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Measure: CMS156

Use of High-Risk Medications in Older Adults

Measure Versions

eMeasure Code Measure Year Full Version Number Title
CMS156v10 2022 10.2.000 Use of High-Risk Medications in Older Adults
CMS156v9 2021 9.3.000 Use of High-Risk Medications in Older Adults
CMS156v8 2020 8.3.000 Use of High-Risk Medications in the Elderly
CMS156v7 2019 7.3.000 Use of High-Risk Medications in the Elderly
CMS156v6 2018 6.4.000 Use of High-Risk Medications in the Elderly
CMS156v5 2017 5.1.000 Use of High-Risk Medications in the Elderly

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).

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

Patient Group Definitions

Group Description Instructions Links
Initial PopulationPatients 65 years and older who had a visit during the measurement periodWebchart Instructions
DenominatorEquals Initial PopulationWebchart Instructions
Denominator ExclusionsExclude patients who are in hospice care for any part of the measurement period. Exclude patients receiving palliative care during the measurement period.Webchart Instructions
NumeratorRate 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).Webchart Instructions
Numerator ExclusionsRate 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.Webchart Instructions
Denominator ExceptionsNone

Details

Full eMeasure Code eMeasure Identifier Measure Year Version NQF # GUID
CMS156v10 2022 10.2.000 Not Applicable a3837ff8-1abc-4ba9-800e-fd4e7953adbd
Steward Developer Endorsed By
National Committee for Quality Assurance National Committee for Quality Assurance
Scoring Method Measure Type Stratification Risk Adjustment
Proportion PROCESS None None

Rate Aggregation

None

Improvement Notation

Lower score indicates better quality

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 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 are unavoidable, studies estimate that between 30 and 80 percent of adverse drug events in older adults 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 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 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 older adult population continues to grow, the number of older adults who present with multiple medical conditions for which several medications are prescribed will continue to increase, resulting in polypharmacy concerns (Gray & Gardner, 2009).

Clinical Recommendation Statement

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 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.

Definition

Index prescription start date. The start date of the earliest prescription ordered for a high-risk medication during the measurement period. 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

