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ACP does not support QPP measure 238: "Use of High-Risk Medications in the Elderly." While it is clinically important to monitor high-risk medications in elderly adults, implementation may result in underuse of clinically appropriate pharmacotherapy in adults aged > 65 years. Furthermore, developers cite the controversial American Geriatrics Society Beers Criteria to form the basis of the measure, which is based on expert opinion as opposed to high-quality evidence. Moreover, we note several issues with the measure specifications. First, the denominator may inaccurately define “elderly adults” as > 65 years of age. Developers should consider revising the specifications to include a more appropriate definition that would classify “elderly adults” according to mental and functional status or increase the denominator threshold to > 80 years of age. Second, the denominator specifications do not stratify patients into well-defined risk groups. It’s conceivable for some patients 66 years and older to tolerate high risk medications as appropriate treatment. Third, the measure specifies medications that are not presumed to be high risk in all elderly adults (e.g., acetaminophen), and fourth, the specifications do not include exclusion criteria for patient preference. Finally, while this measure is appropriate for health plan-level assessment, individual clinicians may encounter interoperability barriers to patient information access.