Safe Use of Opioids - Concurrent PrescribingFHIR - eCQM QICore Content Implementation Guide v2023.0.0

eCQM QICore Content Implementation Guide, published by cqframework. This guide is not an authorized publication; it is the continuous build for version 2023.0.0 built by the FHIR (HL7® FHIR® Standard) CI Build. This version is based on the current content of https://github.com/cqframework/ecqm-content-qicore-2023/ and changes regularly. See the Directory of published versions

Measure: Safe Use of Opioids - Concurrent PrescribingFHIR

Official URL: http://ecqi.healthit.gov/ecqms/Measure/SafeUseofOpioidsConcurrentPrescribingFHIR		Version: 0.1.000
Draft as of 2023-08-17	Responsible: Centers for Medicare & Medicaid Services (CMS)	Computable Name: SafeUseofOpioidsConcurrentPrescribingFHIR
Other Identifiers: Short Name (use: usual, ), UUID:95d529af-66b4-4cfd-bc1f-f43704dc47ad (use: official, ), UUID:4adc0abd-6de0-42e7-ab1a-37f53d3ddd1f (use: official, ), Endorser (use: official, ), Publisher (use: official, )
Usage:Program: EH/CAH
Copyright/Legal: Limited proprietary coding is contained in the Measure specifications for user convenience. Users of proprietary code sets should obtain all necessary licenses from the owners of the code sets. Mathematica disclaims all liability for use or accuracy of any third party codes contained in the specifications. CPT(R) contained in the measure specifications is copyright 2004-2022 American Medical Association. LOINC(R) copyright 2004-2022 Regenstrief Institute, Inc. This material contains SNOMED Clinical Terms(R) (SNOMED CT[R]) copyright 2004-2022 International Health Terminology Standards Development Organisation. ICD-10 copyright 2022 World Health Organization. All Rights Reserved.

Proportion of inpatient hospitalizations for patients 18 years of age and older prescribed, or continued on, two or more opioids or an opioid and benzodiazepine concurrently at discharge

UNKNOWN

Title: Safe Use of Opioids - Concurrent PrescribingFHIR

Id: SafeUseofOpioidsConcurrentPrescribingFHIR

Download cql: SafeUseofOpioidsConcurrentPrescribingFHIR.cql

Version: 0.1.000

Url: Safe Use of Opioids - Concurrent PrescribingFHIR

short-name identifier:

CMS506FHIR

version-independent identifier:

urn:uuid:95d529af-66b4-4cfd-bc1f-f43704dc47ad

version-specific identifier:

urn:uuid:4adc0abd-6de0-42e7-ab1a-37f53d3ddd1f

endorser (NQF) identifier:

3316e

publisher (CMS) identifier:

506FHIR

Effective Period: 2024-01-01 ..2024-12-31

Status: draft

Date: 2023-08-17 18:49:02+0000

Approval Date: 2023-08-18

Last Review Date: 2023-08-18

Name: SafeUseofOpioidsConcurrentPrescribingFHIR

Publisher: Centers for Medicare & Medicaid Services (CMS)

Author: Mathematica: https://www.mathematica.org/

Description:

Proportion of inpatient hospitalizations for patients 18 years of age and older prescribed, or continued on, two or more opioids or an opioid and benzodiazepine concurrently at discharge

Use Context:

code

value

program

Purpose:

UNKNOWN

Copyright:

Limited proprietary coding is contained in the Measure specifications for user convenience. Users of proprietary code sets should obtain all necessary licenses from the owners of the code sets. Mathematica disclaims all liability for use or accuracy of any third party codes contained in the specifications.

CPT(R) contained in the measure specifications is copyright 2004-2022 American Medical Association. LOINC(R) copyright 2004-2022 Regenstrief Institute, Inc. This material contains SNOMED Clinical Terms(R) (SNOMED CT[R]) copyright 2004-2022 International Health Terminology Standards Development Organisation. ICD-10 copyright 2022 World Health Organization. All Rights Reserved.

Disclaimer:

These performance measures are not clinical guidelines, do not establish a standard of medical care, and have not been tested for all potential applications.

THE MEASURES AND SPECIFICATION ARE PROVIDED AS IS WITHOUT WARRANTY OF ANY KIND.

