Use of High-Risk Medications in Older Adults (DAE)

This measure assesses the percentage of Medicare members 67 years of age and older who had at least two dispensing events for the same high-risk medication class. The following rates are reported:

1. Rate 1: The percentage of Medicare members 67 years of age and older who had at least two dispensing events for high-risk medications to avoid from the same drug class.
2. Rate 2: The percentage of Medicare members 67 years of age and older who had at least two dispensing events for high-risk medications to avoid from the same drug class, except for appropriate diagnoses.
3. Total Rate: The sum of the two numerators divided by the denominator, deduplicating for members in both numerators.

Why It Matters

The denominator is the same for all three rates. Members on more than one high-risk medication may appear in the numerators of both the first and second measure rates; members in both of the first two rates will only appear once in the total measure rate. A lower rate represents better performance for all rates. In older adults, certain medications are associated with increased risk of harm from drug side-effects and drug toxicity, and pose a concern for patient safety. Use of potentially inappropriate medications (PIM) in older adults can lead to poor health outcomes, including adverse drug events, confusion, falls, hospitalizations and death.

Older adults, commonly prescribed multiple prescription drugs due to complex medical problems, are increasingly at risk of PIM use. One study found that each additional drug an individual used during the year was associated with a 5.2 percentage point increase in their probability of using a PIM.¹³ PIM use in older adults has been connected to significantly longer hospital stay lengths and increased hospitalization costs,¹⁵ as well as to increased risk of death.¹⁴ Use of specific PIMs such as hypnotics, including benzodiazepine receptor agonists and nonsteroidal anti‐inflammatory drugs (NSAIDS) can also result in increased risk of delirium, falls, fractures, gastrointestinal bleeding and acute kidney injury.¹

The DDE and DAE measures are based on recommendations in the American Geriatrics Society (AGS) 2023 Updated Beers Criteria for Potentially Inappropriate Medication Use in Older Adults.² The AGS Beers Criteria are one of the most widely used sources about the safety of medication prescribing in older adults. They include evidence-based recommendations on medications that are potentially harmful in all older adults and those with specific diseases or conditions. The development of the 2023 Updated Beers Criteria was based on a systematic literature review and discussion by a panel of experts in geriatric care and pharmacotherapy. NCQA’s measurement advisory panels also provide guidance on the specific conditions and medications included in the DDE and DAE measures.

Preventing poor health effects from use of PIMs is a growing concern with the increasing population of adults over 65 and rising prescription medication use, particularly as the hospitalization rate for adverse drug events among adults 65 or older is 7 times higher than that of adults younger than 65.^4,3

Interventions focused on reducing the use of PIMs can lower the incidence of these poor health outcomes. Prescription benefit plans often require preauthorization of specific medications, to limit the use of PIMs in older adults. Additional interventions have included direct patient education⁵ and the use of computer-based reminder systems. Computerized prescribing, combined with clinical decision support systems, can alert a physician when they are attempting to prescribe a PIM to an older adult. Studies have found these systems to be effective in reducing prescribing of PIMs.^6,7,8 Studies have also shown that integration of the Beers Criteria (which list PIMs) in electronic health records can provide instant feedback and medication alternatives when PIMs are originally selected.⁹

Reducing use of PIMs in older adults also represents an opportunity to lower the costs associated with harm from medications (e.g., hospitalizations for drug toxicity) and encourages clinicians to consider safer alternatives. Adverse drug events (ADE) occur often in hospitals and contribute to longer length of stay and increased risk of mortality. Older adults make up approximately 35% of all inpatient stays but contribute to approximately 53% of inpatient stays complicated by ADEs.¹⁰ The impact and the management of ADEs is complex and, as one study found, may cost up to $30.1B annually in the United States.¹¹

The denominator is the same for all three rates. Members on more than one high-risk medication may appear in the numerators of both the first and second measure rates; members in both of the first two rates will only appear once in the total measure rate. A lower rate represents better performance for all rates. In older adults, certain medications are associated with increased risk of harm from drug side-effects and drug toxicity, and pose a concern for patient safety. Use of potentially inappropriate medications (PIM) in older adults can lead to poor health outcomes, including adverse drug events, confusion, falls, hospitalizations and death.

Older adults, commonly prescribed multiple prescription drugs due to complex medical problems, are increasingly at risk of PIM use. One study found that each additional drug an individual used during the year was associated with a 5.2 percentage point increase in their probability of using a PIM.¹³ PIM use in older adults has been connected to significantly longer hospital stay lengths and increased hospitalization costs,¹⁵ as well as to increased risk of death.¹⁴ Use of specific PIMs such as hypnotics, including benzodiazepine receptor agonists and nonsteroidal anti‐inflammatory drugs (NSAIDS) can also result in increased risk of delirium, falls, fractures, gastrointestinal bleeding and acute kidney injury.¹

The DDE and DAE measures are based on recommendations in the American Geriatrics Society (AGS) 2023 Updated Beers Criteria for Potentially Inappropriate Medication Use in Older Adults.² The AGS Beers Criteria are one of the most widely used sources about the safety of medication prescribing in older adults. They include evidence-based recommendations on medications that are potentially harmful in all older adults and those with specific diseases or conditions. The development of the 2023 Updated Beers Criteria was based on a systematic literature review and discussion by a panel of experts in geriatric care and pharmacotherapy. NCQA’s measurement advisory panels also provide guidance on the specific conditions and medications included in the DDE and DAE measures.

Preventing poor health effects from use of PIMs is a growing concern with the increasing population of adults over 65 and rising prescription medication use, particularly as the hospitalization rate for adverse drug events among adults 65 or older is 7 times higher than that of adults younger than 65.^4,3

Interventions focused on reducing the use of PIMs can lower the incidence of these poor health outcomes. Prescription benefit plans often require preauthorization of specific medications, to limit the use of PIMs in older adults. Additional interventions have included direct patient education⁵ and the use of computer-based reminder systems. Computerized prescribing, combined with clinical decision support systems, can alert a physician when they are attempting to prescribe a PIM to an older adult. Studies have found these systems to be effective in reducing prescribing of PIMs.^6,7,8 Studies have also shown that integration of the Beers Criteria (which list PIMs) in electronic health records can provide instant feedback and medication alternatives when PIMs are originally selected.⁹

Reducing use of PIMs in older adults also represents an opportunity to lower the costs associated with harm from medications (e.g., hospitalizations for drug toxicity) and encourages clinicians to consider safer alternatives. Adverse drug events (ADE) occur often in hospitals and contribute to longer length of stay and increased risk of mortality. Older adults make up approximately 35% of all inpatient stays but contribute to approximately 53% of inpatient stays complicated by ADEs.¹⁰ The impact and the management of ADEs is complex and, as one study found, may cost up to $30.1B annually in the United States.¹¹

Historical Results – National Averages

§ Not available due to CMS suspension of data reporting during COVID-19 pandemic.

This State of Healthcare Quality Report classifies health plans differently than NCQA’s Quality Compass. HMO corresponds to All LOBs (excluding PPO and EPO) within Quality Compass. PPO corresponds to PPO and EPO within Quality Compass.

Figures do not account for changes in the underlying measure that could break trending. Contact Information Products via my.ncqa.org for analysis that accounts for trend breaks.