Telligen Quality Innovation Network Quality Improvement Organization

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1 Telligen Quality Innovation Network Quality Improvement Organization PQA Patient Safety Measures for Inappropriate Prescription Opioid Use August 29, 2017

2 Optimizing Patients' Health by Improving the Quality of Medication Use PQA Patient Safety Measures for Inappropriate Prescription Opioid Use August 29, 2017 Lisa Hines, PharmD Senior Director, Performance Measurement

3 Objectives Describe the (PQA) Highlight safety concerns addressed by PQA opioid measures Summarize PQA opioid measure development and specifications Illustrate geographic variation of PQA opioid measures 3

4 Who is the? Mission Statement: Improve the quality of medication management and use across health care settings with the goal of improving patients health through a collaborative process to develop and implement performance measures and recognize examples of exceptional pharmacy quality. Created in 2006 as a public-private partnership Multi-Stakeholder, Member-Based, Non-Profit Transparent & Consensus Based Process Nationwide Measure Developer 4

5 PQA s Industry Cross-Cutting Roles Measures fill gaps in high-priority areas of healthcare Focus on the priorities that align with the National Quality Strategy Consensus-driven process to draft, test, refine, and endorse measures Measure Developer Healthcare Quality Educator Continuing Education in Healthcare Quality for Providers, including Pharmacists Quality Workshops and Webinars (e.g., Quality Connections, Quality Forum) Annual Meetings and Leadership Summits Research and Demonstration Projects in Medication Use and Safety Inclusive of PQA Membership Promotion of Best Practices (e.g., Publications, White Papers) Research Convener Roundtables Collaborations Sharing of Best Practices 5

6 PQA s Membership 18% 27% Percentage by Industry/Sector 14% 15% 26% 15% HIT & Data Pharma/Life Sciences Health Plans, LTC, & Health Systems Academia Pharmacy & Wholesalers All Other Sectors 6

7 PQA s Measure Development Process Measure Concept Idea Measure Concept Development Draft Measure Testing Measure Endorsement Measure Update Measure Advisement Group Measure Development Teams Measure Validity Panel Measure Update Panel Task Forces PQA Member Organizations Stakeholder Advisory Panels Quality Metrics Expert Panel Risk Adjustment Advisory Panel Patient & Caregiver Advisory Panel Implementation Advisory Panel 7

8 Use of PQA Measures Medicare Part D Medicaid Adult Core Measure Set Accreditation Programs Pharmacies & Health Plans Health Insurance Marketplace Quality Rating System Statewide Quality Programs National Alliance of Healthcare Purchaser Coalitions Technology & Data Organizations Research & Pilot Programs Pay-for-Performance Pharmacy Networks Physician Offices 8

9 Medicare Part D Programs Star Ratings Public reporting, marketing/enrollment, financial Display Measures Public reporting, ratings, facilitate quality improvement Patient Safety reports Facilitate quality improvement, monitor performance Overutilization Monitoring System Identify high-risk opioid use 9

10 Rationale for PQA Opioid Prescribing Measures Nearly half of US opioid overdose deaths involve prescription opioids 1. CDC. Wide-ranging online data for epidemiologic research (WONDER); Available at 2. Rudd RA, et al. MMWR Morb Mortal Wkly Rep. epub: 16 December DOI: 10

11 Rationale for Opioid Prescribing Measures (cont.) Nearly 1 of 4 people who receive long-term prescription opioids for noncancer pain struggles with addiction 1. SAMHSA. Highlights of the 2011 Drug Abuse Warning Network (DAWN) findings on drug-related emergency department visits; Available at: 2. Boscarino JA, et al., Addiction 2010;105: org/ /j x 11

12 2016 County Opioid Prescribing Rate Per 100 Persons 1. U.S. County Prescribing Rates, Available at: 12

13 High Dosage Benefits of high-dose opioids for chronic pain not established Compared with dosages <20 MME/day Dosages 50 to <100 MME/day increase opioid overdose risk 1.9- to 4.6-fold Dosages 100 MME/day increase opioid overdose risk 2.0- to 8.9-fold A single dosage threshold for safe opioid use has not been identified CDC guidelines: Carefully assess benefits/risks: 50 MME/day Avoid or carefully justify: 90 MME/day CDC Guideline for Prescribing Opioids for Chronic Pain United States, Available at: 13