Due to technical limitations, registered trademarks are indicated by (R) or [R] and unregistered trademarks are indicated by (TM) or [TM].

Rationale:

Unintentional opioid overdose fatalities have become a major public health concern in the United States (Rudd et al., 2016). Reducing the number of unintentional overdoses has become a priority for numerous federal organizations including, but not limited to, the Centers for Disease Control and Prevention (CDC), the Federal Interagency Workgroup for Opioid Adverse Drug Events, and the Substance Abuse and Mental Health Services Administration.

Concurrent prescriptions of opioids or opioids and benzodiazepines places patients at a greater risk of unintentional overdose due to the increased risk of respiratory depression (Dowell, Haegerich, & Chou, 2016 and Dowell, Ragan, Jones, Baldwin, & Chou, 2022). An analysis of national prescribing patterns shows that more than half of patients who received an opioid prescription in 2009 had filled another opioid prescription within the previous 30 days (National Institute on Drug Abuse, 2011). Studies of multiple claims and prescription databases have shown that between 5%-15% of patients receive concurrent opioid prescriptions and 5%-20% of patients receive concurrent opioid and benzodiazepine prescriptions across various settings (Liu et al., 2013; Mack et al., 2015, Park et al., 2015). Patients who have multiple opioid prescriptions have an increased risk for overdose (Jena et al., 2014). Rates of fatal overdose are ten times higher in patients who are co-dispensed opioid analgesics and benzodiazepines than opioids alone (Dasgupta et al., 2015). The number of opioid overdose deaths involving benzodiazepines increased 14% on average each year from 2006 to 2011, while the number of opioid analgesic overdose deaths not involving benzodiazepines did not change significantly (Jones & McAninch, 2015). Furthermore, concurrent use of benzodiazepines with opioids was prevalent in 31%-51% of fatal overdoses (Dowell, Haegerich, & Chou, 2016). One study found that eliminating concurrent use of opioids and benzodiazepines could reduce the risk of opioid overdose-related emergency department (ED) and inpatient visits by 15% and potentially could have prevented an estimated 2,630 deaths related to opioid painkiller overdoses in 2015 (Sun et al., 2017).

A study on The Opioid Safety Initiative in the Veterans Health Administration (VHA), which includes an opioid and benzodiazepine concurrent prescribing measure that this measure is based on, was associated with a decrease of 20.67% overall and 0.86% patients per month (781 patients per month) receiving concurrent benzodiazepine with an opioid among all adult VHA patients who filled outpatient opioid prescriptions from October 2012 to September 2014 (Lin et al., 2017).

Adopting a measure that calculates the proportion of patients with two or more opioids or opioids and benzodiazepines concurrently has the potential to reduce preventable mortality and reduce the costs associated with adverse events related to opioid use by (1) encouraging providers to identify patients with concurrent prescriptions of opioids or opioids and benzodiazepines and (2) discouraging providers from prescribing two or more opioids or opioids and benzodiazepines concurrently.

Clinical recommendation statement:

The CDC Clinical Practice Guideline for Prescribing Opioids for Pain — United States, 2022 recommends that clinicians should:

“[Use strategies minimizing] opioid use…for both opioid-naïve and opioid-tolerant patients with acute pain when possible. If patients receiving long-term opioid therapy require additional medication for acute pain, nonopioid medications should be used when possible.”
”Use particular caution when prescribing opioid pain medication and benzodiazepines concurrently."
“Review increased risks for respiratory depression when opioids are taken with benzodiazepines, other sedatives, alcohol, nonprescribed or illicit drugs (e.g., heroin), or other opioids (see Recommendations 8 and 11)”
“Closely monitor patients who are unable to taper and who continue on high-dose or otherwise high-risk opioid regimens (e.g., opioids prescribed concurrently with benzodiazepines) and should work with patients to mitigate overdose risk (e.g., by providing overdose education and naloxone) (see Recommendation 8).”
"Discuss information from the PDMP with the patient and confirm that the patient is aware of any additional prescriptions.”
“Discuss safety concerns, including increased risk for respiratory depression and overdose, with patients found to be receiving overlapping prescription opioids from multiple clinicians who are not coordinating the patient’s care or patients who are receiving medications that increase risk when combined with opioids (e.g., benzodiazepines) (see Recommendation 11), and offer naloxone (see Recommendation 8).
"Discuss safety concerns with other clinicians who are prescribing controlled substances for the patient. Ideally, clinicians should first discuss concerns with the patient and inform them that they plan to coordinate care with their other clinicians to improve the patient’s safety.”

