Percentage of female patients 50 to 64 years of age without select risk factors for osteoporotic fracture who received an order for a dual-energy x-ray absorptiometry (DXA) scan during the measurement period

This Physician Performance Measure (Measure) and related data specifications are owned and stewarded by the Centers for Medicare & Medicaid Services (CMS). This measure was developed under CMS Contract No. HHSM-500-2013-13011I, Task Order HHSM-500-TO0001. Mathematica and the National Committee for Quality Assurance (NCQA) supported development of this electronic measure. NCQA is not responsible for any use of the Measure. NCQA makes no representations, warranties, or endorsement about the quality of any organization or physician that uses or reports performance measures and NCQA has no liability to anyone who relies on such measures or specifications.

Limited proprietary coding is contained in the Measure specifications for user convenience. Users of proprietary code sets should obtain all necessary licenses from the owners of the code sets. NCQA disclaims all liability for use or accuracy of any third party codes contained in the specifications. 
 
CPT(R) contained in the Measure specifications is copyright 2004-2021 American Medical Association. LOINC(R) copyright 2004-2021 Regenstrief Institute, Inc. This material contains SNOMED Clinical Terms(R) (SNOMED CT[R]) copyright 2004-2021 International Health Terminology Standards Development Organisation. ICD-10 copyright 2021 World Health Organization. All Rights Reserved.

The performance Measure is not a clinical guideline and does not establish a standard of medical care, and has not been tested for all potential applications. THE MEASURE AND SPECIFICATIONS ARE PROVIDED "AS IS" WITHOUT WARRANTY OF ANY KIND. 

Due to technical limitations, registered trademarks are indicated by (R) or [R] and unregistered trademarks are indicated by (TM) or [TM].

None

None

None

This measure is expected to increase recording of patient risk for fracture data and decrease the amount of inappropriate DXA scans. Current osteoporosis guidelines recommend using bone measurement testing to assess osteoporosis risk in women 65 years and older. In postmenopausal women younger than age 65, guidelines recommend using a formal clinical risk assessment tool to establish a patient's risk for osteoporosis, in order to determine whether to screen a patient for osteoporosis using bone measurement testing. Clinical information, such as age, body mass index (BMI), parental hip fracture history, and alcohol use, can be used to determine a woman's fracture risk (U.S. Preventive Services Task Force [USPSTF], 2018). Additionally, there are potentially avoidable harms associated with screening for osteoporosis in general, including exposure to radiation, false positive exams, and resulting side effects from unnecessary osteoporosis medications, which add costs to an already burdened health care system (Lim, Hoeksema, & Sherin, 2009).

USPSTF:
"The USPSTF recommends screening for osteoporosis with bone measurement testing to prevent osteoporotic fractures in women 65 years and older." This is a B recommendation. 

"The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of screening for osteoporosis to prevent osteoporotic fractures in men." This is an I statement.

"The USPSTF recommends screening for osteoporosis with bone measurement testing to prevent osteoporotic fractures in postmenopausal women younger than 65 years who are at increased risk of osteoporosis, as determined by a formal clinical risk assessment tool." This is a B recommendation. 
"For postmenopausal women younger than 65 years who have at least 1 risk factor, a reasonable approach to determine who should be screened with bone measurement testing is to use a clinical risk assessment tool." 

"Several tools are available to assess osteoporosis risk: the Simple Calculated Osteoporosis Risk Estimate (SCORE; Merck), Osteoporosis Risk Assessment Instrument (ORAI), Osteoporosis Index of Risk (OSIRIS), and the Osteoporosis Self-Assessment Tool (OST). These tools seem to perform similarly and are moderately accurate at predicting osteoporosis. The FRAX tool (University of Sheffield), which assesses a person's 10-year risk of fracture, is also a commonly used tool."

"Because the benefits of treatment are greater in persons at higher risk of fracture, one approach is to perform bone measurement testing in postmenopausal women younger than 65 years who have a 10-year FRAX risk of major osteoporotic fracture (MOF) (without DXA) greater than that of a 65-year-old white woman without major risk factors. For example, in the United States, a 65-year-old white woman of mean height and weight without major risk factors has a 10-year FRAX risk of MOF of 8.4%."

