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:

​Upon internal review, the measure developer determined that although the CMS 156 header states that at least two orders from the same drug class would meet Numerator 1 compliance, the current logic assesses whether there are at least two orders of the same medication, not medications from the same drug class.
 
For example, if on different dates of service during the measurement period, a patient had an order of Brompheniramine and an order of Carbinoxamine, this is considered two orders from the same drug class and the patient meets numerator compliance. However, the logic would assess this patient as numerator not met, because the logic looks for at least two orders of the same medication.
 
This is because the logic evaluates "More Than One of Same Medication Order" per medication, e.g., Brompheniramine and Carbinoxamine, instead of by drug class, e.g., anticholinergics, first-generation antihistamines.
 
The measure developer plans to update the corresponding  logic and terminology to implement measure intent and to align it with the header description. The header description should consistently use the language "...from the same drug class".
 
To facilitate this, the measure developer will group medication value sets into drug class groupings and update the logic to assess "More Than One Order" by drug class.

Proposed Solution:

//Header: Guidance
//Before
...two of the same high-risk medication prescriptions from the same medication class on different days...
...unless the reporting provider also ordered a high-risk medication for them...
 
//After
...two high-risk medication prescriptions from the same drug class on different days...
...unless the reporting provider also ordered a high-risk medication from the same drug class for them...
 
