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 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). Description of issue ​​Vendors have encountered challenges when submitting Numerator Exclusions for this measure to the QPP PY2022 receiving system. To address these challenges, and align with the way these patients are accounted for in the CQM specification, the measure developer is exploring moving the numerator exclusion criteria into the numerator criteria as 'negative inclusion', or looking for these conditions to not exist. Goal of review Obtain clinical and technical feedback

Proposed solution ​//Header - before   Numerator: 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.   Numerator Exclusions: Rate 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 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.   //Header - after   Numerator: 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 except for appropriate diagnosis. a. Patients with two or more antipsychotic prescriptions ordered on different days, and did not 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 IPSD for antipsychotics. b. Patients with two or more benzodiazepine prescriptions ordered on different days, and did not 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.   Numerator Exclusions: None   //Logic - before   define "Numerator 2":  ( "More than One Antipsychotic Order" )    or ( "More than One Benzodiazepine Order" )   define "Numerator Exclusion":  ( "More than One Antipsychotic Order"      and not ( "More than One Benzodiazepine Order" )      and ( exists ( ( ["Diagnosis": "Schizophrenia"]            union ["Diagnosis": "Bipolar Disorder"]            ... ) AntipsychoticTreatedDiagnoses            where AntipsychoticTreatedDiagnoses.prevalencePeriod overlaps Interval[start of "Measurement Period" - 1 year, "Antipsychotic Index Prescription Start Date"]       )     ) )    or ( "More than One Benzodiazepine Order"        and not ( "More than One Antipsychotic Order" )        and ( exists ( ( ["Diagnosis": "Seizure Disorder"]              union ["Diagnosis": "REM Sleep Behavior Disorder"]              union ["Diagnosis": "Benzodiazepine Withdrawal"]              union ["Diagnosis": "Alcohol Withdrawal"]              union ["Diagnosis": "Generalized Anxiety Disorder"] ) BenzodiazepineTreatedDiagnoses              where BenzodiazepineTreatedDiagnoses.prevalencePeriod overlaps Interval[start of "Measurement Period" - 1 year, "Benzodiazepine Index Prescription Start Date"]         )       )   )    or ( "More than One Benzodiazepine Order"        and ( "More than One Antipsychotic Order" )        and ( exists ( ( ["Diagnosis": "Seizure Disorder"]              union ["Diagnosis": "REM Sleep Behavior Disorder"]              union ["Diagnosis": "Benzodiazepine Withdrawal"]              union ["Diagnosis": "Alcohol Withdrawal"]              union ["Diagnosis": "Generalized Anxiety Disorder"] ) BenzodiazepineTreatedDiagnoses              where BenzodiazepineTreatedDiagnoses.prevalencePeriod overlaps Interval[start of "Measurement Period" - 1 year, "Benzodiazepine Index Prescription Start Date"]         )       )        and ( exists ( ( ["Diagnosis": "Schizophrenia"]              union ["Diagnosis": "Bipolar Disorder"]              ... ) AntipsychoticTreatedDiagnoses              where AntipsychoticTreatedDiagnoses.prevalencePeriod overlaps Interval[start of "Measurement Period" - 1 year, "Antipsychotic Index Prescription Start Date"]         )       )   )   define "Numerator 3":  ( "Numerator 2"      and not "Numerator Exclusion" )    or ( "Numerator 1"        and not "Numerator 2"   )   //Logic - after   define "Numerator 2":  ( "More than One Antipsychotic Order"      and ( not exists ( ( ["Diagnosis": "Schizophrenia"]            union ["Diagnosis": "Bipolar Disorder"] ) AntipsychoticTreatedDiagnoses            where AntipsychoticTreatedDiagnoses.prevalencePeriod overlaps Interval[start of "Measurement Period" - 1 year, "Antipsychotic Index Prescription Start Date"]       )     ) )    or ( "More than One Benzodiazepine Order"        and ( not exists ( ( ["Diagnosis": "Seizure Disorder"]              union ["Diagnosis": "REM Sleep Behavior Disorder"]              union ["Diagnosis": "Benzodiazepine Withdrawal"]              union ["Diagnosis": "Alcohol Withdrawal"]              union ["Diagnosis": "Generalized Anxiety Disorder"] ) BenzodiazepineTreatedDiagnoses              where BenzodiazepineTreatedDiagnoses.prevalencePeriod overlaps Interval[start of "Measurement Period" - 1 year, "Benzodiazepine Index Prescription Start Date"]         )       )   )   define "Numerator 3":  "Numerator 2"    or ( "Numerator 1"        and not "Numerator 2"   ) Rationale for change ​​As part of the exploratory effort to reduce reporting burden, the measure developer is proposing an alternative to using "Numerator Exclusions" but still removing patients with conditions where the high-risk medication orders are acceptable. The proposed change is to revise the Numerator Exclusions criterion to a Numerator negative inclusion criterion. This change would also align the measure with its HEDIS parent measure.