When the National Committee for Quality Assurance (NCQA) issued its 2022 update to the Healthcare Effectiveness Data and Information Set (HEDIS®), the organization included a few new measures. This blog post takes a closer look at one of them: "Deprescribing of Benzodiazepines in Older Adults" (DBO). As the health care system moves toward downward dosing protocols for benzodiazepines, many providers may not be experienced in dose reduction schedules and advising patients on their experiences and the rationale behind them. Successful adoption of deprescribing in this setting, and attainment of clinical benchmarks will likely take a team effort among patient, pharmacist and provider in many settings.
7 Things to Know About the DBO HEDIS® Measure and Benzodiazepines
Here are seven things you should know about this new HEDIS® measure and benzodiazepines more generally.
1. What are benzodiazepines?
Benzodiazepines — sometimes called "benzos" — are depressants that produce sedation and hypnosis, help relieve anxiety and muscle spasms, and decrease seizures. Common benzodiazepines are the prescription drugs Ativan, Halcion, Klonopin, Valium, and Xanax. Shorter-acting benzodiazepines used to manage insomnia include estazolam (ProSom), flurazepam (Dalmane), temazepam (Restoril), and triazolam (Halcion), while midazolam (Versed) is used for sedation, anxiety, and amnesia in critical care settings and prior to anesthesia.
The Drug Enforcement Administration classifies benzodiazepines as a Schedule IV controlled substance. The National Institute on Drug Abuse notes that 16% of overdose deaths involving opioids in 2019 also involved benzodiazepines. Benzodiazepines are considered a "major problem" in the illicit drug supply. Their street names include "downers," "nerve pills," and "tranks."
2. Description of Deprescribing of Benzodiazepines in Older Adults
The description of the Deprescribing of Benzodiazepines in Older Adults measure is as follows: "The percentage of members 65 years of age and older who were dispensed benzodiazepines and achieved a 20% decrease or greater in benzodiazepine dose (diazepam milligram equivalent [DME] dose) during the measurement year." Unlike so many quality measures focused on increasing or increasing the rate of something, this measure is unique in that it is measuring a decrease.
3. Applicable population
4. Intent of Deprescribing of Benzodiazepines in Older Adults
The criteria explained the rationale behind this recommendation as follows: "Older adults have increased sensitivity to and decreased metabolism with long-acting agents; increased risk of cognitive impairment, delirium, falls, fractures, and motor vehicle crashes; may be appropriate for seizure disorders, rapid eye movement sleep behavior disorder, benzodiazepine withdrawal, ethanol withdrawal, severe generalized anxiety disorder, and periprocedural anesthesia."
NCQA went on to note that multiple clinical guidelines recommend deprescribing benzodiazepines slowly and safely versus stopping use of the medication immediately to help minimize withdrawal symptoms and improve patient outcomes. As we wrote in this blog post, deprescribing is one of the most effective ways to safely decrease inappropriate and unnecessary polypharmacy.
Finally, NCQA notes that through this new deprescribing HEDIS® measure, "… there is an opportunity to promote harm reduction by assessing progress in appropriately reducing benzodiazepine use in the older adult population."
5. Statistics on benzodiazepine use and prescribing
In its draft of the new Deprescribing of Benzodiazepines in Older Adults HEDIS® measure, NCQA shares some statistics concerning the use and prescribing of benzodiazepines. Here are some of those stats and others about benzodiazepines:
- Older adults are prescribed benzodiazepines at the highest rate and are most at risk of adverse events among all U.S. adults.
- Between 1996 and 2013, the number of adults who filled a benzodiazepine prescription increased by 67%, from 8.1 million to 13.5 million. The quantity obtained also increased from 1.1 kg to 3.6 kg lorazepam-equivalents per 100,000 adults.
- The amount of benzodiazepine medicine found in prescriptions also doubled over this period.
- In 2015, CMS reported that about 18% of all Medicare Part D enrollees were dispensed benzodiazepines.
- A Psychiatric Services article that shared the results of an analysis of the 2015 and 2016 National Survey on Drug Use and Health (NSDUH) notes that 30.6 million adults (~13%) reported past-year benzodiazepine use annually: 25.3 million (~10%) as-prescribed and 5.3 million (~2%) with misuse. Benzodiazepine prevalence among adults 65 and older was highest, at about 9%.
- In 2018, around half of patients who were dispensed oral benzodiazepines received them for two months or longer, reports FDA.
- In 2019, an estimated 92 million benzodiazepine prescriptions were dispensed from U.S. outpatient retail and mail-order pharmacies.
6. One of three new HEDIS® measures for 2022
- Antibiotic Utilization for Respiratory Conditions (AXR) — "The percentage of episodes for members 3 months of age and older with a diagnosis of a respiratory condition that resulted in an antibiotic dispensing event."
- Advance Care Planning (ACP) — "The percentage of adults 66–80 years of age with advanced illness, an indication of frailty or who are receiving palliative care, and adults 81 years of age and older who had advance care planning during the measurement year."
7. Benzodiazepines included in multiple CMS quality measures
The usage of benzodiazepines is included in multiple Centers for Medicare & Medicaid Services (CMS) quality measures, which are used in CMS's quality improvement, public reporting, and pay-for-reporting programs for select healthcare providers. The measures that include benzodiazepines and are endorsed by the National Quality Forum (NQF) are as follows:
- Concurrent Use of Opioids and Benzodiazepines (COB-AD) — Percentage of Medicaid beneficiaries age 18 and older with concurrent use of prescription opioids and benzodiazepines.
- Safe Use of Opioids - Concurrent Prescribing (eCQM) — 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 of High-Risk Medications in Older Adults — Percentage of patients 65 years of age and older who were ordered at least two high-risk medications from the same drug class.
Why HEDIS® and the Deprescribing of Benzodiazepines Measure Matters
HEDIS® is a comprehensive set of standardized performance measures that, as CMS notes, is "designed to provide purchasers and consumers with the information they need for reliable comparison of health plan performance." It's used by more than 90% of U.S. health plans — representing more than 190 million people — to measure performance on dimensions of care and service. HEDIS® is also available for use by medical providers and practices.
For health plans, HEDIS® ratings are important. Measure scores can provide further insight into the quality of care their members are receiving. Furthermore, reporting HEDIS® scores is often required in public markets, with results sometimes reported to the states or counties where plans reside.
The American Pharmacists Association notes that HEDIS® measures are commonly included as required metrics in value-based payment programs and quality rating programs. "HEDIS® measures are used in evaluating the quality of care provided by healthcare practitioners, and meeting HEDIS® measure targets is a factor in determining quality incentive payments."
With the Deprescribing of Benzodiazepines in Older Adults measure confirmed for 2022, organizations providing care and prescribing medications to Medicare patients will want to ensure they understand what HEDIS® is looking for with the new measure (and other applicable measure, including those concerning medication reconciliation); develop processes to meet these expectations; and generate good medical documentation that identifies when actions concerning benzodiazepines deprescribing are performed.