14 High Dosage (cont.) WA opioid dosing guideline: Do not increase chronic therapy to >120 MME/day without specialist consultation 1 Among injured workers in WA, introduction of the guideline in 2007 was temporally associated with 2 26% decrease in average dose for long-acting opioids 35% decrease of opioid doses of 120 MME/day 50% decrease in opioid-related deaths among injured workers ( ) 1. State of Washington s Agency Medical Director s Group Interagency Guideline on Prescribing Opioids for Pain. Available at : Available at: 2. Franklin, et al. Am J Ind Med. 2012;55: doi: /ajim PMID:

15 Multiple Providers Multiple prescribers or pharmacies associated with increased risk for potentially fatal overdose Risk increases with number of prescribers and pharmacies In West Virginia ( ), 4 prescribers and 4 pharmacies in previous 6 months increased risk of drug-related death 3.6-fold 1 In Tennessee ( ), 4 prescribers and 4 pharmacies increased risk of opioid-related overdose death 6.5- and 6.0-fold, respectively 2 1. Peirce GL, et al. Med Care. 2012;50(6): doi: /MLR.0b013e31824ebd81. PubMed PMID: Gwira Baumblatt J et al. JAMA Intern Med 2014;174: PMID:

16 Concurrent Use with Benzodiazepines Concurrent use of benzodiazepines with opioids increased overdose death risk 4-fold among US veterans ( ) 1 Concurrent use increased by nearly 80% (9% to 17%) among privately insured patients ( ) 2 Increased risk of ED visit or hospital admission for opioid overdose 2-fold Eliminating concurrent use could reduce population risk by 15% CDC guidelines: Avoid concurrent prescribing whenever possible 3 FDA added boxed warning to product labeling 4 1. Park et al. BMJ. 2015;350:h2698. doi: /bmj.h2698. PMID: Sun et al. BMJ. 2017;356:j760. doi: /bmj.j760. PMID: CDC Guideline for Prescribing Opioids for Chronic Pain United States, Available at: 4. FDA Drug Safety Communication. August 31, Available at: 16

17 PQA Opioids Measures 1. Use of Opioids at High Dosage in Persons without Cancer (NQF #2940) * 2. Use of Opioids from Multiple Providers in Persons without Cancer (NQF #2950) * 3. Use of Opioids at High Dosage and from Multiple Providers in Persons without Cancer (NQF #2951) * 4. Concurrent Use of Opioids and Benzodiazepines ** NQF = National Quality Forum * PQA-endorsed May 2015; NQF-endorsed March 2017 ** PQA-endorsed December 2016; seeking NQF endorsement in

18 PQA Opioid Measures (cont.) Intended Use Performance measurement for health plans Data Source Prescription and administrative claims 18

19 1. Use of Opioids at High Dosage in Persons without Cancer (OHD) Description The proportion (XX out of 1,000) of individuals (age 18 years) receiving prescriptions for opioids with a daily dosage >120 MME for 90 consecutive days. A lower rate is better. Excludes patients in hospice care and those with cancer Denominator Individuals with 2 prescription claims for opioids filled on 2 separate days, for which the sum of the days supply is 15. Numerator Individuals from the denominator with >120 MME for 90 consecutive days. MME = morphine milligram equivalents 19

20 2. Use of Opioids from Multiple Providers in Persons without Cancer Description The proportion (XX out of 1,000) of individuals (age 18 years) receiving prescriptions for opioids from 4 prescribers AND 4 pharmacies. A lower rate is better. Excludes patients in hospice care and those with cancer Denominator Individuals with 2 prescription claims for opioids filled on 2 separate days, for which the sum of the days supply is 15. Numerator Individuals from the denominator who received opioids from 4 prescribers AND 4 pharmacies. 20

