Brief Description of Measure:

​CMS156: Use of High-Risk Medications in Older Adults:
Percentage of patients 65 years of age and older who were ordered at least two of the same high-risk medications.

Description of Issue:

​​The HEDIS MY2022 Use of High-Risk Medications in Older Adults (DAE) measure includes an average daily dose criteria for meeting Numerator 1 compliance. NCQA recommends adding this average daily dose criteria as an additional way to meet Numerator 1 compliance. This addition will not only address the eCQM standards team's recommendations to consider assessing high-risk dosage, but also to align CMS156 with HEDIS MY2022 DAE measure specifications, based on recommendations in the American Geriatrics Society (AGS) 2019 Updated Beers Criteria for Potentially Inappropriate Medication Use in Older Adults.
 
Patients who meet both of the following are numerator compliant:
1. Two or more orders on different days
2. Each order exceeds the average daily dose criteria:
    - Reserpine > 0.1 mg/day
    - Digoxin > 0.125 mg/day
    - Doxepin > 6 mg/day
 
The measure will include a function to achieve the following average daily dose calculation:
Multiply the quantity of pills  dispensed 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, 0.25mg each pill, has an average daily dose of 0.125mg. To calculate average daily dose for elixirs and concentrates, multiply the volume dispensed by daily dose and divide by the days supply.
 
In CQL QDMv5.6, the following formula will be used: average daily dose =  (dosage*supply)/daysSupplied. In the event that daysSupplied is not available, derive from supply/(dosage*frequency), as recommended by QDM  v5.6 guidance. The supply and dosage Quantity values on the order are assumed to be in terms of the same unit, e.g. tablet or mL.
QDM v5.6 guidance:https://ecqi.healthit.gov/sites/default/files/QDM-v5.6-508.pdf

Proposed Solution:

​//Header: Definition
//Before
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

//After
A high-risk medication is identified by any one of the following:
a. A prescription for medications classified as high risk at any dose and for any duration
b. A prescription for medications classified as high risk at any dose with greater than a 90 day supply
c. A prescription for medications classified as high risk exceeding average daily dose criteria

//Header: Numerator
//Before
Rate 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).

//After
Rate 1: Patients with at least two orders of high-risk medications from the same drug class on different days.
a. At least two orders of high-risk medications from the same drug class
b. At least two orders of high-risk medications from the same drug class with summed days supply greater than 90 days
c. At least two orders of high-risk medications from the same drug class each exceeding average daily dose criteria
Rate 2: Patients with at least two orders of high-risk medications from the same drug class (i.e., antipsychotics and benzodiazepines), on different days.
Total rate (the sum of the two previous numerators, deduplicated).

//Terminology
//Before
...

//After
valueset "Reserpine" (2.16.840.1.113883.3.464.1003.1044)
valueset "Digoxin" (2.16.840.1.113883.3.464.1003.1065)
valueset "Doxepin" (2.16.840.1.113883.3.464.1003.1067)

//Logic
//Before
define "Numerator 1":
  exists ( "Same High Risk Medications Ordered on Different Days" )
    or ( "Two High Risk Medications with Prolonged Duration" )

//After
define "Numerator 1":
  exists ( "Same High Risk Medications Ordered on Different Days" )
    or ( "Two High Risk Medications with Prolonged Duration" )
    or ( "High Risk Medications with Average Daily Dose Criteria" )

define "High Risk Medications with Average Daily Dose Criteria":
  ( Count(("More Than One... Order"(["Medication, Order": "Reserpine"]))Reserpine
        where "Average Daily Dose"(Reserpine)> 0.1 'mg/d'
    )
  ) >= 2
    or ( Count(("More Than One... Order"(["Medication, Order": "Digoxin"]))Digoxin
          where "Average Daily Dose"(Digoxin)> 0.125 'mg/d'
      )
    ) >= 2
    or ( Count(("More Than One... Order"(["Medication, Order": "Doxepin"]))Doxepin
          where "Average Daily Dose"(Doxepin)> 6 'mg/d'
      )
    ) >= 2
define function "Average Daily Dose"(MedicationOrder "Medication, Order" ):
  MedicationOrder Order
    let DaysSupplied: Coalesce(Order.daysSupplied, Order.supply.value /(Order.dosage.value * CMD.ToDaily(Order.frequency)))
    return if DaysSupplied is not null
      and ( Order.dosage.unit = 'mg'
          or ( Order.dosage.unit = 'mg/mL'
              and Order.supply.unit = 'mL'
          )
      ) then ( ( Order.dosage * Order.supply ) / Quantity { value: DaysSupplied, unit: 'day' } )
      else null

Rationale for Change:

​The proposed change incorporates eCQM standards team's recommendation to assess high-risk dosage, and aligns the measure its HEDIS parent measure, which is based on recommendations in the American Geriatrics Society (AGS) 2019 Updated Beers Criteria for Potentially Inappropriate Medication Use in Older Adults.