Table. Performance Measures of Opioid Overutilization Criteria for Classifying Medicare Beneficiaries With Opioid Use Disorder or Overdose, 2011-2014.
| 6-Month Cycles by Study Year | Eligible Sample, No.a | Patients Meeting CMS Criteria for Opioid Overutilizers, No. (%)b,c | Patients With OUD or Overdose Diagnosis at 18-mo Follow-up, No. (%)c,d | No. of Patients Followed Up | Performance Measures of CMS Criteria, % (95% CI)e,f | |||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Diagnosis of OUD or Overdose | No Diagnosis of OUD or Overdose | |||||||||||
| Yes | No | Yes | No | Met CMS Criteria | Did Not Meet CMS Criteria | Met CMS Criteria | Did Not Meet CMS Criteria | Sensitivity | Specificity | Positive Predictive Value | ||
| 2011 | ||||||||||||
| January 1–June 30 | 142 036 | 739 (0.52) | 141 297 | 5559 (3.91) | 136 477 | 276 | 5283 | 463 | 136 014 | 4.96 (4.42-5.58) | 99.66 (99.63-99.69) | 37.35 (33.87-40.96) |
| April 1–September 30 | 162 841 | 929 (0.57) | 161 912 | 7055(4.33) | 155 786 | 327 | 6728 | 602 | 155 184 | 4.64 (4.16-5.16) | 99.61 (99.58-99.64) | 35.20 (32.14-38.38) |
| July 1–December 31 | 163 809 | 944 (0.58) | 162 865 | 7460 (4.55) | 156 349 | 350 | 7110 | 594 | 155 755 | 4.69 (4.23-5.20) | 99.62 (99.59-99.65) | 37.08 (34.00-40.26) |
| 2012 | ||||||||||||
| January 1–June 30 | 166 522 | 641 (0.38) | 165 881 | 8180 (4.91) | 158 342 | 262 | 7918 | 379 | 157 963 | 3.20 (2.84-3.61) | 99.76 (99.74-99.78) | 40.87 (37.06-44.80) |
| April 1–September 30 | 166 920 | 646 (0.39) | 166 274 | 8477 (5.08) | 158 443 | 256 | 8221 | 390 | 158 053 | 3.02 (2.67-3.41) | 99.75 (99.73-99.78) | 39.63 (35.85-43.53) |
| July 1–December 31 | 167 288 | 612 (0.37) | 166 676 | 8718 (5.21) | 158 570 | 236 | 8482 | 376 | 158 194 | 2.71 (2.38-3.08) | 99.76 (99.74-99.79) | 38.56 (34.71-42.56) |
| 2013 | ||||||||||||
| January 1–June 30 | 190 320 | 787 (0.41) | 189 533 | 9911 (5.21) | 180 409 | 323 | 9588 | 464 | 179 945 | 3.26 (2.92-3.63) | 99.74 (99.72-99.77) | 41.04 (37.59-44.58) |
| April 1–September 30 | 189 752 | 795 (0.42) | 188 957 | 10 310 (5.43) | 179 442 | 313 | 9997 | 482 | 178 960 | 3.04 (2.72-3.39) | 99.73 (99.71-99.75) | 39.37 (35.97-42.87) |
| July 1–December 31 | 189 103 | 735 (0.39) | 188 368 | 10 663 (5.64) | 178 440 | 332 | 10 331 | 403 | 178 037 | 3.11 (2.80-3.47) | 99.77 (99.75-99.80) | 45.17 (41.54-48.85) |
| 2014 | ||||||||||||
| January 1–June 30 | 174 415 | 637 (0.37) | 173 778 | 11 113 (6.37) | 163 302 | 285 | 10 828 | 352 | 162 950 | 2.56 (2.28-2.88) | 99.78 (99.76-99.81) | 44.74 (40.85-48.70) |
| April 1–September 30 | 174 676 | 650 (0.37) | 174 026 | 11 527 (6.60) | 163 149 | 294 | 11 233 | 356 | 162 793 | 2.55 (2.27-2.86) | 99.78 (99.76-99.80) | 45.23 (41.37-49.15) |
| July 1–December 31 | 171 917 | 642 (0.37) | 171 275 | 12 972 (7.55) | 158 945 | 327 | 12 645 | 315 | 158 630 | 2.52 (2.26-2.81) | 99.80 (99.78-99.82) | 50.94 (47.00-54.86) |
Abbreviations: CMS, Centers for Medicare & Medicaid Services; OUD, opioid use disorder.
In each cycle, the eligible sample was required to have continuous enrollment for 18 months, with the first 6 months devoted to the assessment of CMS criteria and the entire 18 months to determine the diagnosis of OUD or overdose diagnosis.
The CMS defined opioid overutilizers as receiving prescription opioids with a mean daily morphine equivalent dose ≥90 mg and from >3 clinician prescribers and >3 pharmacists or receiving a prescription of opioids with a mean daily morphine equivalent dose of ≥90 mg by >4 prescribers.
The denominator is the total eligible sample.
Opioid use disorder or overdose was defined as having at least 1 inpatient or outpatient encounter claim with one of the following International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) codes: 304.0x, 304.7x, 305.5x, 965.0x, E850.0-E850.2 or ICD-10-CM codes: F11.xx and T40.0X1, T40.0X4, T40.1X1, T40.1X4, T40.2X1, T40.2X4, T40.3X1, T40.3X4, T40.4X1, T40.4X4, T40.601, T40.604, T40.691, T40.694 in any diagnostic position of inpatient or outpatient encounter claims.
Sensitivity is calculated by dividing the number of patients who were diagnosed as having OUD or overdose and met CMS criteria by the total number of patients who were diagnosed as having OUD or overdose. Specificity is calculated by dividing the number of patients who were not diagnosed as having OUD or overdose and did not meet CMS criteria by the total number of patients who were not diagnosed as having OUD or overdose. The positive predictive value is calculated by dividing the number of patients who were diagnosed as having OUD or overdose and met CMS criteria by the total number of those who met CMS criteria.
Test for trend was examined using linear regression. Sensitivity was P<.001; specificity, P=.001; and positive predictive value, P <.001.