DHS sentinel measures and opioid prescribing reports

DHS, under the guidance of the OPWG, developed the seven sentinel measures to assess individual clinicians’ opioid prescribing patterns in the acute, post-acute and chronic pain phases by comparing prescribing rates among same specialty peers. The measures also served as indicators to support the quality improvement arm of the program. Importantly, the intent of the measures and reports was to help DHS identify clinicians who may benefit from additional information or support; they were not intended to evaluate the quality of one’s clinical practice.

Quick links

Additional resources related to the sentinel measures include:

• Sentinel Measures: averages by specialty
• OPIP: Overview of sentinel measures (DHS-7902A) (PDF): A one-page overview of the sentinel measures
• OPIP Sentinel Measures (DHS-7902B) (PDF): Technical specifications for sentinel measures

Measure 1: Percent of enrollees prescribed an index opioid prescription

This measure shows the percent of enrollees prescribed one or more index opioid prescriptions between January and December of the measurement year:

• Numerator: the number of opioid naïve enrollees prescribed new opioid prescriptions in the measurement year.
• Denominator: the number of enrollees seen in the measurement year.

Measure 2: Percent of index opioid prescriptions exceeding the recommended dose

This measure shows the percent of index opioid prescriptions that exceeded the recommended dose in the measurement year. The recommended dose is less than 100 morphine milligram equivalence (MME) for medical specialties and less than 200 MME for surgical specialties.

• Numerator: the number of index opioid prescriptions prescribed that exceeded the recommended dose in the measurement year.
• Denominator: the number of index opioid prescriptions prescribed in the measurement year.

Measure 3: Percent of prescriptions exceeding 700 cumulative MME

This measure shows the percent of opioid prescriptions prescribed that met or exceeded 700 cumulative MME in the post-acute pain phase (up to 45 days following an acute event). This includes the index opioid prescription and any other opioids prescribed within a 45-day window of the date of the index opioid prescription.

• Numerator: the number of prescriptions prescribed during the post-acute pain period that met or exceeded the 700 cumulative MME threshold in the measurement year.
• Denominator: the number of opioid prescriptions prescribed during the post-acute pain period in the measurement year.

Measure 4: Percent of patients with chronic opioid analgesic therapy (COAT)

This measure shows the number of patients prescribed an opioid prescription during a period of chronic opioid analgesic therapy (COAT) in the measurement year:

• Numerator: the number of patients prescribed an opioid in the measurement year during a span of COAT (greater than or equal to 60 consecutive days’ supply of opioids).
• Denominator: the total number of patients with at least one opioid prescription prescribed in the measurement year.

Measure 5: Percent COAT enrollees exceeding 90 MME per day

This measure shows the percent of patients prescribed COAT with the daily dose exceeding 90 MME per day in the measurement year:

• Numerator: the number of patients prescribed at least a 28 days' supply of opioids within a COAT span in the measurement year with the daily dose exceeding 90 MME per day.
• Denominator: the number of patients with an opioid prescription during a COAT period in the measurement year. 

Measure 6: Percent COAT enrollees receiving concomitant benzodiazepines

This measure shows the percent of patients receiving elevated doses of COAT who received a concomitant benzodiazepine prescription:

• Numerator: the number of patients prescribed at least a 28 days’ supply of opioids within a COAT span greater than 50 MME per day and an overlapping benzodiazepine prescription greater than 7 days in the measurement year.
• Denominator: the number of patients prescribed an opioid prescription during a COAT period in the measurement year.

Measure 7: Percent of COAT patients receiving opioids from multiple providers

This measure shows the percent of COAT patients receiving opioids from multiple prescribers:

• Numerator: the number of patients prescribed COAT who received opioids from more than two other providers while on COAT in the measurement year.
• Denominator: the number of patients prescribed COAT in the measurement year.

Refer to Medicaid Opioid Prescribing Report (DHS-7906) (PDF) to review a sample of the DHS opioid prescribing report reflecting the seven sentinel measures.

• Index opioid prescription: The first opioid prescription after at least 90 days of opioid naiveté.
  
  
• Opioid naïve enrollee: A patient prescribed an opioid medication who does not have an active opioid prescription in the 90-day period before the index opioid prescription. The enrollee had to be continuously enrolled in Minnesota Medicaid or MinnesotaCare through the 90-day period before the index opioid prescription.
  
