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  • Measure Summary
  • NQMC:010650
  • Jul 2015

Use of opioids from multiple providers or at high dosage in persons without cancer: the proportion of individuals without cancer receiving prescriptions for opioids with a daily dosage greater than 120 mg morphine equivalent dose (MED) for 90 consecutive days or longer.

Pharmacy Quality Alliance (PQA). Technical specifications for PQA approved measures. Springfield (VA): Pharmacy Quality Alliance (PQA); 2015 Jul. 66 p.

This is the current release of the measure.

Primary Measure Domain

Related Health Care Delivery Measures: Use of Services

Secondary Measure Domain

Does not apply to this measure

Description

This measure is used to assess the proportion (XX out of 1,000) of individuals 18 years and older without cancer receiving prescriptions for opioids with a daily dosage greater than 120 mg morphine equivalent dose (MED) for 90 consecutive days or longer.

Rationale

The purpose of quality measurement is to improve quality, inform consumers, reduce risk to patients and influence payment. At this time, the goal is to develop measure concepts that are indicative of potential improvements in or to our healthcare system so that evidence-based patient care can be provided and patient outcomes can be achieved, in consideration of costs and, ultimately, value.

Towards this end, the Pharmacy Quality Alliance (PQA) proposes 3 measures related to opioid use that are indicative of the quality of care for these medications. PQA proposes these measures to examine the quality of use related to the dose of the medications over time, access to the medications and the combination of both of these criteria.

Claims data from commercially insured patients indicate that approximately 8% of opioid prescriptions for acute pain and 12% for chronic pain specify a daily dosage of 120 morphine equivalent dose (MED) or more (Office of Disease Prevention and Health Promotion, 2014). The proportion of patients being treated at this dosage for more than 90 days has not been described. However, one study of veterans treated with 180 MED/day or more for 90+ days (Liu et al., 2013) found that this group was characterized by high rates of psychiatric and substance abuse disorders and frequently did not receive care consistent with clinical guidelines. Other studies have suggested the people at high opioid dosage are at greater risk of overdoses and fractures (Morasco et al., 2010; Washington State Agency Medical Directors Group, 2010; Dunn et al., 2010). The Washington State Agency Medical Directors Group has suggested 120 MED as a dosage level that should not be exceeded without special consideration (Paulozzi et al., 2012).

Prescription drug monitoring programs, which track the use of multiple providers by patients, indicate that such use is typically found among a small proportion of patients, with the proportion declining as the number of providers increases. In Massachusetts in 2006, considering only Schedule II opioids, 0.5% of patients saw 4+ prescribers and 4+ pharmacies (Saunders et al., 2010). A national study found that 13% of patients had overlapping prescriptions from two or more different prescribers during an 18-month period. Of these, 0.5% used 4+ prescribers and 4+ pharmacies (Katz et al., 2010). People who see multiple prescribers or use multiple pharmacies are more likely to die of drug overdoses (Washington State Agency Medical Directors Group, 2010). Data from the California Prescription Drug Monitoring Program (PDMP) indicates that people with higher daily dosages are more likely to see multiple prescribers or go to multiple pharmacies (Cepeda et al., 2012).

The data above suggest that prevention of opioid overdose deaths should focus on strategies that target (1) high-dose opioid users as well as (2) persons who seek care from multiple doctors and pharmacies. The data suggest that these criteria can be considered separately, as measures related to prescribed opioids for legitimate uses versus diverted uses. Thus, PQA proposes 3 measures: one for each criteria (see the related National Quality Measures Clearinghouse [NQMC] measure summary of the PQA measure Use of opioids from multiple providers or at high dosage in persons without cancer: the proportion of individuals without cancer receiving prescriptions for opioids from four (4) or more prescribers AND four (4) or more pharmacies) and one that is the intersection of both criteria (see the related NQMC measure summary of the PQA measure Use of opioids from multiple providers or at high dosage in persons without cancer: the proportion of individuals without cancer receiving prescriptions for opioids with a daily dosage greater than 120 mg morphine equivalent dose (MED) for 90 consecutive days or longer, AND who received opioid prescriptions from four (4) or more prescribers AND four (4) or more pharmacies). This approach will also assist health plans in managing the number of patients who meet the measure criteria and planning their respective interventions, so that a balance of identification and intervention can be determined.