Transmission Format

TBD

Applicable Value Sets

Category Value Set OID
Diagnosis Alcohol Withdrawal 2.16.840.1.113883.3.464.1003.105.12.1209
Diagnosis Benzodiazepine Withdrawal 2.16.840.1.113883.3.464.1003.105.12.1208
Diagnosis Bipolar Disorder 2.16.840.1.113883.3.464.1003.105.12.1157
Diagnosis Generalized Anxiety Disorder 2.16.840.1.113883.3.464.1003.105.12.1210
Diagnosis Other Bipolar Disorder 2.16.840.1.113883.3.464.1003.105.12.1204
Diagnosis REM Sleep Behavior Disorder 2.16.840.1.113883.3.464.1003.105.12.1207
Diagnosis Schizophrenia 2.16.840.1.113883.3.464.1003.105.12.1205
Diagnosis Seizure Disorder 2.16.840.1.113883.3.464.1003.105.12.1206
Encounter, Performed Annual Wellness Visit 2.16.840.1.113883.3.526.3.1240
Encounter, Performed Care Services in Long-Term Residential Facility 2.16.840.1.113883.3.464.1003.101.12.1014
Encounter, Performed Discharge Services - Nursing Facility 2.16.840.1.113883.3.464.1003.101.12.1013
Encounter, Performed Encounter Inpatient 2.16.840.1.113883.3.666.5.307
Encounter, Performed Home Healthcare Services 2.16.840.1.113883.3.464.1003.101.12.1016
Encounter, Performed Nursing Facility Visit 2.16.840.1.113883.3.464.1003.101.12.1012
Encounter, Performed Office Visit 2.16.840.1.113883.3.464.1003.101.12.1001
Encounter, Performed Online Assessments 2.16.840.1.113883.3.464.1003.101.12.1089
Encounter, Performed Ophthalmologic Outpatient Visit 2.16.840.1.113883.3.464.1003.101.11.1206
Encounter, Performed Palliative Care Encounter 2.16.840.1.113883.3.464.1003.101.12.1090
Encounter, Performed Preventive Care Services - Established Office Visit, 18 and Up 2.16.840.1.113883.3.464.1003.101.12.1025
Encounter, Performed Preventive Care Services-Initial Office Visit, 18 and Up 2.16.840.1.113883.3.464.1003.101.12.1023
Encounter, Performed Telephone Visits 2.16.840.1.113883.3.464.1003.101.12.1080
Intervention, Order Hospice care ambulatory 2.16.840.1.113762.1.4.1108.15
Intervention, Performed Hospice care ambulatory 2.16.840.1.113762.1.4.1108.15
Intervention, Performed Palliative Care Intervention 2.16.840.1.113883.3.464.1003.198.12.1135
Medication, Order Amitriptyline Hydrochloride 2.16.840.1.113883.3.464.1003.196.12.1373
Medication, Order Amoxapine 2.16.840.1.113883.3.464.1003.196.12.1273
Medication, Order Anti Infectives, other 2.16.840.1.113883.3.464.1003.196.12.1481
Medication, Order Antipsychotic 2.16.840.1.113883.3.464.1003.196.12.1523
Medication, Order Atropine / Diphenoxylate 2.16.840.1.113883.3.464.1003.196.12.1274
Medication, Order Benzodiazepine 2.16.840.1.113883.3.464.1003.196.12.1522
Medication, Order Benztropine 2.16.840.1.113883.3.464.1003.196.12.1361
Medication, Order Brompheniramine 2.16.840.1.113883.3.464.1003.196.12.1427
Medication, Order Butabarbital 2.16.840.1.113883.3.464.1003.196.12.1402
Medication, Order Butalbital 2.16.840.1.113883.3.464.1003.196.12.1514
Medication, Order Carbinoxamine 2.16.840.1.113883.3.464.1003.196.12.1306
Medication, Order Carisoprodol 2.16.840.1.113883.3.464.1003.196.12.1369
Medication, Order Chlorpheniramine 2.16.840.1.113883.3.464.1003.196.12.1352
Medication, Order Chlorpropamide 2.16.840.1.113883.3.464.1003.196.12.1303
Medication, Order Chlorzoxazone 2.16.840.1.113883.3.464.1003.196.12.1362
Medication, Order Clemastine 2.16.840.1.113883.3.464.1003.196.12.1308
Medication, Order Clomipramine 2.16.840.1.113883.3.464.1003.196.12.1336
Medication, Order Conjugated Estrogens 2.16.840.1.113883.3.464.1003.196.12.1357
Medication, Order Cyclobenzaprine Hydrochloride 2.16.840.1.113883.3.464.1003.196.12.1372
Medication, Order Cyproheptadine 2.16.840.1.113883.3.464.1003.196.12.1277
Medication, Order Desiccated Thyroid 2.16.840.1.113883.3.464.1003.196.12.1354
Medication, Order Desipramine 2.16.840.1.113883.3.464.1003.196.12.1278
Medication, Order Dexbrompheniramine 2.16.840.1.113883.3.464.1003.196.12.1375
Medication, Order Dexchlorpheniramine 2.16.840.1.113883.3.464.1003.196.12.1300
Medication, Order Dicyclomine 2.16.840.1.113883.3.464.1003.196.12.1279
Medication, Order Dimenhydrinate 2.16.840.1.113883.3.464.1003.196.12.1500
Medication, Order Diphenhydramine 2.16.840.1.113883.3.464.1003.196.12.1293
Medication, Order Dipyridamole 2.16.840.1.113883.3.464.1003.196.12.1349
Medication, Order Disopyramide 2.16.840.1.113883.3.464.1003.196.12.1311
Medication, Order Doxylamine 2.16.840.1.113883.3.464.1003.196.12.1515
Medication, Order Esterified Estrogens 2.16.840.1.113883.3.464.1003.196.12.1419
Medication, Order Estradiol 2.16.840.1.113883.3.464.1003.196.12.1365
Medication, Order Estropipate 2.16.840.1.113883.3.464.1003.196.12.1319
Medication, Order Glyburide 2.16.840.1.113883.3.464.1003.196.12.1368
Medication, Order Guanfacine 2.16.840.1.113883.3.464.1003.196.12.1341
Medication, Order Hydroxyzine 2.16.840.1.113883.3.464.1003.196.12.1374
Medication, Order Hyoscyamine 2.16.840.1.113883.3.464.1003.196.12.1501
Medication, Order Imipramine 2.16.840.1.113883.3.464.1003.196.12.1359
Medication, Order Indomethacin 2.16.840.1.113883.3.464.1003.196.12.1366
Medication, Order Isoxsuprine 2.16.840.1.113883.3.464.1003.196.12.1422
Medication, Order Ketorolac Tromethamine 2.16.840.1.113883.3.464.1003.196.12.1364
Medication, Order List of Single RxNorm Code Concepts for High Risk Drugs for the Elderly 2.16.840.1.113883.3.464.1003.196.12.1272
Medication, Order Meclizine 2.16.840.1.113883.3.464.1003.196.12.1506
Medication, Order Megestrol 2.16.840.1.113883.3.464.1003.196.12.1342
Medication, Order Meperidine 2.16.840.1.113883.3.464.1003.196.12.1351
Medication, Order Meprobamate 2.16.840.1.113883.3.464.1003.196.12.1284
Medication, Order Metaxalone 2.16.840.1.113883.3.464.1003.196.12.1358
Medication, Order Methocarbamol 2.16.840.1.113883.3.464.1003.196.12.1370
Medication, Order Methscopolamine 2.16.840.1.113883.3.464.1003.196.12.1525
Medication, Order Methyldopa 2.16.840.1.113883.3.464.1003.196.12.1331
Medication, Order Nifedipine 2.16.840.1.113883.3.464.1003.196.12.1353
Medication, Order Nonbenzodiazepine hypnotics 2.16.840.1.113883.3.464.1003.196.12.1480
Medication, Order Nortriptyline 2.16.840.1.113883.3.464.1003.196.12.1507
Medication, Order Orphenadrine 2.16.840.1.113883.3.464.1003.196.12.1302
Medication, Order Paroxetine 2.16.840.1.113883.3.464.1003.196.12.1508
Medication, Order Pentobarbital 2.16.840.1.113883.3.464.1003.196.12.1518
Medication, Order Phenobarbital 2.16.840.1.113883.3.464.1003.196.12.1348
Medication, Order Promethazine Hydrochloride 2.16.840.1.113883.3.464.1003.196.12.1367
Medication, Order Propantheline 2.16.840.1.113883.3.464.1003.196.12.1519
Medication, Order Protriptyline 2.16.840.1.113883.3.464.1003.196.12.1509
Medication, Order Pyrilamine 2.16.840.1.113883.3.464.1003.196.12.1524
Medication, Order Scopolamine 2.16.840.1.113883.3.464.1003.196.12.1520
Medication, Order Secobarbital 2.16.840.1.113883.3.464.1003.196.12.1521
Medication, Order Trihexyphenidyl 2.16.840.1.113883.3.464.1003.196.12.1334
Medication, Order Trimipramine 2.16.840.1.113883.3.464.1003.196.12.1285
Medication, Order Triprolidine 2.16.840.1.113883.3.464.1003.196.12.1408
Patient Characteristic Ethnicity Ethnicity 2.16.840.1.114222.4.11.837
Patient Characteristic Payer Payer 2.16.840.1.114222.4.11.3591
Patient Characteristic Race Race 2.16.840.1.114222.4.11.836
Patient Characteristic Sex ONC Administrative Sex 2.16.840.1.113762.1.4.1