In addition to the 2022 CDC Clinical Practice Guideline for Prescribing Opioids for Pain, opioid prescribing guidelines issued by various state agencies and professional societies for various settings agree with the recommendation to avoid concurrently prescribing opioids (American Academy of Emergency Medicine and Washington Agency Medical Directors’ Group (WAMDG)), and opioids and benzodiazepines (WAMDG, American Society of Interventional Pain Physicians, and New York City Department Of Health and Mental Hygiene) whenever possible as the combination of these medications may potentiate opioid-induced respiratory depression.

Guidance (Usage): Clinician judgement, clinical appropriateness, or both may indicate concurrent prescribing of two unique opioids or an opioid and benzodiazepine is medically necessary, thus the measure is not expected to have a zero rate. Inpatient hospitalizations with discharge medications of a new or continuing opioid or a new or continuing benzodiazepine prescription should be included in the initial population. Inpatient hospitalizations with discharge medications of two or more new or continuing opioids or new or continuing opioid and benzodiazepine resulting in concurrent therapy at discharge should be included in the numerator. Each benzodiazepine and opioid included on the medication discharge list is considered a unique prescription. The denominator population includes patients with inpatient hospitalizations and patients from Acute Hospital Care at Home programs, who are treated and billed as inpatients but receive care in their home. This eCQM is an episode-based measure. An episode is defined as each inpatient hospitalization or encounter that ends during the measurement period. This FHIR-based measure has been derived from the QDM-based measure: CMS506v6. Please refer to the HL7 QI-Core Implementation Guide (http://hl7.org/fhir/us/qicore/index.html) for more information on QI-Core and mapping recommendations from QDM to QI-Core 4.1.1 (http://hl7.org/fhir/us/qicore/qdm-to-qicore.html).

Population Criteria:

64345d297c12bd4a0fdf28b2

Initial Population:

Inpatient hospitalizations (inpatient stay less than or equal to 120 days) that end during the measurement period, where the patient is 18 years of age and older at the start of the encounter and prescribed one or more new or continuing opioid or benzodiazepine at discharge

Denominator:

Initial Population

Denominator Exclusion:

Inpatient hospitalizations where patients have cancer that begins prior to or during the encounter or are ordered or are receiving palliative or hospice care (including comfort measures, terminal care, and dying care) during the hospitalization or in an emergency department encounter or observation stay immediately prior to hospitalization, patients discharged to another inpatient care facility, and patients who expire during the inpatient stay.

Numerator:

Inpatient hospitalizations where the patient is prescribed or continuing to take two or more opioids or an opioid and benzodiazepine at discharge

Numerator Exclusion:

None

Denominator Exception:

None

Supplemental Data Guidance :

Supplemental Data Elements: SDE Ethnicity SDE Payer SDE Race SDE Sex

Libraries:

SafeUseofOpioidsConcurrentPrescribingFHIR

Related Artifact Dependencies: Library/SupplementalDataElements|3.4.000

Library/CQMCommon|1.4.000

Library/FHIRHelpers|4.3.000

Library/FHIRHelpers|4.3.000

Library/QICoreCommon|1.5.000

Library/FHIRHelpers|4.3.000

Library/FHIRHelpers|4.3.000

Library/QICoreCommon|1.5.000

MedicationRequest Category Codes

Condition Category Codes

US Core Condition Category Extension Codes

Condition Clinical Status Codes

Encounter Inpatient

Schedule II and III Opioid Medications

Schedule IV Benzodiazepines

Payer

All Primary and Secondary Cancer

Palliative or Hospice Care

Observation Services

Emergency Department Visit

Discharge To Acute Care Facility

Hospice Care Referral or Admission

Patient Expired

Parameters:

name

use

min

max

type

Measurement Period

Period

SDE Sex

Out

Coding

Numerator

Out

Resource

Denominator

Out

Resource

SDE Payer

Out

Resource

Initial Population

Out

Resource

SDE Ethnicity

Out

Resource

Denominator Exclusion

Out

Resource

SDE Race

Out

Resource

DataRequirements:

Type Elements Valueset Name Valueset

Patient(QICorePatient)

Patient(http://hl7.org/fhir/Patient) gender gender.value birthDate birthDate.value

Encounter(QICoreEncounter) type status status.value period Encounter Inpatient Encounter Inpatient

Patient(QICorePatient)

Encounter(QICoreEncounter) type status status.value period Encounter Inpatient Encounter Inpatient

MedicationRequest(QICoreMedicationRequest) medication Schedule II, III Opioid Medications Schedule II and III Opioid Medications

MedicationRequest(QICoreMedicationRequest) medication Schedule IV Benzodiazepines Schedule IV Benzodiazepines

MedicationRequest(QICoreMedicationRequest) medication status status.value intent intent.value authoredOn authoredOn.value Schedule IV Benzodiazepines Schedule IV Benzodiazepines

Encounter(QICoreEncounter) type status status.value period Encounter Inpatient Encounter Inpatient

MedicationRequest(QICoreMedicationRequest) medication status status.value intent intent.value authoredOn authoredOn.value Schedule IV Benzodiazepines Schedule IV Benzodiazepines

Encounter(QICoreEncounter) type status status.value period Encounter Inpatient Encounter Inpatient

Coverage(QICoreCoverage) type period Payer Type Payer

uri(http://hl7.org/fhir/uri) value

Patient(QICorePatient) url extension

Condition(http://hl7.org/fhir/Condition) clinicalStatus

Condition(QICoreCondition) id id.value

ServiceRequest(QICoreServiceRequest) code Palliative or Hospice Care Palliative or Hospice Care

Procedure(QICoreProcedure) code Palliative or Hospice Care Palliative or Hospice Care

Patient(QICorePatient)

Encounter(QICoreEncounter) type status status.value period Observation Services Observation Services

Encounter(QICoreEncounter) type status status.value period Emergency Department Visit Emergency Department Visit

Encounter(QICoreEncounter) type status status.value period Observation Services Observation Services

Encounter(QICoreEncounter) type status status.value period Emergency Department Visit Emergency Department Visit

Condition(QICoreCondition) code All Primary and Secondary Cancer All Primary and Secondary Cancer

Patient(QICorePatient) url extension

Coverage(QICoreCoverage) type period Payer Type Payer

Patient(QICorePatient) url extension

Direct Reference Codes:

display

code

system

Community

community

http://terminology.hl7.org/CodeSystem/medicationrequest-category

Discharge

discharge

http://terminology.hl7.org/CodeSystem/medicationrequest-category

Problem List Item

problem-list-item

http://terminology.hl7.org/CodeSystem/condition-category

Health Concern

health-concern

http://hl7.org/fhir/us/core/CodeSystem/condition-category

active

http://terminology.hl7.org/CodeSystem/condition-clinical

recurrence

http://terminology.hl7.org/CodeSystem/condition-clinical

relapse

http://terminology.hl7.org/CodeSystem/condition-clinical

Logic Definitions:

Group Scoring Population Criteria Expression

64345d297c12bd4a0fdf28b2 Group scoring: proportion

Initial Population

define "Initial Population":
  "Inpatient Encounters with an Opioid or Benzodiazepine at Discharge"

Denominator

define "Denominator":
  "Initial Population"

Denominator Exclusion

define "Denominator Exclusion":
  /*Excludes encounters of patients with cancer or who are receiving palliative or hospice care at the time of the encounter*/
  
