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Measures and Methods

Definitions

Opioid-Naïve
Beneficiaries with an opioid prescription, who did not have an opioid prescription the previous quarter (Bree Collaborative's specification)

Opioid Prescription
Medicare Part D record with a relevant National Drug Code (all opioid medications, excluding methadone and buprenorphine)

Benzodiazepine Prescription
Medicare Part D record with a relevant National Drug Code

Chronic Use
More than 60 days' dosage prescribed (total amount from all providers) for use within a calendar quarter; based on the Bree Collaborative definition

Non-Fatal Overdose
An emergency department visit or inpatient stay with relevant ICD-10 codes; identical to specifications used in the Bree Collaborative's Metric 8

MMEs
Morphine milligram equivalents (MMEs); calculated using the CDC algorithm

The measure criteria and analysis methods used in our recent among Washington's Medicare beneficiaries is described below. (See results for the Medicare population and for healthcare professionals.)

Project Measures

Qualis Health analyzed the following metrics for Washington's Medicare population:

Any beneficiaries, regardless of opioid use level

  • Non-fatal opioid overdose (with an additional focus on opioids prescribed shortly before an overdose)
  • Beneficiaries prescribed any opioid
     

Beneficiaries with a new opioid prescription (no prescription during the previous quarter)

  • Opioid prescription for beneficiaries with new low back pain
  • High-dosage opioid prescription (>210 MMEs) for opioid-naïve beneficiaries
     

Beneficiaries who use opioids at a chronic level

  • Beneficiaries with chronic opioid prescriptions
  • High-dosage opioid prescription (>50 MMEs per day) for beneficiaries who use opioids at a chronic level
  • Chronic benzodiazepine prescription for beneficiaries using opioids at a chronic level
     

The overdose measure complements the work being done in the state by the Bree Collaborative, and the remaining measures are directly related to the CDC's prescribing guidelines.
 

Data Sources & Patient Population

Analyses were conducted using Medicare Part A, Part B, and Part D claims. The most recent 12-month period of data available at the start of this work was July 2016 - June 2017.

Medicare beneficiaries were included in the initial data set if they met all of the following criteria:

  • Must have been enrolled in Medicare Part A or B during part of the measurement year (July 2016 - June 2017)
  • Must have been enrolled in Medicare Part D during part of the measurement year, and for at least one quarter before the event that triggered our study criteria
  • Must have a Washington address

 

Data Selection

The steps taken by Qualis Health to select the appropriate data sets are outlined in the following table.

Measure
 

Time Period: Q3 2016 - Q2 2017

 

 

 

Selected Data
 
 
Exclusions
 
 
Non-fatal opioid overdose
Beneficiaries with qualifying diagnosis and an opioid prescription before or after the event

 

 
None
   

 
Denominator
Time Period: Q3 2016 - Q2 2017

 

Numerator
(within the selected denominator)

 

Selected Data
Exclusions
 
Selected Data
Time Period
Exclusions
Beneficiaries prescribed any opioid
Medicare beneficiaries
Cancer or hospice in the past year
 
Opioid prescriptions
Q3 2016 - Q2 2017
None
Opioid prescription for beneficiaries with new low back pain
Beneficiaries with qualifying diagnoses

(Aligns with HEDIS low back pain measure)

Cancer, trauma, or hospice in the past year; other low back pain in previous 6 months
 
Opioid prescriptions
Within 7 days following diagnosis
None
High-dosage opioid prescription for acute pain in opioid-naïve beneficiaries
Beneficiaries meeting criteria for opioid-naïve
 

(See definition, above)

 

Beneficiaries' first quarter of Part D eligibility
 
High-dosage (over 210 MMEs in total) opioid prescription for acute pain
 

(Aligns with Ohio specifications)

Q3 2016 - Q2 2017
Cancer or hospice within last 2 years
 
(CMS measure specification uses a two-year window)
 
Beneficiaries with chronic opioid prescriptions
Medicare beneficiaries
Cancer or hospice within last 2 years
 
Beneficiaries meeting criteria for chronic use of opioids
Q3 2016 - Q2 2017
None
High-dosage opioid prescription for beneficiaries who use opioids at a chronic level
Beneficiaries meeting criteria for chronic use of opioids
 

(See definition, above)

Cancer or hospice within last 2 years
 
 
Opioid prescription(s) totaling over 50 MMEs per day

(Aligns with Bree Collaborative specifications)

Q3 2016 - Q2 2017
None
Chronic benzodiazepine prescription for beneficiaries using opioids at a chronic level
Beneficiaries meeting criteria for chronic use of opioids
 

(See definition, above

Cancer or hospice within last 2 years
 
(CMS measure specification uses a two-year window)
 
Beneficiaries meeting criteria for chronic use of benzodiazepine
Within the same calendar quarter that qualified for chronic opioid use
None

 

Analytic Approach

A two-phase approach was used to analyze the data—first in several aggregate groupings focused on the beneficiary, then by individual provider.

By beneficiary location and demographics

The results were aggregated by several levels of location (state, Accountable Community of Health, county). It is important to note that these locations were determined by the beneficiary's residence, not where the care was provided.
 

By provider

Using the Medicare claims data, Qualis Health identified the healthcare professionals (primary care, emergency care, surgeons, dentists, and others) who wrote the prescriptions included in our data set. In some situations, there were multiple providers who prescribed opioids and/or benzodiazepines to a single beneficiary.
 

Outreach Methodology

In order to increase the number of prescribers who consistently use the Prescription Monitoring Program and are following the latest clinical guidelines regarding opioids, as well as to alert providers that some of their patients experienced an opioid-related overdose, we are contacting a subset of the prescribers identified from our data set. 

We mailed the following subset of providers their individual results:

  • Providers who prescribed an opioid to one or more Washington Medicare beneficiaries who later suffered a non-fatal opioid overdose. (The relevant time period was defined as the number of days' supply for the selected prescription, plus 10%. For example, the risk period for a 30-day supply would be 33 days after the prescription was written.)
     
  • Providers whose rate of prescribing opioids for low back pain was higher, by a statistically significant margin, than the statewide average.
     
  • All providers who prescribed opioids to at least one beneficiary whose total prescriptions reached the high-dosage threshold, for either the opioid-naive or chronic opioid metric.
     
  • Providers who prescribed chronic benzodiazepines to 10 or more of their patients who were also using opioids at a chronic level.
     

The individualized results were mailed in February 2018. In the spring of 2018, a sampling of these providers will also be contacted by phone for further discussion.