//Terminology
//Before
valueset "Amitriptyline Hydrochloride" (2.16.840.1.113883.3.464.1003.196.12.1373)
valueset "Amoxapine" (2.16.840.1.113883.3.464.1003.196.12.1273)
valueset "Benztropine" (2.16.840.1.113883.3.464.1003.196.12.1361)
valueset "Brompheniramine" (2.16.840.1.113883.3.464.1003.196.12.1427)
valueset "Butabarbital" (2.16.840.1.113883.3.464.1003.196.12.1402)
valueset "Butalbital" (2.16.840.1.113883.3.464.1003.196.12.1514)
valueset "Carbinoxamine" (2.16.840.1.113883.3.464.1003.196.12.1306)
valueset "Carisoprodol" (2.16.840.1.113883.3.464.1003.196.12.1369)
valueset "Chlorpheniramine" (2.16.840.1.113883.3.464.1003.196.12.1352)
valueset "Chlorpropamide" (2.16.840.1.113883.3.464.1003.196.12.1303)
valueset "Chlorzoxazone" (2.16.840.1.113883.3.464.1003.196.12.1362)
valueset "Clemastine" (2.16.840.1.113883.3.464.1003.196.12.1308)
valueset "Clomipramine" (2.16.840.1.113883.3.464.1003.196.12.1336)
valueset "Conjugated Estrogens" (2.16.840.1.113883.3.464.1003.196.12.1357)
valueset "Cyclobenzaprine Hydrochloride" (2.16.840.1.113883.3.464.1003.196.12.1372)
valueset "Cyproheptadine" (2.16.840.1.113883.3.464.1003.196.12.1277)
valueset "Desiccated Thyroid" (2.16.840.1.113883.3.464.1003.196.12.1354)
valueset "Desipramine" (2.16.840.1.113883.3.464.1003.196.12.1278)
valueset "Dexbrompheniramine" (2.16.840.1.113883.3.464.1003.196.12.1375)
valueset "Dexchlorpheniramine" (2.16.840.1.113883.3.464.1003.196.12.1300)
valueset "Dicyclomine" (2.16.840.1.113883.3.464.1003.196.12.1279)
valueset "Dimenhydrinate" (2.16.840.1.113883.3.464.1003.196.12.1500)
valueset "Diphenhydramine" (2.16.840.1.113883.3.464.1003.196.12.1293)
valueset "Dipyridamole" (2.16.840.1.113883.3.464.1003.196.12.1349)
valueset "Disopyramide" (2.16.840.1.113883.3.464.1003.196.12.1311)
valueset "Doxylamine" (2.16.840.1.113883.3.464.1003.196.12.1515)
valueset "Esterified Estrogens" (2.16.840.1.113883.3.464.1003.196.12.1419)
valueset "Estradiol" (2.16.840.1.113883.3.464.1003.196.12.1365)
valueset "Estropipate" (2.16.840.1.113883.3.464.1003.196.12.1319)
valueset "Glyburide" (2.16.840.1.113883.3.464.1003.196.12.1368)
valueset "Guanfacine" (2.16.840.1.113883.3.464.1003.196.12.1341)
valueset "Hydroxyzine" (2.16.840.1.113883.3.464.1003.196.12.1374)
valueset "Hyoscyamine" (2.16.840.1.113883.3.464.1003.196.12.1501)
valueset "Imipramine" (2.16.840.1.113883.3.464.1003.196.12.1359)
valueset "Indomethacin" (2.16.840.1.113883.3.464.1003.196.12.1366)
valueset "Isoxsuprine" (2.16.840.1.113883.3.464.1003.196.12.1422)
valueset "Ketorolac Tromethamine" (2.16.840.1.113883.3.464.1003.196.12.1364)
valueset "List of Single RxNorm Code Concepts for High Risk Drugs for the Elderly" (2.16.840.1.113883.3.464.1003.196.12.1272)
valueset "Meclizine" (2.16.840.1.113883.3.464.1003.196.12.1506)
valueset "Megestrol" (2.16.840.1.113883.3.464.1003.196.12.1342)
valueset "Meperidine" (2.16.840.1.113883.3.464.1003.196.12.1351)
valueset "Meprobamate" (2.16.840.1.113883.3.464.1003.196.12.1284)
valueset "Metaxalone" (2.16.840.1.113883.3.464.1003.196.12.1358)
valueset "Methocarbamol" (2.16.840.1.113883.3.464.1003.196.12.1370)
valueset "Methscopolamine" (2.16.840.1.113883.3.464.1003.196.12.1525)
valueset "Methyldopa" (2.16.840.1.113883.3.464.1003.196.12.1331)
valueset "Nifedipine" (2.16.840.1.113883.3.464.1003.196.12.1353)
valueset "Nortriptyline" (2.16.840.1.113883.3.464.1003.196.12.1507)
valueset "Orphenadrine" (2.16.840.1.113883.3.464.1003.196.12.1302)
valueset "Paroxetine" (2.16.840.1.113883.3.464.1003.196.12.1508)
valueset "Pentobarbital" (2.16.840.1.113883.3.464.1003.196.12.1518)
valueset "Phenobarbital" (2.16.840.1.113883.3.464.1003.196.12.1348)
valueset "Promethazine Hydrochloride" (2.16.840.1.113883.3.464.1003.196.12.1367)
valueset "Propantheline" (2.16.840.1.113883.3.464.1003.196.12.1519)
valueset "Protriptyline" (2.16.840.1.113883.3.464.1003.196.12.1509)
valueset "Pyrilamine" (2.16.840.1.113883.3.464.1003.196.12.1524)
valueset "Secobarbital" (2.16.840.1.113883.3.464.1003.196.12.1521)
valueset "Trihexyphenidyl" (2.16.840.1.113883.3.464.1003.196.12.1334)
valueset "Trimipramine" (2.16.840.1.113883.3.464.1003.196.12.1285)
valueset "Triprolidine" (2.16.840.1.113883.3.464.1003.196.12.1408)
 
//After
valueset "Anticholinergics, anti-Parkinson agents" (2.16.840.1.113883.3.464.1003.1049)
valueset "Anticholinergics, first-generation antihistamines" (2.16.840.1.113883.3.464.1003.1043)
valueset "Antispasmodics" (2.16.840.1.113883.3.464.1003.1050)
valueset "Antithrombotic" (2.16.840.1.113883.3.464.1003.1051)
valueset "Cardiovascular, alpha agonists, central" (2.16.840.1.113883.3.464.1003.1052)
valueset "Cardiovascular, other" (2.16.840.1.113883.3.464.1003.1053)
valueset "Central nervous system, antidepressants" (2.16.840.1.113883.3.464.1003.1054)
valueset "Central nervous system, barbiturates" (2.16.840.1.113883.3.464.1003.1055)
valueset "Central nervous system, other" (2.16.840.1.113883.3.464.1003.1057)
valueset "Central nervous system, vasodilators" (2.16.840.1.113883.3.464.1003.1056)
valueset "Endocrine system, estrogens with or without progestins" (2.16.840.1.113883.3.464.1003.1058)
valueset "Endocrine system, other" (2.16.840.1.113883.3.464.1003.1060)
valueset "Endocrine system, sulfonylureas, long-duration" (2.16.840.1.113883.3.464.1003.1059)
valueset "Pain medications, other" (2.16.840.1.113883.3.464.1003.1063)
valueset "Pain medications, skeletal muscle relaxants" (2.16.840.1.113883.3.464.1003.1062)
 