  "Inpatient Encounters with an Opioid or Benzodiazepine at Discharge" InpatientEncounter
    where exists ( [Condition: "All Primary and Secondary Cancer"] Cancer
        where ( Cancer.isProblemListItem ( )
            or Cancer.isHealthConcern ( )
        )
          and Cancer.isActive ( )
          and Cancer.prevalenceInterval ( ) overlaps InpatientEncounter.period
    )
      or exists ( ( InpatientEncounter.encounterDiagnosis ( ) ) InpatientEncounterDiagnosis
          where InpatientEncounterDiagnosis.code in "All Primary and Secondary Cancer"
      )
      or exists ( "Intervention Palliative or Hospice Care" PalliativeOrHospiceCare
          where Coalesce(PalliativeOrHospiceCare.performed.toInterval(), PalliativeOrHospiceCare.authoredOn.toInterval()) during day of CQMCommon."HospitalizationWithObservation" ( InpatientEncounter )
      )
      or ( InpatientEncounter.hospitalization.dischargeDisposition in "Discharge To Acute Care Facility"
          or InpatientEncounter.hospitalization.dischargeDisposition in "Hospice Care Referral or Admission"
          or InpatientEncounter.hospitalization.dischargeDisposition in "Patient Expired"
      )

Numerator

define "Numerator":
  /*Encounters of patients prescribed two or more opioids or an opioid and benzodiazepine at discharge.*/
  
  ( "Inpatient Encounter with Age Greater than or Equal to 18" InpatientEncounter
      where ( Count("Opioid at Discharge" Opioids
            return distinct Opioids.medication
        ) >= 2
      )
  )
    union ( "Inpatient Encounter with Age Greater than or Equal to 18" InpatientEncounter
        with "Opioid at Discharge" OpioidsDischarge
          such that OpioidsDischarge.authoredOn during InpatientEncounter.period
        with "Benzodiazepine at Discharge" BenzodiazepinesDischarge
          such that BenzodiazepinesDischarge.authoredOn during day of InpatientEncounter.period
    )

Numerator Exclusion None

Denominator Exception None

Library Name Name

SupplementalDataElements SDE Sex

define "SDE Sex":
  case
      when Patient.gender = 'male' then Code { code: 'M', system: 'http://hl7.org/fhir/v3/AdministrativeGender', display: 'Male' }
      when Patient.gender = 'female' then Code { code: 'F', system: 'http://hl7.org/fhir/v3/AdministrativeGender', display: 'Female' }
      else null
    end

Library Name Name

SafeUseofOpioidsConcurrentPrescribingFHIR SDE Sex

define "SDE Sex":
  SDE."SDE Sex"

Library Name Name

CQMCommon Inpatient Encounter

define "Inpatient Encounter":
  [Encounter: "Encounter Inpatient"] EncounterInpatient
		where EncounterInpatient.status = 'finished'
		and EncounterInpatient.period ends during day of "Measurement Period"

Library Name Name

SafeUseofOpioidsConcurrentPrescribingFHIR Inpatient Encounter with Age Greater than or Equal to 18

define "Inpatient Encounter with Age Greater than or Equal to 18":
  CQMCommon."Inpatient Encounter" InpatientHospitalEncounter
    where AgeInYearsAt(date from start of InpatientHospitalEncounter.period) >= 18

Library Name Name

SafeUseofOpioidsConcurrentPrescribingFHIR Opioid at Discharge

define "Opioid at Discharge":
  ( [MedicationRequest: "Schedule II & III Opioid Medications"] OpioidMedications
    where ( OpioidMedications.isCommunity ( )
        or OpioidMedications.isDischarge ( )
    ) ) OpioidDischargeMedication
    where OpioidDischargeMedication.status in { 'active', 'completed' }
      and OpioidDischargeMedication.intent = 'order'

Library Name Name

SafeUseofOpioidsConcurrentPrescribingFHIR Benzodiazepine at Discharge

define "Benzodiazepine at Discharge":
  ( [MedicationRequest: medication in "Schedule IV Benzodiazepines"] BenzoMedications
    where ( BenzoMedications.isCommunity ( )
        or BenzoMedications.isDischarge ( )
    ) ) BenzodiazepineDischargeMedication
    where BenzodiazepineDischargeMedication.status in { 'active', 'completed' }
      and BenzodiazepineDischargeMedication.intent = 'order'

Library Name Name

SafeUseofOpioidsConcurrentPrescribingFHIR Numerator

define "Numerator":
  /*Encounters of patients prescribed two or more opioids or an opioid and benzodiazepine at discharge.*/
  
