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Rx Data Deemed Ineffective for Measuring Opioid Crisis

Majority of Medicare Part D patients diagnosed with OUD were not identified as overutilizers

A PPM Brief

CMS opioid overutilization criteria may not accurately identify those at risk for opioid use disorder (OUD) or overdose, according to new research.1  Using the 5% Medicare sample from 2011 through 2014, researchers out of the University of Florida estimated the predictive value of the agency’s opioid overutilization criteria in correctly identifying prescription opioid users at risk for OUD or overdose. They identified between 142,036 and 190,320 beneficiaries who had at least one opioid prescription filled every 6 months; had been continuously enrolled in Parts A, B and D; and met CMS criteria as opioid overutilizers (ie, those receiving prescription opioids with a mean daily morphine equivalent dose 90 mg from more than three or four prescribers and pharmacists).

The majority of Medicare Part D patients diagnosed with OUD were not identified as overutilizers. (Source: 123RF)

With three 6-month cycles, researchers analyzed the performance measures over time to assess whether accuracy changed with increasing efforts to combat the opioid crisis. During any 6-month cycle, the proportion of beneficiaries who met CMS overutilization criteria ranged from 0.37% to 0.58%. Throughout the entire 18-month follow-up:

  • The proportion of patients who had an OUD diagnosis or overdose increased from 3.91% in the first cycle to 7.55% in the last
  • Researchers observed low sensitivity of the criteria during the study period, which ranged from 4.96% at the beginning to 2.52% at the end (P < 0.001)
  • Positive predictive values ranged from 35.2% to 50.95%, and specificity was greater than 99% in all cycles.
Last updated on: March 14, 2019
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CMS Tackles Opioid Prescribing
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