//Logic: Numerator
//Before
define "Same High Risk Medications Ordered on Different Days":
  "More Than One of Same Medication Order of Single RxNorm Code Concepts"(["Medication, Order": "List of Single RxNorm Code Concepts for High Risk Drugs for the Elderly"])
    union "More Than One of Same Medication Order"(["Medication, Order": "Amitriptyline Hydrochloride"])
    union "More Than One of Same Medication Order"(["Medication, Order": "Amoxapine"])
    union "More Than One of Same Medication Order"(["Medication, Order": "Orphenadrine"])
    union "More Than One of Same Medication Order"(["Medication, Order": "Atropine"])
    union "More Than One of Same Medication Order"(["Medication, Order": "Benztropine"])
    union "More Than One of Same Medication Order"(["Medication, Order": "Brompheniramine"])
    union "More Than One of Same Medication Order"(["Medication, Order": "Butabarbital"])
    union "More Than One of Same Medication Order"(["Medication, Order": "Butalbital"])
    union "More Than One of Same Medication Order"(["Medication, Order": "Carbinoxamine"])
    union "More Than One of Same Medication Order"(["Medication, Order": "Carisoprodol"])
    union "More Than One of Same Medication Order"(["Medication, Order": "Chlorpheniramine"])
    union "More Than One of Same Medication Order"(["Medication, Order": "Chlorpropamide"])
    union "More Than One of Same Medication Order"(["Medication, Order": "Chlorzoxazone"])
    union "More Than One of Same Medication Order"(["Medication, Order": "Clemastine"])
    union "More Than One of Same Medication Order"(["Medication, Order": "Clomipramine"])
    union "More Than One of Same Medication Order"(["Medication, Order": "Conjugated Estrogens"])
    union "More Than One of Same Medication Order"(["Medication, Order": "Cyclobenzaprine Hydrochloride"])
    union "More Than One of Same Medication Order"(["Medication, Order": "Cyproheptadine"])
    union "More Than One of Same Medication Order"(["Medication, Order": "Desiccated Thyroid"])
    union "More Than One of Same Medication Order"(["Medication, Order": "Desipramine"])
    union "More Than One of Same Medication Order"(["Medication, Order": "Dexbrompheniramine"])
    union "More Than One of Same Medication Order"(["Medication, Order": "Dexchlorpheniramine"])
    union "More Than One of Same Medication Order"(["Medication, Order": "Dicyclomine"])
    union "More Than One of Same Medication Order"(["Medication, Order": "Dimenhydrinate"])
    union "More Than One of Same Medication Order"(["Medication, Order": "Diphenhydramine"])
    union "More Than One of Same Medication Order"(["Medication, Order": "Dipyridamole"])
    union "More Than One of Same Medication Order"(["Medication, Order": "Disopyramide"])
    union "More Than One of Same Medication Order"(["Medication, Order": "Doxylamine"])
    union "More Than One of Same Medication Order"(["Medication, Order": "Esterified Estrogens"])
    union "More Than One of Same Medication Order"(["Medication, Order": "Estradiol"])
    union "More Than One of Same Medication Order"(["Medication, Order": "Estropipate"])
    union "More Than One of Same Medication Order"(["Medication, Order": "Glyburide"])
    union "More Than One of Same Medication Order"(["Medication, Order": "Guanfacine"])
    union "More Than One of Same Medication Order"(["Medication, Order": "Hydroxyzine"])
    union "More Than One of Same Medication Order"(["Medication, Order": "Hyoscyamine"])
    union "More Than One of Same Medication Order"(["Medication, Order": "Imipramine"])
    union "More Than One of Same Medication Order"(["Medication, Order": "Indomethacin"])
    union "More Than One of Same Medication Order"(["Medication, Order": "Isoxsuprine"])
    union "More Than One of Same Medication Order"(["Medication, Order": "Ketorolac Tromethamine"])
    union "More Than One of Same Medication Order"(["Medication, Order": "Meclizine"])
    union "More Than One of Same Medication Order"(["Medication, Order": "Megestrol"])
    union "More Than One of Same Medication Order"(["Medication, Order": "Meperidine"])
    union "More Than One of Same Medication Order"(["Medication, Order": "Meprobamate"])
    union "More Than One of Same Medication Order"(["Medication, Order": "Metaxalone"])
    union "More Than One of Same Medication Order"(["Medication, Order": "Methocarbamol"])
    union "More Than One of Same Medication Order"(["Medication, Order": "Methyldopa"])
    union "More Than One of Same Medication Order"(["Medication, Order": "Nifedipine"])
    union "More Than One of Same Medication Order"(["Medication, Order": "Nortriptyline"])
    union "More Than One of Same Medication Order"(["Medication, Order": "Paroxetine"])
    union "More Than One of Same Medication Order"(["Medication, Order": "Pentobarbital"])
    union "More Than One of Same Medication Order"(["Medication, Order": "Phenobarbital"])
    union "More Than One of Same Medication Order"(["Medication, Order": "Promethazine Hydrochloride"])
    union "More Than One of Same Medication Order"(["Medication, Order": "Protriptyline"])
    union "More Than One of Same Medication Order"(["Medication, Order": "Propantheline"])
    union "More Than One of Same Medication Order"(["Medication, Order": "Scopolamine"])
    union "More Than One of Same Medication Order"(["Medication, Order": "Secobarbital"])
    union "More Than One of Same Medication Order"(["Medication, Order": "Trihexyphenidyl"])
    union "More Than One of Same Medication Order"(["Medication, Order": "Trimipramine"])
    union "More Than One of Same Medication Order"(["Medication, Order": "Triprolidine"])
    union "More Than One of Same Medication Order"(["Medication, Order": "Nonbenzodiazepine hypnotics"])
    union "More Than One of Same Medication Order"(["Medication, Order": "Methscopolamine"])
    union "More Than One of Same Medication Order"(["Medication, Order": "Pyrilamine"])
 