References

CITATIONAmerican 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.
CITATIONBeers, M. H. (1997). Explicit criteria for determining potentially inappropriate medication use by the elderly. Archives of Internal Medicine, 157, 1531-1536.
CITATIONCampanelli, 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.
CITATIONFick, 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.
CITATIONFick, 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.
CITATIONFu, 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.
CITATIONGray, C. L., & Gardner, C. (2009). Adverse drug events in the elderly: An ongoing problem. Journal of Managed Care & Specialty Pharmacy, 15(7), 568-571.
CITATIONHagstrom, 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.
CITATIONInstitute 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.
CITATIONKaufman, 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.
CITATIONLau, 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.
CITATIONMacKinnon, 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.
CITATIONRothberg, 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.
CITATIONZhan, C., Sangl, J., Bierman, A. S., et al. (2001). Potentially inappropriate medication use in the community-dwelling elderly. JAMA, 286(22), 2823-2868.
CITATION2019 American Geriatrics Society Beers Criteria Update Expert Panel. (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.
CITATIONMerel, S.E., and 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.
CITATIONTakada, M., M. Fujimoto, and K. Hosomi. (2016). Association between benzodiazepine use and dementia: data mining of different medical databases. International Journal of Medical Sciences, 13(11), 825-834.
CITATIONTampi ,R.R., D.J. Tampi, S. Balachandran, and 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.
CITATIONZhong, G., Y. Wang, Y. Zhang, and Y. Zhao. (2015). Association between benzodiazepine use and dementia: a meta-analysis. PLoS One, 10(5).

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].

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 2004-2020 American Medical Association. LOINC(R) copyright 2004-2020 Regenstrief Institute, Inc. This material contains SNOMED Clinical Terms(R) (SNOMED CT[R]) copyright 2004-2020 International Health Terminology Standards Development Organisation. ICD-10 copyright 2020 World Health Organization. All Rights Reserved.

Source: https://ecqi.healthit.gov/ecqm/measures/cmsv1