Evidence for Rationale

Cepeda MS, Fife D, Chow W, Mastrogiovanni G, Henderson SC. Assessing opioid shopping behaviour: a large cohort study from a medication dispensing database in the US. Drug Saf. 2012;35(4):325-34. PubMed External Web Site Policy

Dunn KM, Saunders KW, Rutter CM, Banta-Green CJ, Merrill JO, Sullivan MD, Weisner CM, Silverberg MJ, Campbell CI, Psaty BM, Von Korff M. Opioid prescriptions for chronic pain and overdose: a cohort study. Ann Intern Med. 2010 Jan 19;152(2):85-92. PubMed External Web Site Policy

Katz N, Panas L, Kim M, Audet AD, Bilansky A, Eadie J, Kreiner P, Paillard FC, Thomas C, Carrow G. Usefulness of prescription monitoring programs for surveillance--analysis of Schedule II opioid prescription data in Massachusetts, 1996-2006. Pharmacoepidemiol Drug Saf. 2010 Feb;19(2):115-23. PubMed External Web Site Policy

Liu Y, Logan JE, Paulozzi LJ, Zhang K, Jones CM. Potential misuse and inappropriate prescription practices involving opioid analgesics. Am J Manag Care. 2013 Aug;19(8):648-65. PubMed External Web Site Policy

Morasco BJ, Duckart JP, Carr TP, Deyo RA, Dobscha SK. Clinical characteristics of veterans prescribed high doses of opioid medications for chronic non-cancer pain. Pain. 2010 Dec;151(3):625-32. PubMed External Web Site Policy

Office of Disease Prevention and Health Promotion. National action plan for adverse drug event prevention. Washington (DC): U.S. Department of Health and Human Services; 2014. 178 p.

Paulozzi LJ, Kilbourne EM, Shah NG, Nolte KB, Desai HA, Landen MG, Harvey W, Loring LD. A history of being prescribed controlled substances and risk of drug overdose death. Pain Med. 2012 Jan;13(1):87-95. PubMed External Web Site Policy

Pharmacy Quality Alliance (PQA). Technical specifications for PQA approved measures. Springfield (VA): Pharmacy Quality Alliance (PQA); 2015 Jul. 66 p.

Saunders KW, Dunn KM, Merrill JO, Sullivan M, Weisner C, Braden JB, Psaty BM, Von Korff M. Relationship of opioid use and dosage levels to fractures in older chronic pain patients. J Gen Intern Med. 2010 Apr;25(4):310-15. PubMed External Web Site Policy

Washington State Agency Medical Directors Group. Interagency guideline on opioid dosing for chronic non-cancer pain. Olympia (WA): Washington State Agency Medical Directors Group; 2010. 55 p.

Primary Health Components

Opioids; high dosage; morphine equivalent dose (MED)

Denominator Description

Any member with two or more prescription claims for opioids filled on at least two separate days, for which the sum of the days supply is greater than or equal to 15 (see the related "Denominator Inclusions/Exclusions" field)

Numerator Description

Any member in the denominator with greater than 120 mg morphine equivalent dose (MED) for greater than or equal to 90 consecutive days (see the related "Numerator Inclusions/Exclusions" field)

Type of Evidence Supporting the Criterion of Quality for the Measure

  • A clinical practice guideline or other peer-reviewed synthesis of the clinical research evidence
  • A formal consensus procedure, involving experts in relevant clinical, methodological, public health and organizational sciences
  • One or more research studies published in a National Library of Medicine (NLM) indexed, peer-reviewed journal

Additional Information Supporting Need for the Measure

Unspecified

Extent of Measure Testing

This measure was pilot tested during measure development (see process below), which included reliability testing.