function "More Than One of Same Medication Order":

...
define "More Than One Antispychotic Order":
exists ( "More Than One of Same Medication Order"(["Medication, Order": "Antipsychotic"]))  
 
define "More Than One Benzodiazepine Order":
exists ( "More Than One of Same Medication Order"(["Medication, Order": "Benzodiazepine"]))  
 
//After
define "Same High Risk Medications Ordered on Different Days":
   "More Than One Order"(["Medication, Order": "Anticholinergics, first generation antihistamines"])
    union "More Than One Order"(["Medication, Order": "Anticholinergics, antiParkinson agents"])
    union "More Than One Order"(["Medication, Order": "Antispasmodics"])
    union "More Than One Order"(["Medication, Order": "Antithrombotic"])
    union "More Than One Order"(["Medication, Order": "Cardiovascular, alpha agonists, central"])
    union "More Than One Order"(["Medication, Order": "Cardiovascular, other"])
    union "More Than One Order"(["Medication, Order": "Central nervous system, antidepressants"])
    union "More Than One Order"(["Medication, Order": "Central nervous system, barbiturates"])
    union "More Than One Order"(["Medication, Order": "Central nervous system, vasodilators"])
    union "More Than One Order"(["Medication, Order": "Central nervous system, other"])
    union "More Than One Order"(["Medication, Order": "Endocrine system, estrogens with or without progestins"])
    union "More Than One Order"(["Medication, Order": "Endocrine system, sulfonylureas, long duration"])
    union "More Than One Order"(["Medication, Order": "Endocrine system, other"])
    union "More Than One Order"(["Medication, Order": "Nonbenzodiazepine hypnotics"])
    union "More Than One Order"(["Medication, Order": "Pain medications, skeletal muscle relaxants"])
    union "More Than One Order"(["Medication, Order": "Pain medications, other"])
 
function "More Than One Order":
...
 
define "More Than One Antispychotic Order":
exists ( "More Than One Order"(...))  
 
define "More Than One Benzodiazepine Order":
exists ( "More Than One Order"(...)) 

Rationale for Change:

​The goal of this change is to align the logic expression with the measure intent and header description to accurately capture two or more medications of the same drug class.