  ( "Inpatient Encounter with Age Greater than or Equal to 18" InpatientEncounter
      where ( Count("Opioid at Discharge" Opioids
            return distinct Opioids.medication
        ) >= 2
      )
  )
    union ( "Inpatient Encounter with Age Greater than or Equal to 18" InpatientEncounter
        with "Opioid at Discharge" OpioidsDischarge
          such that OpioidsDischarge.authoredOn during InpatientEncounter.period
        with "Benzodiazepine at Discharge" BenzodiazepinesDischarge
          such that BenzodiazepinesDischarge.authoredOn during day of InpatientEncounter.period
    )

Library Name Name

SafeUseofOpioidsConcurrentPrescribingFHIR Inpatient Encounters with an Opioid or Benzodiazepine at Discharge

define "Inpatient Encounters with an Opioid or Benzodiazepine at Discharge":
  "Inpatient Encounter with Age Greater than or Equal to 18" InpatientEncounter
    with ( "Opioid at Discharge"
      union "Benzodiazepine at Discharge" ) OpioidOrBenzodiazepineAtDischarge
      such that OpioidOrBenzodiazepineAtDischarge.authoredOn during day of InpatientEncounter.period

Library Name Name

SafeUseofOpioidsConcurrentPrescribingFHIR Initial Population

define "Initial Population":
  "Inpatient Encounters with an Opioid or Benzodiazepine at Discharge"

Library Name Name

SafeUseofOpioidsConcurrentPrescribingFHIR Denominator

define "Denominator":
  "Initial Population"

Library Name Name

SupplementalDataElements SDE Payer

define "SDE Payer":
  [Coverage: type in "Payer Type"] Payer
    return {
      code: Payer.type,
      period: Payer.period
    }

Library Name Name

SafeUseofOpioidsConcurrentPrescribingFHIR SDE Payer

define "SDE Payer":
  SDE."SDE Payer"

Library Name Name

SupplementalDataElements SDE Ethnicity

define "SDE Ethnicity":
  Patient.ethnicity E
    return Tuple {
      codes: { E.ombCategory } union E.detailed,
      display: E.text
    }

Library Name Name

SafeUseofOpioidsConcurrentPrescribingFHIR SDE Ethnicity

define "SDE Ethnicity":
  SDE."SDE Ethnicity"

Library Name Name

SafeUseofOpioidsConcurrentPrescribingFHIR Intervention Palliative or Hospice Care

define "Intervention Palliative or Hospice Care":
  [ServiceRequest: "Palliative or Hospice Care"]
    union [Procedure: "Palliative or Hospice Care"]

Library Name Name

SafeUseofOpioidsConcurrentPrescribingFHIR Denominator Exclusion

define "Denominator Exclusion":
  /*Excludes encounters of patients with cancer or who are receiving palliative or hospice care at the time of the encounter*/
  
  "Inpatient Encounters with an Opioid or Benzodiazepine at Discharge" InpatientEncounter
    where exists ( [Condition: "All Primary and Secondary Cancer"] Cancer
        where ( Cancer.isProblemListItem ( )
            or Cancer.isHealthConcern ( )
        )
          and Cancer.isActive ( )
          and Cancer.prevalenceInterval ( ) overlaps InpatientEncounter.period
    )
      or exists ( ( InpatientEncounter.encounterDiagnosis ( ) ) InpatientEncounterDiagnosis
          where InpatientEncounterDiagnosis.code in "All Primary and Secondary Cancer"
      )
      or exists ( "Intervention Palliative or Hospice Care" PalliativeOrHospiceCare
          where Coalesce(PalliativeOrHospiceCare.performed.toInterval(), PalliativeOrHospiceCare.authoredOn.toInterval()) during day of CQMCommon."HospitalizationWithObservation" ( InpatientEncounter )
      )
      or ( InpatientEncounter.hospitalization.dischargeDisposition in "Discharge To Acute Care Facility"
          or InpatientEncounter.hospitalization.dischargeDisposition in "Hospice Care Referral or Admission"
          or InpatientEncounter.hospitalization.dischargeDisposition in "Patient Expired"
      )

Library Name Name

SupplementalDataElements SDE Race

define "SDE Race":
  Patient.race R
    return Tuple {
      codes: R.ombCategory union R.detailed,
      display: R.text
    }

Library Name Name

SafeUseofOpioidsConcurrentPrescribingFHIR SDE Race

define "SDE Race":
  SDE."SDE Race"