The changing seasons of quality: The new IQR measures, part 1

Oct. 28, 2019 / By Cheryl Manchenton, RN

“A time to weep and a time to laugh; a time to mourn, and a time to dance” Ecclesiastes 3:4

Fall brings joy to some and sadness to others. I mourn because of the ever shortening days and cool temperatures while others celebrate all things pumpkin, leaves and fall. In my previous blogs, I described the changing times as reflected in the proposed and not yet finalized new electronic Clinical Quality Measures (eCQMs). Over these next three blogs, I will discuss the two new quality measures under the Inpatient Quality Reporting Program (IQR), as well as one that was not finalized.  The new programs, again, clearly reflect the changes in health care and the focus of quality initiatives.

Today we will discuss adoption of the new eCQM, Safe Use of Opioids—Concurrent Prescribing. 

CMS noted that fatalities from unintentional opioid overdose have become an epidemic in the last 20 years. They stated that more than 42,000 deaths were due to opioid overdose and 40 percent of those deaths were due to prescription opioids. The also referenced a recent retrospective study of claims data that noted concurrent benzodiazepine and opioid use increased by 80 percent between 2001 and 2013 in a sample of privately insured patients and this increase significantly contributed to the overall population risk of opioid overdose in the United States.

Clinical practice clearly indicates that both medications increase the risk of respiratory depression and concurrent use of benzodiazepines with opioids was present in more than 30 percent of fatal overdoses. Even with this current knowledge, these medications have continued to be prescribed simultaneously. They also noted rates of fatal overdose are 10 times higher in patients who are co-dispensed opioid analgesics and benzodiazepines versus opioids alone. The rates of overdoses due to both drugs used together have steadily increased by 14 percent each year from 2006 to 2011, but those due to opioids alone did not change significantly. Finally, a study of patients in 2015 noted that reducing concurrent use of opioids and benzodiazepines could reduce risk of opioid-related overdose related ED and inpatient visits by 15 percent and could have prevented an estimated 2,630 deaths.

CMS noted the intent of monitoring opioid prescription is to reduce preventable mortality and costs associated with other adverse events associated with opioid use. They also note no current measure exists to assess nationwide rates of concurrent prescribing of opioids and benzodiazepines at the hospital level. The opioid crisis is recognized as a priority focus area by CMS and HHS, and collection and reporting concurrent prescribing rates advances one of the key strategies prioritized by HHS in its five-point opioid strategy. This eCQMs addresses additional Meaningful Measures quality priorities in the IQR program not currently addressed by any eCQM: “Promoting Effective Prevention and Treatment of Chronic Disease” and “Making Care Safer by Reducing Harm caused in the Delivery of Care” in the areas of “Prevention and Treatment of Opioid and Substance Use Disorders” and “Preventable Healthcare Harm.”

The measure’s concept is based on the 2016 CDC Guideline for Prescribing Opioids for Chronic Pain, which includes the recommendation that clinicians should avoid prescribing opioids and benzodiazepines concurrently whenever possible.

The measure calculates the proportion of patients ages 18 and older who were concurrently prescribed or continued on two or more opioids (Schedule I or II) or opioids (Schedule II or III) and benzodiazepines (Schedule IV) at discharge from a hospital-based encounter (inpatient stay equal or less than 120 days.  They also noted for patients admitted to ED or observation may not ultimately be admitted as inpatients and would not be part of this eCQM.

An improvement in performance would be evidenced by a decrease in the measure score (percentage of patients prescribed) and CMS noted they did not expect the measure rate to be zero as there are rare occasions when it is appropriate to prescribe multiple opioids or a combination of opioids and a benzodiazepine.

Note the measure was studied to determine if patients on long-term opioids and benzodiazepines should be excluded from the measure. However, testing indicated this was a very small portion of eligible cases captured by the numerator during testing. They noted the only guidelines supporting exclusion of patients would be for cancer and palliative care and as such, this eCQM excludes patients with a diagnosis of active cancer or order for palliative care during the encounter. The measure also only includes those prescribed at discharge (rather than those spanning the duration of the encounter).

There is no risk-adjustment, as it is a process measure and risk-adjustment is made via the excluded populations of active cancer and palliative care status.

