The percentage of individuals ≥18 years of age who received prescriptions for opioids from ≥4 prescribers AND ≥4 pharmacies within ≤180 days.
' + 'A lower rate indicates better performance.
' + 'Intended Use
' + 'Performance measurement for health plans.
' + 'Data Sources
' + 'Medical and prescription claims data.
' + 'Denominator
' + 'Individuals ≥18 years of age with ≥2 prescription claims for opioid medications on different dates of service and with a cumulative days' supply ≥15 during the measurement year.
" + 'Exclusions
' + 'Hospice, cancer, and sickle cell disease.
' + 'Numerator
' + 'Individuals from the denominator with opioid prescription claims from ≥4 prescribers AND ≥4 pharmacies within ≤180 days during the opioid episode.
' + 'Since 1999, the amount of prescription opioids sold in the U.S. nearly quadrupled, as did resultant deaths.' +
'
High-Dosage.' +
' According to the Centers for Disease Control and Prevention (CDC) Guideline for Prescribing Opioids for Chronic Pain, the benefits of high-dose opioids for chronic pain are not established and the risks for serious harms increase in a dose-dependent manner.' +
'
The CDC prescribing guideline states that clinicians should: use caution when prescribing opioids at any dosage; carefully reassess evidence of individual benefits and risks when considering increasing dosage to ≥50 MME/day; and either avoid increasing dosage to ≥90 MME/day or carefully justify a decision to titrate dosage to ≥90 MME/day (recommendation category: A, evidence type: 3).' +
'
' + //Multiple Providers.' +
' Use of multiple prescribers or pharmacies is associated with an increased risk for potentially fatal overdose, and the risk increases with the number of prescribers and pharmacies.' +
'
The criterion of ≥4 prescribers and ≥4 pharmacies has been used as an indicator of potential non-medical use and diversion of prescription opioids.' +
'
' + //Summary. These measures were
'This measure was designed for monitoring and improving quality of care across populations of patients and are not intended to guide clinical care for individual patients. Patients with cancer diagnoses and those receiving hospice care are excluded from the measures because of their unique therapeutic goals, ethical considerations, opportunities for medical supervision, and balance of risks and benefits.' +
'
The purpose is to exclude individuals with only irregular/one-time use of opioids, such as for dental procedures, from the denominator.
' + 'Prescription opioid cough products are not included in the OHD measure because of the difficulty in accurately calculating daily morphine milligram (MME) equivalents.
' + 'Buprenorphine, as a partial agonist is not expected to be associated with overdose risk in the same dose-dependent manner as for full agonist opioids
PQA uses NPIs to identify prescribers. CMS has investigated the use of tax identification numbers (TIN) in the Overutilization Monitoring System (OMS) but did not find a significant impact to the measure rates
PQA considered and tested various thresholds when the measure initially was developed. Based upon research studies
Prior to 2019: The proportion (XX out of 1,000) of individuals from the denominator receiving prescriptions for opioids from ≥4 prescribers AND ≥4 pharmacies.
' + '2019 to Present: The percentage of individuals ≥18 years of age who received prescriptions for opioids from ≥4 prescribers and ≥4 pharmacies within ≤180 days.
' + 'Rationale: The numerator evaluation period was shortened from the measurement year to ≤180 days in order to reduce false positives. Moreover, this aligns with underlying evidence (studies used 6 months) and recommendations from the CDC and other experts.
' + "The table below summarizes all of the changes to these measures.
" + '| Change | Impacted Measure(s) | Rationale |
|---|---|---|
| Lower the threshold from >120 to ≥90 MME | OHD, OHDMP | A lower MME threshold aligns with the CDC guideline (amount generally suggested to avoid increasing above). |
| Use average MME rather than ≥90 consecutive days of high MME | OHD, OHDMP | By allowing gaps between prescription fills and days' supply in the calculation, the average MME methodology improves identification of individuals who are chronic users of high opioid doses compared to evaluating consecutive days and reduces false positives. |
| Shorten the numerator evaluation period from 12 months to 6 months | OMP, OHDMP (only the multiple provider criteria) | A shortened measurement period better identifies current potential overutilizers, reduces the number of false positives, and aligns with underlying evidence (studies used 6 months) and recommendations from the CDC and other experts. |
| Rates reported as percent instead of XX out of 1,000 individuals | OHD, OMP, OHDMP | Using a percent improves understanding about measure rates. |
After publication of the CDC guideline, CMS revised the OMS criteria/methodology from >120 MME/day for 90 consecutive days, to an average MME/day of ≥90 (for any number of days). The table below highlights the key differences between PQA's measures and OMS.
" + '| Criteria | PQA | OMS |
|---|---|---|
| Evaluation Period | Measurement year for high dose and ≤180 days for multiple provider criteria | Most recent six months for high dose and multiple provider criteria |
| High Dose | Average daily dosage of ≥90 morphine milligram equivalents (MME) within ≥90 days | Average daily morphine equivalent dose (MED) ≥90 mg for any duration |
| Multiple Providers | ≥4 prescribers and ≥4 pharmacies (prescribers are identified via NPI) | ≥3 prescribers and ≥3 pharmacies, or ≥5 prescribers regardless of the number of pharmacies (prescribers are identified via TIN) |