This guest blog is one in a series by sponsors of the 2026 PQA Annual Meeting explores polypharmacy quality metrics. PQA does not endorse, recommend or favor any product, service or organization that is a sponsor.
Polypharmacy is broadly defined as the concurrent use of five or more medications. Although polypharmacy is common in the care of older adults, the quality infrastructure designed to address it remains fragmented. Current quality measures targeting polypharmacy tend to focus on narrow subsets of the problem: high-risk drug classes, specific drug-drug interactions, or potentially inappropriate medications per criteria such as the Beers list. Recent studies have highlighted the limitations of these cut-point measures and emphasized the need to move toward more multidimensional assessments of polypharmacy.¹ In the setting of polypharmacy, we know that one drug is rarely the culprit in a prescribing or adverse effect cascade, and thus targeting a single drug class or interaction is only a small step in tackling the problem of polypharmacy. Siloed measures fail to capture the full burden that polypharmacy imposes on an aging patient: the cumulative physiologic toll, the care coordination failures between specialists and primary care providers, and the decline of functional status over time. A more global outcome measure is needed, and the frailty index may be a feasible solution.
Current Polypharmacy Measure Limitations
Existing quality metrics address polypharmacy in fragments. A measure could flag concurrent use of an anticoagulant and an antiplatelet agent, and some current measures identify a patient on a benzodiazepine, but none meaningfully capture whether the medication burden is driving downstream harm. This is compounded by a deeper definitional problem: the threshold of “five medications” to define polypharmacy is increasingly recognized as insufficient when assessing patients with higher disease burden. The quality of medication treatment is crucial for successful or beneficial therapy rather than the number of medications used in the same patient. Appropriate polypharmacy should address both over- and under-treatment in older patients.² A patient on five guideline-directed medical therapies (GDMT) following a myocardial infarction is different from a frail 84-year-old prescribed fifteen medications across five specialties with no unified care plan. Polypharmacy complications include frailty, disability, and delirium, potentially leading to multiple preventable hospital or clinic visits, prolonged hospitalizations, and long-term care placement.³ A measure that uses a definition too narrow to reflect the complexity of patient care will lose utility in clinical practice, producing results that mean something in one setting and little in another.
Diverging from Standards of Care
The tension between evidence-based prescribing and patient-centered care is particularly acute in the context of frailty and goals-of-care conversations. Deprescribing is particularly contentious for older adults in the setting of multimorbid conditions such as cardiovascular disease and concomitant geriatric conditions, including polypharmacy, frailty, and cognitive dysfunction. Treatment considerations for examples such as these are not addressed in current clinical practice guidelines.⁴ GDMT protocols are developed in populations that largely exclude frail older adults and may impose pharmacologic burdens that directly compromise quality of life without meaningful mortality benefit in this population. This exclusion is not without precedent in quality measurement: HEDIS measures routinely exclude frail older adults from performance calculations, recognizing that applying standard metrics to this population is clinically inappropriate.⁵ Yet exclusion from measurement is not the same as exclusion from accountability – omitting frail older adults from quality frameworks risks overlooking the social risk factors that disproportionately affect this population. Frail older adults, many of whom are Medicare or Medicaid beneficiaries living with disabilities, are among the most socially vulnerable patients in the health system, and their exclusion from standard measures obscures the role that social determinants of health play in medication burden and care complexity. Many existing quality measures already recognize the need for exceptions (i.e. palliative care and hospice enrollees) and exclude them from performance calculations. Targeted deprescribing trials in older adults with advanced frailty and polypharmacy have examined outcomes including unscheduled hospital presentations, falls, quality of life, and medication costs,⁶ suggesting these are the clinically meaningful endpoints when aggressive disease management is no longer the primary goal. When a patient’s documented goals of care do not support aggressive disease management, adherence to GDMT should not be treated as a quality imperative and deprescribing should be recognized as the clinically appropriate intervention.
Frailty Index Scores as an Outcome
Current polypharmacy quality measures are largely process-based, measuring whether a medication is prescribed rather than whether the patient benefits. When considering deprescribing and polypharmacy in the setting of complex multimorbid older adults, outcomes matter more than process. The frailty index captures exactly what no single medication metric can: the cumulative functional reserve of a patient. It can be derived from a deficit accumulation model or tools such as the Clinical Frailty Scale. The Clinical Frailty Scale is a well-validated scale used to quantify the degree of disability from frailty, and can be used by an interprofessional healthcare team to classify frailty and identify patients at high risk for adverse outcomes.⁷ Linking deprescribing interventions to frailty index scores offers a clinically tangible outcome. Hospital length of stay (LOS) represents a quantifiable downstream measure of polypharmacy burden: evidence shows that the frailty syndrome increases the risk of functional decline at discharge, mortality, and length of hospital stay.⁸ Frailty is associated with an increased risk of negative short-term and long-term hospital outcomes, including readmission, length of stay, and reduced quality of life in hospitalized older adults.⁹ Despite being a good indicator of frailty burden, hospitalization is not a predictable event and cannot be used to measure the success of polypharmacy management for patients who have not been hospitalized.
