Statement on Inconsistency between Technical Specification and Published Guidance Associated with eCQM CMS156 (NQF0022)

In review of eCQM tools in our EHR we have discovered a critical flaw in the technical specifications for CMS 156 (NQF 0022) – Use of High Risk Medications for the Elderly.

It concerns the use of topical estrogen creams for vaginal dryness and dyspareunia frequently associated with menopause. Consequently, these pharmaceuticals are very commonly used by women in the geriatric population.

The Clinical Recommendation Statement accompanying CMS 156 states, “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.” (https://ecqi.healthit.gov/system/files/ecqm/measures/CMS156v5_3.html#d1e647, Retrieved on 7/26/2017) Further, the document references Campanelli, Christine 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, and 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 in support of the standard.

However, the latter document, the 2015 Updated Beers Criteria, reviewed and retained unaltered for the 2017 guideline statement of the American Geriatric Society very clearly states, “Evidence indicates that vaginal estrogens for the treatment of vaginal dryness are safe and effective”. The guideline recommendations maintain that it is, “acceptable to use low-dose intravaginal estrogen for management of dyspareunia, lower urinary tract infections, and other vaginal symptoms”. (Radcliff, S., Yue, J., Rocco, G., Aiello, S. E., Ickowicz, E., Hurd, Z., ... & Beers, M. H. (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. Downloaded from https://geriatricscareonline.org/toc/american-geriatrics-society-updated-beers-criteria-for-potentially-inappropriate-medication-use-in-older-adults/CL001)

Review of the NLM Value Set for this measure reflects the omission of the following RxNorm codes for low-dose (0.06%) topical estrogen gel:

379698

405452 (Estrogel)

581549

581547

706464 (Elestrin)

706465

706467.

Curiously, however, RxNorm code 226597 which corresponds with the identical medication does appear in the value set. This technical specification contradicts both the published standard for the metric and the source material cited as evidence for its contents.

As the technical specification is inconsistent with the published standard for the eCQM as well as with common clinical application based on the cited guideline, it should be corrected by deletion of RxNorm code 226597 from the value set and from technical guidelines for the measure effective for the 2017 reporting period.