21 3. Use of Opioids at High Dosage and From Multiple Providers in Persons without Cancer Description The proportion (XX out of 1,000) of individuals (age 18 years) receiving prescriptions for opioids with a daily dosage >120 MME for 90 consecutive days, AND from 4 prescribers AND 4 pharmacies. A lower rate is better. Excludes patients in hospice care and those with cancer. Denominator Individuals with 2 prescription claims for opioids filled on 2 separate days, for which the sum of the days supply is 15. Numerator Individuals from the denominator with >120 MME for 90 consecutive days AND who received opioid prescriptions from 4 prescribers AND 4 pharmacies. MME = morphine milligram equivalents 21

22 4. Concurrent Use of Opioids and Benzodiazepines Description The percentage of individuals (age 18 years) with concurrent use of prescription opioids and benzodiazepines for 30 or more cumulative days. A lower rate is better. Excludes patients in hospice care and those with cancer. Denominator Individuals with 2 prescription claims for opioids filled on 2 separate days, for which the sum of the days supply is 15. Numerator Individuals from the denominator with 2 prescription claims for benzodiazepines filled on 2 separate days, and concurrent use of opioids and benzodiazepines for 30 cumulative days. 22

23 Use of PQA Opioid Measures in Medicare Part D High Dosage (#1), Multiple Providers (#2), and High Dosage/Multiple Providers (#3) reported through the Patient Safety Analysis website starting in 2016 High Dosage/Multiple Provider (#3) planned to be added to the 2019 Display Page (using 2017 data) Concurrent Benzodiazepines (#4) referenced in the Calendar Year 2018 Final Call Letter for future testing/consideration CMS. CY 2018 Medicare Advantage Capitation Rates and Medicare Advantage and Part D Payment Policies and Final Call Letter and Request for Information. April 3, Available at: 23

24 Use of PQA Opioid Measures in Medicaid Medicaid Adult Core Measure Set High Dosage (#1) added to measure set in Concurrent Benzodiazepines (#4) conditionally supported (pending NQF endorsement) by the Measures Application Partnership for addition 2 NQF = National Quality Forum 1. Medicaid Adult Health Care Quality Measures. Available at: 2. Measures Application Partnership. Medicaid Adult Draft Report for Comment. August 8, Available at 24

25 Geographic Variation of Inappropriate Prescription Opioid Use among Disabled Medicare Beneficiaries Objective To examine geographic variation of potentially inappropriate prescription opioid use among non-cancer disabled Medicare beneficiaries Design Cross-sectional study Methods 5% random sample of Medicare beneficiaries from Primary outcome: Among disabled Medicare opioid users ( 2 prescriptions with total days supply 15 days) by Dartmouth Atlas of Healthcare Hospital Referral Regions each year, % of beneficiaries with high-dose, multiple providers, or concurrent benzodiazepines 25

26 2011 High-dose,

27 Multiple Providers,

28 Concurrent Benzodiazepine Use,

29 Research Team University of Arizona Drs. Jenny Lo-Ciganic, Kent Kwoh, Daniel Malone, Sandipan Bhattacharjee, Jeannie Lee, Melanie Bell, Ms. Lili Zhou and Mr. Westra Jordan University of Pittsburgh Drs. Walid Gellad & Julie Donohue University of Wisconsin Dr. Anne Roubal Dr. Lisa Hines ESRI Inc. Mr. Jeremiah Lindemann 29

30 Conclusion There is wide variation in opioid prescribing PQA opioid measures address high-risk opioid prescribing among persons without cancer Performance measures are one tool to address the US prescription opioid crisis Use of opioid measures in performance programs will be monitored for possible unintended consequences PQA will continue to evaluate the need for potential changes or additional measures 30

31 Questions? Lisa Hines Senior Director, Performance Measurement 31

32 Telligen QIN-QIO Contacts Katy Brown, PharmD, Program Manager Lead, Telligen Desk: Cell: Medication Safety webpage at: 32 This material was prepared by the and is being provided by Telligen, the Medicare Quality Innovation Network Quality Improvement Organization for Colorado, Illinois and Iowa under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents presented do not necessarily reflect CMS policy. 11SOW-QIN-C3.6-08/23/