Process for Development and Testing of Performance Measures

Step 1: Pharmacy Quality Alliance (PQA) workgroups identify measure concepts that may be appropriate for development into fully specified performance measures. The workgroups focus on specific aspects of the medication-use system and/or specific therapeutic areas. The workgroups are open to all members of PQA and use a consensus-based approach to identify, prioritize and recommend the measure concepts that are deemed to be highly important for supporting quality improvement related to medications.

Step 2: The measure concepts that are recommended for further development through a vote by the PQA workgroups are forwarded to the PQA Quality Metrics Expert Panel (QMEP) for evaluation and refinement. The QMEP reviews the measure concepts to provide an initial assessment of the key properties of performance measures (i.e., feasibility, usability and scientific validity). The measure concepts that are rated highly on these key properties will then undergo technical specification.

Step 3: The draft measure is provided to PQA member organizations for their comments prior to preparing technical specifications for pilot testing. The QMEP reviews member comments, edits the draft measure accordingly and poses testing questions based on this all-member feedback.

Step 4: PQA selects partners to test the draft measure. These partners are often PQA member health plans or academic institutions with expertise in quality and performance measure testing. The testing partner implements the draft technical specifications with their existing datasets and provides a report to PQA that details testing results and recommendations for modifications of the technical specifications.

Step 5: The workgroup that developed the measure reviews the testing results and provides comment. The QMEP reviews the workgroup comments, testing results, recommendations and potential modifications and provides a final assessment of the feasibility and scientific validity of the draft performance measures.

Step 6: Measures that are recommended by the QMEP for endorsement are posted on the PQA Web site for member review, written comments are requested, and a conference call for member organizations is scheduled to address any questions. This process allows members to discuss their views on the measures in advance of the voting period.

Step 7: PQA member organizations vote on the performance measure(s) considered for endorsement.

Evidence for Extent of Measure Testing

Pharmacy Quality Alliance (PQA). Technical specifications for PQA approved measures. Springfield (VA): Pharmacy Quality Alliance (PQA); 2015 Jul. 66 p.

State of Use

Current routine use

Current Use

Internal quality improvement

Measurement Setting

Managed Care Plans

Other

Professionals Involved in Delivery of Health Services

Pharmacists

Physicians

Least Aggregated Level of Services Delivery Addressed

Single Health Care Delivery or Public Health Organizations

Statement of Acceptable Minimum Sample Size

Specified

Target Population Age

Age greater than or equal to 18 years

Target Population Gender

Either male or female

IOM Care Need

Not within an IOM Care Need

IOM Domain

Not within an IOM Domain

Case Finding Period

Twelve-month measurement year

Denominator Sampling Frame

Enrollees or beneficiaries

Denominator (Index) Event or Characteristic

Patient/Individual (Consumer) Characteristic

Therapeutic Intervention

Denominator Time Window

Time window follows index event

Denominator Inclusions/Exclusions

Inclusions
Any member with two or more prescription claims for opioids* filled on at least two separate days, for which the sum of the days supply is greater than or equal to 15

Note: Eligible Population:

  • Ages: 19 years and older as of the last day of the measurement period.
  • Continuous Enrollment Using Enrollment Data: Subjects should be continuously enrolled during the measurement period.
  • Allowable Gap: No more than one gap in continuous enrollment of up to 45 days during the measurement year. To determine continuous enrollment for a Medicaid beneficiary for whom enrollment is verified monthly, the member may not have more than a 1-month gap in coverage (i.e., a member whose coverage lapses for 2 months [60 consecutive days] is not considered continuously enrolled).
  • Measurement Period: The patient's measurement period begins on the date of the first fill of the target medication (i.e., index date) and extends through the last day of the enrollment period or until death or disenrollment.

*Opioid: Also include tramadol and tapentadol. Refer to Table Opioid-A in the original measure documentation for opioid medications.

