Use of High-Risk Medications in Older Adults

Measure Specification

Certain medications are associated with increased risk of harm from drug side-effects and drug toxicity and pose a concern for patient safety. There is clinical consensus that these drugs pose increased risks in older adults. Potentially inappropriate medication (PIM) use in older adults has been connected to significantly longer hospital stay lengths and increased hospitalization costs as well as increased risk of death.

Use of specific high-risk medications such as hypnotics, including benzodiazepine receptor agonists, and nonsteroidal anti-inflammatory drugs (NSAIDS) can result in increased risk of delirium, falls, fractures, gastrointestinal bleeding and acute kidney injury. Long-term use of benzodiazepines in older adults has been associated with increased risk of dementia.

Additionally, the use of antipsychotics can lead to increased risk of stroke and greater cognitive decline in older adults with dementia. Among Medicare beneficiaries it is estimated that the prevalence of PIM use was 77% among long-stay nursing home residents (defined as >101 consecutive days in a nursing home). The most common PIMs were benzodiazepines, antipsychotics, and insulin.

Older adults receiving inappropriate medications are more likely to report poorer health status at follow-up, compared to those who receive appropriate medications. A study of the prevalence of potentially inappropriate medication use in older adults found that 40 percent of individuals 65 and older filled at least one prescription for a potentially inappropriate medication and 13 percent filled two or more.

While some adverse drug events (ADEs) are unavoidable, studies estimate that between 30 and 80 percent of ADEs in older adults are preventable. More recently with the onset of the COVID-19 pandemic, several studies have shown an increase in anxiety, insomnia and depression rates, which could result in an increase in the use of high-risk medications in order to treat these conditions.

Reducing the number of inappropriate prescriptions can lead to improved patient safety and significant cost savings. Conservative estimates of extra costs due to potentially inappropriate medications in older adults average $7.2 billion a year. Medication use by older adults will likely increase further as the U.S. population ages, new drugs are developed, and new therapeutic and preventive uses for medications are discovered.

The annual direct costs of preventable ADEs in the Medicare population have been estimated to exceed $800 million. By the year 2030, nearly one in five U.S. residents is expected to be aged 65 years or older; this age group is projected to more than double from 38.7 million in 2008 to more than 88.5 million in 2050. Likewise, the population aged 85 years or older is expected to increase almost four-fold, from 5.

4 million to 19 million between 2008 and 2050. As the older adult population continues to grow, the number of older adults who present with multiple medical conditions for which several medications are prescribed will likely continue to increase, resulting in polypharmacy concerns.

The measure is based on recommendations from the American Geriatrics Society Beers Criteria for Potentially Inappropriate Medication Use in Older Adults (2023). 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, 2015 and 2019 and, most recently the American Geriatrics Society Beers Criteria Update Expert Panel in 2023.

The Beers Criteria identifies lists of drugs that are potentially inappropriate for all older adults, except for those with certain conditions for which some high-risk medications may be warranted, and drugs that are potentially inappropriate in older adults based on various high-risk factors such as dosage, days’ supply and underlying diseases or conditions.

NCQA's Geriatric Measurement Advisory Panel recommended a subset of drugs that should be used with caution in older adults for inclusion in the proposed measure based upon the recommendations in the Beers Criteria.

This measure contains two strata defined by two submission criteria. This measure produces two performance rates. There are 2 Submission Criteria for this measure: 1) Patients 65 years of age and older who were ordered at least two high-risk medications from the same drug class. AND 2) 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.

This measure will be calculated with 2 performance rates: 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.

For accountability reporting in the CMS MIPS program, the rate for submission criteria 1 is used for performance. For the purposes of MIPS implementation, this patient-process measure is submitted a minimum of once per patient during the performance period. The most advantageous quality data code (QDC) will be used if the measure is submitted more than once.

This is an inverse measure which means a lower calculated performance rate for this measure indicates better clinical care or control. The “Performance Not Met” numerator option for this measure is the representation of the better clinical quality or control. Submitting that numerator option will produce a performance rate that trends closer to 0%, as quality increases.

For inverse measures, a rate of 100% means all of the denominator eligible patients did not receive the appropriate care or were not in proper control.