Barriers to Implementation
Realizing this framework in practice requires navigating substantial structural barriers. Patients receiving care from various providers across different healthcare settings experience disjointed care, resulting in gaps in medication management that often lead to polypharmacy. This results in insufficient coordination and issues such as duplicate prescriptions, adverse medication interactions, and inadequate monitoring.¹⁰ Provider and system-level barriers to deprescribing include time constraints within clinical encounters, limited incentives to stop medications, electronic health records limitations on bi-directional data sharing, fragmented care between providers and health systems, and inapplicability of disease-specific performance metrics to older patients with multiple chronic conditions.¹¹ Compounding this is the inconsistent adoption of frailty assessment tools across clinical settings. Despite the growing recognition of frailty indices as risk stratification tools in research, their adoption in clinical practice has been slow, partly attributed to a lack of consensus on the most appropriate next steps following frailty identification.¹² Adoption of a brief, standardized, validated frailty screening tool is imperative to translate frailty-specific effects from research into clinical practice.¹³ A further structural gap is the absence of medical billing codes that directly quantify frailty index scores. Current coding systems capture individual frailty-related conditions such as sarcopenia, debility, and gait abnormality, but no codes exist to document or bill for a composite frailty index score, limiting the ability to track frailty burden across clinical encounters and payer data. Fragmented health records and limited interoperability mean that even well-intentioned deprescribing efforts lack the comprehensive view required to act safely and effectively.
A Path Forward
Deprescribing needs a measure that reflects the whole patient rather than isolated prescribing decisions. Frailty index scores used as an outcome offer a framework that is clinically meaningful, patient-centered, and actionable. The path forward requires consensus on frailty assessment standardization, thoughtful application of goals-of-care exclusions, and the care coordination infrastructure to support shared deprescribing accountability across providers. Establishing standardized medical billing codes that capture composite frailty index scores is equally critical, enabling payers, health systems, and quality measure developers to track frailty burden consistently across care settings and over time. Most importantly, it requires a shared commitment across health plans, health systems, pharmacies, and policymakers to prioritize patient outcomes over process compliance. In the care of frail older adults, doing less can mean doing more.
References
- Welton NJ, et al. A multidimensional measure of polypharmacy for older adults using the Health and Retirement Study. Sci Rep. 2021;11(1):8783. doi:10.1038/s41598-021-86331-x
- Pazan F, Wehling M. Polypharmacy in older adults: a narrative review of definitions, epidemiology and consequences. Aging Clin Exp Res. 2021;33(6):1473-1487. doi:10.1007/s40520-021-01822-x
- Nguyen T, et al. Strategies to reduce polypharmacy in older adults. In: StatPearls. Treasure Island, FL: StatPearls Publishing; 2024. https://www.ncbi.nlm.nih.gov/books/NBK574550/. Accessed April 2025.
- Krishnaswami A, Steinman MA, Goyal P, et al. Deprescribing in older adults with cardiovascular disease. J Am Coll Cardiol. 2019;73(20):2584-2595. doi:10.1016/j.jacc.2019.03.467
- National Committee for Quality Assurance. HEDIS 2026 Measure Technical Specifications. Washington, DC: NCQA; 2025. https://www.ncqa.org/hedis/. Accessed April 2025.
- O’Mahony D, O’Sullivan D, Byrne S, et al. Deprescribing in older people approaching end of life: a randomized controlled trial using STOPPFrail criteria. J Am Geriatr Soc. 2020;68(4):762-769. doi:10.1111/jgs.16278
- Shears M, et al. Clinical Frailty Scale. In: StatPearls. Treasure Island, FL: StatPearls Publishing; 2023. https://www.ncbi.nlm.nih.gov/books/NBK559009/. Accessed April 2025.
- Muñoz-Ibáñez C, Formiga F, Culla A, et al. Frailty as a predictor of adverse outcomes in hospitalized older adults: a systematic review and meta-analysis. Ageing Res Rev. 2019;54:100953. doi:10.1016/j.arr.2019.100953
- Yousefi Z, et al. Role of frailty in prediction of hospitalized older adult patient’s outcomes: a prospective study. BMC Geriatr. 2022;22:16. doi:10.1186/s12877-021-02717-6
- Dillon EC, et al. Towards a prescription for change: interprofessional management of polypharmacy and deprescribing. Curr Geriatr Rep. 2024;13:210–220. doi:10.1007/s13670-024-00420-z
- Linsky A, Zimmerman KM. Provider and system-level barriers to deprescribing: interconnected problems and solutions. Public Policy Aging Rep. 2018;28(4):129-133. doi:10.1093/ppar/pry030
- Sezgin D, et al. Frailty indices based on routinely collected data: a scoping review. J Frailty Aging. 2025. doi:10.1016/j.jfa.2025.100020
- Dent E, et al. Frailty as an effect modifier in randomized controlled trials: a systematic review. J Nutr Health Aging. 2024;28(6):100237. doi:10.1016/j.jnha.2024.100237