Metric #6 - Hypnotics and Sedatives

JUNE 2016 - In the final installment of this blog series, we will examine the most criticized new metric, the Percentage of Long-Stay Resident Who Received an Antianxiety or Hypnotic Medication.

The most interesting part of this new quality metric is its vagueness related to what is included in these categories. On the pharmacy provider side, the Benzodiazepine Sedative Hypnotic Quality Measure has been in effect in the Medicare D program, also endorsed by the Pharmacy Quality Alliance (PQA), since 2015, using 2013 data, under the broader “High Risk Medications in the Elderly” or “HRM”. This measure calculates the percent of patients 65 years and older who have received two or more prescription fills for any benzodiazepine medications in a cumulative 90-day period. The metric is tracked through Medicare D claims data.

The Nursing Home Compare metric, however, is far less defined and would include numerous categories of drugs, not always used for the purpose to sedate or induce sleep. Until further clarification can be reached, the new metric will not contribute to the Star Rating calculation, but it will be published on the Nursing Home Compare website, alongside the rest of the QM/QIs. Similar to the off-label use of antipsychotic medications for older adults, the use of antianxiety and hypnotic medications has been linked to increased risk of adverse outcomes such as cognitive impairment, delirium, falls, and fractures.

The qualifications of the new metric have been provided by CMS, in their slide presentation, released in March:

1. It assesses the percentage of long-stay residents in a nursing home who receive ANY antianxiety or hypnotic medications.

2. It is intended to prompt nursing homes to reexamine their prescribing patterns in order to encourage practice consistent with clinical recommendations and guidelines (i.e., preventing and stopping long-term use of benzodiazepine).

3. The measure currently will have no risk adjustment.

4. During a target period, it is expected that facilities may have residents receiving antianxiety and hypnotic medications for a short term who have appropriate clinical indications or are under a gradual dose reduction program.

5. It is the third of the new measures that are MDS-based only.

6. It will NOT be used in Five-Star due to concerns about its specificity and appropriate thresholds for star ratings. This means that the measure will show up on Nursing Home Compare, but it will not be used in calculating the rating for a nursing home.

7. Higher values of this measure indicate worse performance on the measure.

8. Residents who are receiving hospice care or have a life expectancy of less than 6 months at the time of the target assessment are excluded from this measure.

Note that all of the long-stay measures include all residents who have resided in the nursing home for an episode of at least 101 days as of the end of the target period. An episode is a period of time spanning one or more stays, beginning with an admission and ending with either a discharge or the end of the target period (whichever comes first).

Nursing restorative care, social services activities and other resident activities can help redirect residents from anxiety to current activities, and through socialization, alleviate the resident’s anxious condition. Success in alleviating anxiety through behavioral intervention and change can result in improving this measure.

Current Exclusions

There is no risk adjustment for this measure, but long-stay residents are excluded from the measure if they meet the following criteria:
• The resident was comatose on the prior assessment; OR
• The resident had life expectancy of less than 6 months: OR
• The resident was in Hospice on the target assessment; OR
• Antianxiety medications received notation was missing on target assessment; OR
• Hypnotic medications received notation was missing on target assessment.

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