Quality Essentials Review: Strategies for Reducing Polypharmacy to Improve Medication Safety

The PQA Quality Essentials Webinar series provides education on the fundamentals of quality measurement, which is important for effective measure implementation and performance, and information about where and how PQA quality measures are used.  

The September 14, 2023, PQA Quality Essentials Webinar welcomed members of PQA’s Performance Measurement team and speakers from Kaiser Permanente to discuss strategies to improve medication safety through reduction of polypharmacy in older adults.  

Carolyn Lockwood, RN, MSN, PQA’s Director of Performance Measurement, opened the webinar by reviewing PQA’s measure development and stewardship process. Each measure, whether in development or under review, is evaluated under the same criteria: importance, scientific acceptability, feasibility, and usability. Lockwood mentioned that PQA leverages internal and external expertise to develop and maintain quality measures to address high priority areas. She highlighted reduction of polypharmacy the use of multiple drugs to treat diseases and other conditions as an area of high priority.  

Razanne Oueini, PharmD, MSc, CPHQ, PQA’s Senior Manager of Performance Measurement, discussed the impact and the drivers of polypharmacy in older adults. Additionally, she presented PQA’s efforts in improving medication safety through performance measures that specifically aim to reduce polypharmacy.  

Oueini described polypharmacy as an area of concern in older adults who are subject to more pronounced adverse drug events due to the natural decline in organ function with aging. The use of multiple medications in older adults is common and can be attributed to patient, provider and system related factors such as fragmentations of care, a culture of prescribing, and knowledge gaps in medication use. A reduction in polypharmacy within this population can potentially decrease healthcare costs while improving patient outcomes 

PQA has devoted extensive resources and efforts to developing and maintaining quality measures to improve medication safety for older adults. The first of these measures, Use of High-Risk Medications in the Elderly (HRM), aimed to reduce the concurrent use of potentially inappropriate medications in older adults. The rationale of the measure was grounded on the Beers Criteria published by the American Geriatrics Society (AGS), which lists potentially inappropriate medications that are best avoided in older adults. The HRM measure was retired in 2021 to allow PQA to allocate resources to newer medication safety measures with greater opportunity for meaningful impact. 

Oueini went on to review two additional PQA polypharmacy measures that focus on a subset of therapeutic categories for medications outlined in the Beers Criteria: Polypharmacy: Use of Multiple Anticholinergic Medications in Older Adults (POLY-ACH) and Polypharmacy: Use of Multiple CNS-Active Medications in Older Adults (POLY-CNS). The POLY-ACH and POLY-CNS measures capture the percentage of individuals ≥65 years of age with concurrent use of 2 or more anticholinergic or 3 or more central nervous system (CNS)-active medications, respectively. Ultimately, these measures aim to reduce the use of these combinations of medications in the older adult population, for which serious safety concerns have been documented.  

Continued support and use of the POLY-ACH and POLY-CNS measures has grown over the years since their endorsement by PQA’s membership in 2017. Both measures were subsequently implemented into the Medicare Part D Patient Safety Reports in 2018 before moving to the Part D Display page in 2021. More recently, in the proposed rule published by the Centers for Medicare and Medicaid Services (CMS) in December 2022, 4201-P, CMS proposed the addition of the POLY-ACH and POLY-CNS measures to the 2026 Part D Star Ratings, a proposal that has not yet been finalized. 

Continuing the discussion, Daniel Powers, PharmD, MBA, BCPS, Director of Drug Use Management, alongside Eric Anthony Lee, MD, Co-Chair of High Risk Drugs in the Elderly Committee, Southern California (SCAL) at Kaiser Permanente, demonstrated how they address polypharmacy issues in their practice setting.  

Powers described initiatives to address polypharmacy in older adults as a “unifying approach to geriatric syndromes.He emphasized polypharmacy as a risk factor that may exacerbate geriatric syndromes or conditions that are common and sometimes specific to aging. Reducing this sole risk factor will impact numerous geriatric syndromes. Powers presented data derived from a population-based survey to illustrate that deprescribing aligns with patients' goals of care, underscoring the importance of interprofessional collaboration in this process 

Lee then followed with real-world case-based examples that demonstrated how polypharmacy continues to be addressed in his practice.  

With 24 years of experience as a primary care provider, Lee discussed ways to reconsider high-risk medications by taking a patient-centered approach and shared the following valuable clinical pearls:  

  • Patient-clinician conversations on the potential harms of medications should occur before prescribing, as the deprescribing process can be challenging.  
  • Patients' self-reported experiences with their medications can provide valuable information to address polypharmacy. 
  • Medications risk-benefit profiles must be evaluated in the context of the patient at the start of treatment and continuously through the patient’s care journey.  

Lee concluded by emphasizing that through dedicated effort and focus, and by addressing polypharmacy PQA measures, it is possible to achieve a reduction in the concurrent use of high-risk medications in the older adults. The panel went on to answer questions from the audience on changes to Part D Stars Ratings Program involving PQA’s polypharmacy measures, and further clarification on real-world strategies to address polypharmacy.    

You can Listen to the full recording of this Quality Essentials Webinar on PQA’s YouTube channel. PQA members can access the presentation slides on the Member Resource Library 

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