• Measure 238: Use of High-Risk Medications in the Elderly


    Updated January 2018.

    Reporting Options: 

    • IRIS Registry EHR: group and individual
    • IRIS Registry manual data entry: group and individual
    • EHR through your vendor (if offered): group and individual

    Measure Type: Process - High Priority

    Description: This measure is to be submitted a minimum of once per performance period for patients, aged 65 years and older, who were ordered high-risk medications.

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

    There are two submission criteria for this measure:

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

    Definitions:

    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.

    To Which Patients Does the Measure Apply?

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

    1. Patient characteristics: Description located in “Instructions” (see above).
    2. Diagnosis codes (ICD-10-CM): Codes located in “Diagnosis Codes.”
    3. Procedure codes (CPT or HCPCS): Codes located in “CPT Codes.”

    The quality measure also has exclusions for the denominator.

    Diagnosis Codes

    This measure does not require a specific diagnosis to be submitted during the encounter.

    CPT Codes

    99201, 99202, 99203, 99204, 99205, 99212, 99213, 99214, 99215, 99341, 99342, 99343, 99344, 99345, 99347, 99348, 99349, 99350, G0438, G0439

    Note: Eye visit codes are not included in this measure.

    Exclusion (patient ineligible): G9741 Patients who use hospice services any time during the measurement period

    How to Report the Option 1, IRIS Registry Manual Reporting

    Numerator: Percentage of patients who were ordered at least one high-risk medication during the measurement period.

    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.

    2018 additions in red.

    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 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 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)
    • Trihexyphenidyl
    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
    • Guanabenz
    • 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
    • Mephobarbital
    • 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

    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

    How to Report the Option 2, IRIS Registry Manual Reporting

    Numerator: Percentage of patients with at least two orders for the same high-risk medication- during the measurement period

    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.

    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)
    • Trihexyphenidyl
    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
    • Guanabenz
    • 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
    • Mephobarbital
    • 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 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

    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
    • Performance met (patient included in numerator and denominator): G9365 One high-risk medication ordered
      G9367 At least two orders for the same high-risk medication
    • Performance not met (patient not included in numerator, but included in denominator): G9366 One high-risk medication not ordered
      G9368 At least two orders for the same high-risk medications not ordered

    How to Report This Measure, IRIS Registry EHR Reporting

    2018 additions in red.

    Instructions: Percentage of patients 65 years of age and older who were ordered high-risked medications.

    Two rates are reported –

    • Percentage of patients who were ordered at least one high-risk medication.
    • Percentage of patients who were ordered at least two of the same high-risk medications

    These are the required elements to be documented at least once a year to meet the measure performance requirements.

    • Prescription of high-risk medications in the elderly population. No ophthalmic medication are categorized as high-risk in 2018.

    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 Medication Management expert 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. Certain medications (MacKinnon 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 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).

    How CMS Scores Your Performance

    • If you successfully report a measure for less than 60 percent of your patients, you will earn points based on your practice size:
      • Small practices (≤ 15 clinicians) will receive 3 points,
      • Larger practices (> 15 clinicians) will receive 1 point.
    • If you successfully report a measure for at least 60 percent of your patients, but do not report at least 20 cases, you will receive 3 points.
    • If you report this measure for at least 60 percent of applicable patients and on at least 20 patients during a reporting period, you will earn points based on the decile that corresponds to your performance rate. Not all measures offer points for every decile.
    Decile/Points EHR (including IRIS integration) Registry (No EHR)
    3 12.02 – 6.84 11.54 – 7.33
    4 6.83 – 3.53 7.32 – 4.11
    5 3.52 – 1.50 4.10 – 1.94
    6 1.49 – 0.49 1.93 – 0.77
    7 0.48 – 0.01 0.76 – 0.24
    8 -- 0.23 – 0.01
    9 -- --
    10 0.00 0.00