Lower score indicates better quality

Reference Type: CITATION

Reference Text: 'Lim, L. S., Hoeksema, L. J., & Sherin, K. (2009). Screening for osteoporosis in the adult U.S. population: ACPM position statement on preventive practice. American Journal of Preventive Medicine, 36(4), 366-375.'

Reference Type: CITATION

Reference Text: 'U.S. Preventive Services Task Force, Curry S. J., Krist, A. H., et al. (2018). Screening for osteoporosis to prevent fractures: U.S. Preventive Services Task Force recommendation statement. JAMA, 319(24), 2521-2531.'

The measure allows for clinicians to use 4 tools to assess osteoporosis or osteoporotic fracture risk.

1. The Fracture Risk Assessment Tool (FRAX[R]) is used to calculate 10-year absolute fracture risk. The FRAX evaluates a patient's 10-year probability of hip fracture and major osteoporotic fracture (clinical spine, forearm, hip, or shoulder fracture). It is applicable to people aged 40-90 years.
2. The Osteoporosis Risk Assessment Instrument (ORAI) is used to calculate osteoporosis risk. It is applicable to women >=45 years. 
3. The Osteoporosis Index of Risk (OSIRIS) is used to calculate osteoporosis risk. It is applicable to patients of any age.
4. The Osteoporosis Self Assessment Tool (OST) is used to calculate osteoporosis risk. It is applicable to patients of any age.

Patients are excluded from the measure if they have one or more risk factors for osteoporosis, including a result indicating that the patient should be considered for bone density testing on one of the following risk assessment instruments:
• 10-year probability of major osteoporotic fracture of 8.4 percent or higher as determined by the FRAX
• ORAI score of >=9
• OSIRIS score of <1
• OST score of <2

This eCQM is a patient-based measure.

This version of the eCQM uses QDM version 5.6. Please refer to the eCQI resource center (https://ecqi.healthit.gov/qdm) for more information on the QDM.

TBD

Female patients ages 50 to 63 years at the start of the measurement period with an encounter during the measurement period

Equals Initial Population

Exclude patients with one of the following risk factors.

Risk factors are grouped by when they occur in relation to the measurement period.

The following risk factors must be active during the measurement period:
BMI <= 20 kg/m2 (must be the first BMI of the measurement period)
Alcohol consumption (> two units per day (one unit is 12 oz. of beer, 4 oz. of wine, or 1 oz. of liquor))

The following risk factors may occur at any time in the patient's history prior to the start of the measurement period:
Osteoporosis
Osteopenia

The following risk factors may occur at any time in the patient's history prior to the start of the measurement period, but do not need to be active during the measurement period:
Gastric bypass
Aromatase inhibitors
Documentation of history of hip fracture in parent

The following risk factors may occur at any time in the patient's history or during the measurement period:
Glucocorticoids [cumulative medication duration >= 90 days]
Osteoporotic fracture
Malabsorption Syndromes: celiac disease, inflammatory bowel disease, ulcerative colitis, Crohn's disease, cystic fibrosis, malabsorption
Chronic malnutrition
Chronic liver disease
Rheumatoid arthritis
Hyperthyroidism
Type I Diabetes 
End stage renal disease
Osteogenesis imperfecta
Ankylosing spondylitis
Psoriatic arthritis
Ehlers-Danlos syndrome
Cushing's syndrome
Hyperparathyroidism
Marfan syndrome
Lupus
Chemotherapy
Multiple myeloma
Premature menopause
Double or bilateral oophorectomy
Eating disorder
Amenorrhea
Organ transplant

Female patients who received an order for at least one DXA scan in the measurement period

Exclude patients with a result on one of the following tools, which indicates the patient should be considered for bone density testing, anytime in the patient’s history prior to the time of the first DXA scan during the measurement period:
FRAX[R] ten-year probability of all major osteoporosis related fracture >= 8.4 percent
ORAI score of >=9 
OSIRIS score of <1
OST score of <2

None

For every patient evaluated by this measure also identify payer, race, ethnicity and sex