Pharmacies

Addressing High-Risk Medication Use

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The pharmacy, prescriber and patient all benefit from converting HRMs to safer alternatives.

Independent pharmacies across the country are looking for ways to leverage best practices for improving Medicare Star Ratings, which include as a key measure patient safety and the use of high-risk medications (HRMs).

The Star Rating system defines HRM, quality measure D11, as the percentage of patients 65 years of age and older, who received two or more prescription fills for certain drugs with high risk of adverse effects, where there may be safer drug choices available.

2016 Star Ratings, which are based on 2014 data, show that Medicare Advantage Prescription Drug plans average 7 percent on the HRM measure, within the range for a Four Star rating. Other prescription drug plans average 11 percent, within range for a Three Star rating.1

KD_cutpoints _chart

The Pharmacy Quality Alliance website indicates that the average rate for HRM for MAPD plans is 7.4% and 10.9% for PDP plans.2

The declining percentages indicate improvement in reducing HRM use over time. Pharmacists are successfully collaborating with prescribers to help convert patients from HRMs to healthier alternatives. However, plenty of work remains to be done.

Why high-risk medications are important
Two primary concerns dominate discussions surrounding HRMs:

  1. The high cost of adverse reactions. The impact and management of adverse drug reactions may exceed $30 billion in costs to the U.S. healthcare system due to increased hospitalizations, prolonged hospital stays and clinical investigations in serious cases.3
  2. Preventing adverse reactions. Multiple studies have concluded that adverse drug events are common and often preventable among older persons in ambulatory clinical settings. Such studies support that adverse drug events are preventable at least 27 percent — and up to 42 percent — of the time.4

For these reasons, HRMs have become a collective target within the Medicare Star Rating system.

At Moundsville Pharmacy in Moundsville, WV, where I practice, we started looking into the HRM quality measure in 2014, about the same time we dove into medication synchronization. It’s now an integral part of our workflow to identify HRMs and associated patients during the prescription-filling process.

Action-item HRMs
So, which specific medications actually qualify as “high-risk”?

The Physician Quality Alliance (PQA) maintains a list of HRMs divided into nine therapeutic classes:

  • Anticholinergics
  • Antithrombotics
  • Anti-infectives
  • Cardiovascular
  • Central Nervous System (CNS)
  • Endocrine
  • Gastrointestinal
  • Pain Medications
  • Skeletal Muscle Relaxants

I highly recommend that pharmacies print a copy of the PQA list and have it readily available for reference when working on prescriptions throughout the day. The list shows the medication classification within each category and the medication names for each of those classifications.

In each case, the pharmacist would call an identified patient with an upcoming refill for a HRM and have a discussion about switching to an alternative therapy.

Note the caveats
When working with the PQA HRM list, pharmacists should recognize certain medications denoted for special consideration. For example, Medicare only considers digoxin a HRM if it is prescribed at a dose greater than 125 micrograms (mcg) per day. A single 125 mcg tablet taken daily by a patient does not qualify as HRM therapy. However, if the patient uses two 125 mcg tablets per day or uses a single 250 mcg tablet daily, that would qualify as HRM therapy and alternatives should be considered.

There is limited benefit to the patient of taking digoxin at a dose greater than 125 mcg daily. Additionally, at a higher dose, there is reduced renal clearance, which increases the risk of toxicity.

Another example worth noting is nitrofurantoin, an anti-infective. PQA lists the drug with an asterisk, specifically for patients who are using it for greater than 90 days. Nitrofurantoin does not qualify as a HRM for patients using it for acute or one-time therapy. Nonetheless, dispensing greater than a 90-day supply within a measurement period would qualify the patient as being on a HRM.

Chronic nitrofurantoin use carries the risks of pulmonary toxicity, peripheral neuropathy and hepatotoxicity.

In either case — digoxin or nitrofurantoin — pharmacists need to work with providers to identify whether a HRM is in play, the indication for the medication, and which alternatives would be best for the individual patient.

Identifying HRM patients
Having taken notice of commonly prescribed HRMs, pharmacies should assess their performance score on the HRM measure and seek to identify the patients impacting that score.

There are a number of resources available to pharmacies for identifying HRM patients. Established partnerships and other industry organizations provide various reports to assist pharmacies.

Ultimately, once the pharmacy establishes a source and cadence for accessing HRM information, a report should be downloaded and posted in the pharmacy so that pharmacists and staff can see the current performance score and compare it to past periods. The pharmacy should also identify how many patients would be needed to convert from HRM therapy to safer alternative therapy in order to increase one Star level or achieve the Top 20 percent performance level among peer pharmacies.

Click here to access my Good Neighbor Pharmacy HRM webinar explaining the various sources available and how to work through these calculations and identify individual HRM patients.

Best practices
Pharmacies can take a few practical steps to help them prepare for and carry out their HRM initiatives.

  • Be knowledgeable about HRMs and be able to identify resources for alternative therapies. Depending on the pharmacy’s preference, reference material can be printed out and inserted in a shared binder at the front counter or other appropriate location, or electronic files and documents can be saved to a shared folder accessible from computer desktops/laptops. Include a list of all HRMs and charts of alternative therapies.
  • Prepare letters of recommendation. Ideally, each letter would be sent to the prescriber after the pharmacy has discussed a HRM and alternative therapies with the patient. A sample letter is available to EQuIPP license-holders.
  • Organize a plan and set a schedule. It will take some time to review HRM information. Schedule a slot every week during which the focus will be on HRMs and identifying patients. Also map out how the pharmacy will handle HRM discussions with patients. And perhaps most important, allow time for follow-up communications with prescribers (e.g., re-faxing recommendations, calling prescriber offices, or making in-person visits to providers to discuss specific HRMs and alternative therapies).
  • Document the medications for which the pharmacy has made recommendations and track the outcomes. This step enables the pharmacy to see what has been accomplished and determine the success rate.


Overall, making progress on the HRM measurement is a matter of finding the necessary references and resources and carrying out a plan of action. Virtually every pharmacy has at least a handful of patients who are on a HRM even though a safer alternative is available. The challenge lies in convincing both the patient and the prescriber to convert to that safer alternative.

The risk of taking some medications increases as the patient ages. When pharmacies stay mindful about that fact, they can make a measurable positive impact on the patient’s health.

1. Medicare prescription drug coverage, 2016 Star Ratings data. https://www.cms.gov/medicare/prescription-drug-coverage/prescriptiondrugcovgenin/performancedata.html
2. http://pqaalliance.org/measures/cms.asp
3. Clinical and economic burden of adverse drug reactions. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3853675/
4. Incidence and preventability of adverse drug events among older persons in the ambulatory setting. http://www.ncbi.nlm.nih.gov/pubmed/12622580



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