This measure has been endorsed by the National Quality Forum (NQF). Also keep in mind the anticipated effects noted by CMS were:

• Encourage hospital prescribers to use data from prescription drug-monitoring programs
• Increase effective communication among providers to coordinate care across hospital and ambulatory care settings
• Establishment of a benchmark of opioid prescribing in inpatient settings

In addition to mandated eCQMs, starting with CY2022, hospitals are required to submit data on three self-selected eCQMs and the finalized Safe Use of Opioids-Concurrent Prescribing eCQM. Failure to report would result in a payment adjustment for FY2024. However, hospitals may voluntarily begin reporting for CY2021 with payment adjustment in 2023. 

Note CMS also proposed an eCQM Hospital Harm—Opioid-Related Adverse Events eCQM which was not finalized and will be the subject of an upcoming blog.

Look for future blogs on the other finalized IQR measure as well as other finalized changes to the quality programs.

Cheryl Manchenton is a senior inpatient consultant and project manager for 3M Health Information Systems.

Register now for our upcoming November Quality webinar: Preventing the Preventables.

References

¹Rudd, R., Aleshire, N., Zibbell, J. & Gladden, R.M. (2016). Increases in Drug and Opioid Overdose Deaths – United States, 2000-2014. Morbidity and Mortality Weekly Report, 64(50): 1378-82. Available at: http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6450a3.htm.

² Centers for Disease Control and Prevention. Drug Overdose Epidemic: Behind the Numbers. Available at: https://www.cdc.gov/drugoverdose/data/index.html.

³Sun, E., Dixit, A., Humphreys, K., Darnall, B., Baker, L. & Mackey, S. (2017). Association Between Concurrent Use of Prescription Opioids and Benzodiazepines and Overdose: Retrospective Analysis. BMJ, 356: j760.

⁴National Institute on Drug Abuse. Benzodiazepines and Opioids. Available at: https://www.drugabuse.gov/drugs-abuse/opioids/benzodiazepines -opioids.

⁵Sun, E., Dixit, A., Humphreys, K., Darnall, B., Baker, L. & Mackey, S. (2017). Association Between Concurrent Use of Prescription Opioids and Benzodiazepines and Overdose: Retrospective Analysis. BMJ, 356: j760.

⁶Dasgupta, N., Jonsson Funk, M., Proescholdbell, S., Hirsch, A., Ribisl, K.M. & Marshall, S. (2015). Cohort Study of the Impact of High-Dose Opioid Analgesics on Overdose Mortality. Pain Medicine. Available at: http://onlinelibrary.wiley.com/doi/10.1111/pme.12907/abstract.

⁷Liu, Y., Logan, J., Paulozzi, L., Zhang, K., Jones, C. (2013). Potential Misuse and Inappropriate Prescription Practices Involving Opioid Analgesics. American Journal of Managed Care, 19(8): 648-65.

⁸Mack, K., Zhang, K., Paulozzi, L. & Jones, C. (2015). Prescription Practices Involving Opioid Analgesics Among Americans with Medicaid, 2010. Journal of Health Care for the Poor and Underserved, 26(1): 182-98.

⁹Park, T., Saitz, R., Ganoczy, D., Ilgen, M.A. & Bohnert, A.S.B. (2015). Benzodiazepine Prescribing Patterns and Deaths from Drug Overdose Among U.S. Veterans Receiving Opioid Analgesics: Case -Cohort Study. BMJ, 350: h2698.

¹⁰Jones, C.M. & McAninch, J.K. (2015). Emergency Department Visits and Overdose Deaths from Combined Use of Opioids and Benzodiazepines. American Journal of Preventive Medicine, 49(4): 493-501.

¹¹Sun, E., Dixit, A., Humphreys, K., Darnall, B., Baker, L. & Mackey, S. (2017). Association Between Concurrent Use of Prescription Opioids and Benzodiazepines and Overdose: Retrospective Analysis. BMJ, 356: j760.

¹²Office of the Assistant Secretary for Preparedness and Response (ASPR). Public Health Emergency Declarations. Available at: https://www.phe.gov/emergency/news/healthactions/phe/pages/default.aspx.

¹³The Safe Use of Opioids – Concurrent Prescribing measure also addresses the quality priority of “Promoting Effective Communication and Coordination of Care” through the Meaningful Measure area of “Medication Management.” More in formation on CMS’ Meaningful Measures Initiative is available at: https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/QualityInitiativesGenInfo/MMF/General-info-Sub-Page.html.

¹⁴ Dowell, D., Haegerich, T. & Chou, R. (2016). CDC Guideline for Prescribing