  
• Post-acute pain period: A time period representing the date of the index opioid prescription plus 45 days. The time period captures opioid analgesia prescribed for acute and post-acute, or sub-acute, pain following an injury or procedure.
  
  
• Morphine milligram equivalence (MME): The equianalgesic of a specific dose and formulation of opioids to parenteral morphine. Standard conversion ratios are used to calculate each opioid’s equianalgesic dose.
  • Conversion formula for total morphine milligram equivalence (MME) of prescription (total MME of prescription): (Drug strength)*(Drug quantity)*(MME conversion factor)
  • Conversion formula for daily MME: (Drug strength)*(Drug quantity)*(MME conversion factor)/(Days’ supply)
    
    
• Cumulative morphine milligram equivalence: The sum of the total morphine milligram equivalence of each opioid prescription received in a given timeframe. The DHS opioid prescribing reports provide data on the cumulative MME prescribed during the acute and post-acute pain period.
  
  
• Chronic opioid analgesic therapy: greater than or equal to 60 consecutive days’ supply of opioids from any number of prescriptions. A gap less than or equal to three days is permissible between prescriptions.
  
  
• High-dose chronic opioid analgesic therapy: Greater than or equal to 60 consecutive days’ supply of opioids and the daily dose is greater than or equal to 90 morphine milligram equivalence per day.
  
  
• Concomitant chronic opioid analgesic therapy and benzodiazepine prescriptions: Greater than or equal to 60 days’ supply of opioids and a benzodiazepine prescription that has greater than seven days’ supply of overlap with the chronic opioid analgesic therapy during the measurement year.

The data in each report comes from Medicaid and MinnesotaCare pharmacy claims data (not the Minnesota Prescription Drug Monitoring Program). This means that only data on Medicaid and MinnesotaCare patients are included in the DHS prescribing reports. The following patients, settings or medications were excluded from the reports:

• Individuals who received a cancer diagnosis or treatment within the measurement period
• Individuals who received hospice services during the measurement year (enrollees with a claim from a hospice place of service or hospice provider type)
• Procedural sedation or anesthesia
• Medications administered in an emergency department or from an inpatient pharmacy
• Medications prescribed to treat opioid use disorder
• All buprenorphine products

The reports compare providers’ prescribing data to the average rate of their anonymized peers. Specialty comparison data for all seven measures is provided in the reports. Providers were assigned to one of 30 specialty groups based on their National Provider Identifier (NPI) primary taxonomy code or direct confirmation with the provider about their practice type.

Specialty information comes from the Centers for Medicare & Medicaid Services (CMS) National Plan and Provider Enumeration System. Specialty group is based on the National Provider Identifier (NPI) primary taxonomy code.

The legend explains how to read the graphs in the report:

• The blue horizontal bar displays specific data for an individual provider
• The orange horizontal bar displays the average data for all providers of the same specialty
• The vertical red line indicates the quality improvement threshold for each given measure

The quality improvement thresholds served to identify a point where an individual clinician may be prescribing opioids beyond the norm of the community standard. Quality thresholds were established by analyzing Medicaid and MinnesotaCare pharmacy claims data. The Opioid Prescribing Work Group set the thresholds at clear inflection points in the data. The quality improvement thresholds are uniform across all specialties. 

The following are quality improvement thresholds for each measure:

• Measure 1: Greater than 8 percent. Note: the quality improvement threshold only applies to providers in nonsurgical specialties. There is no threshold for surgical specialties, including Obstetricians & Gynecologists.
  
  
• Measure 2: Greater than 50 percent of all index opioid prescriptions exceeded the recommended dose (100 total MME for non-surgical specialties; 200 total MME for surgical specialties).
  
  
• Measure 3: Greater than 15 percent of opioid prescriptions prescribed during the initial index opioid prescribing episode met or exceeded 700 cumulative MME.
  
  
• Measure 4: No quality improvement threshold, this measure is for informative purposes only.
  
  
• Measure 5: Greater than 10 percent of enrollees prescribed chronic opioid analgesic therapy (COAT) had a daily dosage that met or exceeded 90 MME per day.
  
  
• Measure 6: Greater than 10 percent of enrollees prescribed COAT with a daily dosage of at least 50 MME per day had an overlapping benzodiazepine prescription.
  
  
• Measure 7: No quality improvement threshold, this measure is for informative purposes only.