Exclusions
Any member with Prescription Drug Hierarchical Condition Categories (RxHCCs) 8, 9, 10, 11, or a hospice indicator from the enrollment database (see the original measure documentation for RxHCC list and associated diagnoses).

Exclusions/Exceptions

Does not apply to this measure

Numerator Inclusions/Exclusions

Inclusions
Any member in the denominator with greater than 120 mg morphine equivalent dose (MED) for greater than or equal to 90 consecutive days

Note:

  • Morphine Equivalent Dose (MED): The dose of oral morphine that is the analgesic equivalent of a given dose of another opioid analgesic.
  • To identify members with prescription opioids that exceeded the MED threshold, each claim is to be converted into the MED using the appropriate conversion factor associated with the opioid product of that prescription claim. The MED for each day's claims then are summed to determine the total MED for that day.

Refer to the original measure documentation for additional information.

Exclusions
Unspecified

Numerator Search Strategy

Fixed time period or point in time

Data Source

Administrative clinical data

Electronic health/medical record

Pharmacy data

Type of Health State

Does not apply to this measure

Instruments Used and/or Associated with the Measure

Unspecified

Measure Specifies Disaggregation

Does not apply to this measure

Scoring

Rate/Proportion

Interpretation of Score

Does not apply to this measure (i.e., there is no pre-defined preference for the measure score)

Allowance for Patient or Population Factors

Analysis by high-risk subgroup (stratification by vulnerable populations)

Analysis by subgroup (stratification by individual factors, geographic factors, etc.)

Description of Allowance for Patient or Population Factors

This measure requires that separate rates be reported for:

  • Commercial, Medicaid, Medicare (report each product line separately)
  • Low income subsidy (LIS) population (report rates for LIS population and non-LIS population separately)

Standard of Comparison

External comparison at a point in, or interval of, time

External comparison of time trends

Internal time comparison

Original Title

Use of opioids from multiple providers or at high dosage in persons without cancer: measure 1 (opioid high dosage).

Measure Collection Name

Pharmacy Quality Alliance (PQA) Measures

Measure Set Name

Medication Safety Measures

Submitter

Pharmacy Quality Alliance - Clinical Quality Collaboration

Developer

Pharmacy Quality Alliance - Clinical Quality Collaboration

Funding Source(s)

None

Composition of the Group that Developed the Measure

PQA Medication Safe Use Workgroup

Measure development begins in PQA workgroups comprised of individuals appointed by member organizations. Workgroups identify measurement needs within the high-priority areas and/or gaps in existing performance measure sets. Meeting regularly through conference calls, workgroups use a consensus-driven process to draft, refine and recommend high-priority measures of medication.

Financial Disclosures/Other Potential Conflicts of Interest

None

Adaptation

This measure was not adapted from another source.

Date of Most Current Version in NQMC

2015 Jul

Measure Maintenance

Annually

Date of Next Anticipated Revision

2016

Measure Status

This is the current release of the measure.

Source(s)

Pharmacy Quality Alliance (PQA). Technical specifications for PQA approved measures. Springfield (VA): Pharmacy Quality Alliance (PQA); 2015 Jul. 66 p.

Measure Availability

Source not available electronically.

For more information, contact the Pharmacy Quality Alliance (PQA) at 6213 Old Keene Mill Court, Springfield, VA 22152; Phone: 703-690-1987; Fax: 703-842-8150; Web site: www.pqaalliance.org External Web Site Policy; Email: info@PQAalliance.org.

NQMC Status

This NQMC summary was completed by ECRI Institute on April 1, 2016. The information was verified by the measure developer on May 6, 2016.

Copyright Statement

This NQMC summary is based on the original measure, which is subject to the measure developer's copyright restrictions.

The Pharmacy Quality Alliance (PQA) performance measures and supporting drug code lists may be used for non-commercial use with permission from PQA. Commercial use of the PQA measures requires a licensing agreement. For information contact PQA at info@PQAalliance.org.

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