative Medication Duration – an individual’s total number of medication days over a specific period; the period counts multiple prescriptions with gaps in between, but does not count the gaps during which a medication was not dispensed.

To determine the cumulative medication duration, determine first the number of the Medication Days for each prescription in the period: the number of doses divided by the dose frequency per day. Then add the Medication Days for each prescription without counting any days between the prescriptions.

For example, there is an original prescription for 30 days with 2 refills for thirty days each. After a gap of 3 months, the medication was prescribed again for 60 days with 1 refill for 60 days. The cumulative medication duration is (30 x 3) + (60 x 2) = 210 days over the 10 month period.

Table 4 - High-Risk Medications at any dose or duration

Description

Prescription

 

Anticholinergics, first-generation antihistamines

Brompheniramine
Carbinoxamine
Chlorpheniramine
Clemastine
Cyproheptadine
Dexbrompheniramine
Dexchlorpheniramine
Dimenhydrinate

Diphenhydramine (oral)
Doxylamine
Hydroxyzine
Meclizine
Promethazine
Triprolidine

Anticholinergics, anti-Parkinson agents

Benztropine (oral)

Trihexyphenidy

Antispasmodics

Atropine (exclude ophthalmic)
Belladonna alkaloids
Clidinium-chloradiazepoxide
Dicyclomide

Hyoscyamine
Propantheline
Scopolamine

Antithrombotics

Dipyridamole, oral shortacting (does not apply to the combination with aspirin)

Ticlopidine

Cardiovascular, alpha agonists, centra

Methyldopa

Guanfacine

Cardiovascular, other

Disopyramide

Nifedipine, immediate release

Central nervous system, antidepressants

Amitriptyline
Clomipramine
Amoxapine
Desipramine

Imipramine
Trimipramine 
Nortriptyline
Paroxetine
Protriptyline

Central nervous system, barbiturates

Amobarbital
Butabarbital
Butalbital

Pentobarbital
Phenobarbital 
Secobarbital 

Central nervous system, vasodilators

Ergot mesylates

Isoxsuprine

Central nervous system, other

 

Meprobamate

Endocrine system, estrogens with or without progestins;
include only oral and topical patch products

Conjugated estrogen
Estropipate

Estradiol
Esterified estrogen

Endocrine system, sulfonylureas, long- duration

Chlorpropamide

Glyburide

Endocrine system, other

Desiccated thyroid

Megestrol

Pain medications, skeletal muscle relaxants

Carisoprodol
Chlorzoxazone
Cyclobenzaprine

Metaxalone
Methocarbamol 
Orphenadrine

Pain medications, other

Indomethacin
Meperidine

Ketorolac, includes parenteral
Pentazocine

*The registry version of the measure specifications only indicates the classes of drugs that are considered high-risk and do not include the specific coding of RxNorm. However, this measure aligns with the eCQM measure (CMS 156) and providers may review the RxNorm codes in the applicable eCQM value sets for submission.

Table 5 - High-Risk Medications With Days Supply Criteria

Description

Prescription

 

Days Supply Criteria

Anti-Infectives, other

Nitrofurantoin
Nitrofurantoin
macrocrystals

Nitrofurantoin
macrocrystals-
monohydrate

>90 days

Nonbenzodiazepine hypnotics

Eszopiclone
Zaleplon

Zolpidem

>90 days

NUMERATOR NOTE: Some high-risk medications are not included in this specific measure but should be avoided above a specified average daily dose. These medications are listed in Table 6. To calculate an average daily dose multiply the quantity of pills ordered by the dose of each pill and divide by the days supply. For example, a prescription for a 30-days supply of digoxin containing 15 pills, 0.250 mg each pill, has an average daily dose of 0.125 mg.

Table 6 - DAE-C: High-Risk Medications With Average Daily Dose Criteria

Description

Prescription

Average Daily Dose Criteria

Alpha agonists, central

Reserpine

>0.1 mg/day

Cardiovascular, other

Digoxin

>0.125 mg/day

Tertiary TCAs (as single agent or as part of combination products)

Doxepin

>6 mg/day

Numerator Instructions:

INVERSE MEASURE - A lower calculated performance rate for this measure indicates better clinical care or control. The “Performance Not Met” numerator option for this measure is the representation of the better clinical quality or control. Submitting that numerator option will produce a performance rate that trends closer to 0%, as quality increases. For inverse measures a rate of 100% means all of the denominator eligible patients did not receive the appropriate care or were not in proper control.

A high-risk medication is identified by either of the following:

• A prescription for medications classified as high risk at any dose and for any duration listed in Table 4
• Prescriptions for medications classified as high risk at any dose with greater than a 90 day cumulative medication duration listed in Table 5

Numerator Options:

Performance Met: At least two orders for the same high-risk medication (G9367)

OR

Performance Not Met: At least two orders for the same high-risk medications not ordered (G9368)

 

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). Studies link prescription drug use by the elderly with adverse drug events that contribute to hospitalization, increased length of hospital stay, increased duration of illness, nursing home placement and falls and fractures that are further associated with physical, functional and social decline in the elderly (AHRQ 2009). 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 (Lau et al. 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 and 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 (IOM, 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 and Gardner 2009)

 

Clinical Recommendation Statements

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, Zahn in 2001 and an updated process by Fick 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.

 

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