eCQM Title | # Bone density evaluation for patients with prostate cancer and receiving androgen deprivation therapy
eCQM Identifier (Measure Authoring Tool) | 645 | eCQM Version Number | 7.0.000
NQF Number | Not Applicable | GUID | 977b302e-cdf3-4ba2-8020-5e099d93ad18
Measurement Period | January 1, 20XX through December 31, 20XX
Measure Steward | Oregon Urology
Measure Developer | Oregon Urology
Endorsed By | None
Description |
    Percentage of patients determined as having prostate cancer who are currently starting or undergoing androgen deprivation therapy (ADT), for an anticipated period of 12 months or greater and who receive an initial bone density evaluation. The bone density evaluation must be prior to the start of ADT or within 3 months of the start of ADT.
Copyright |
    Limited proprietary coding is contained in the measure specifications for convenience. Users of the proprietary code sets should obtain all necessary licenses from the owners of these code sets. Oregon Urology Institute (OUI) and Large Urology Group Practice Association (LUGPA) disclaim all liability for use or accuracy of third party codes contained in the specifications.

    CPT(R) contained in the Measure specifications is copyright 2004-2022. American Medical Association. LOINC(R) copyright 2004-2022 Regenstrief Institute, Inc. This material contains SNOMED Clinical Terms(R) (SNOMED CT[R]) copyright 2004-2022. International Health Terminology Standards Development Organisation. ICD-10 copyright 2022 World Health Organization. All Rights Reserved.
Disclaimer |
    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 MEASURES 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].
Measure Scoring | Proportion
Measure Type | Process
Stratification |
    None
Risk Adjustment |
    None
Rate Aggregation |
    None
Rationale |
    Androgen suppression as a treatment for prostate cancer can cause osteoporosis (Qaseem, 2008). Men undergoing prolonged androgen deprivation therapy (ADT) incur bone loss at a rate higher than menopausal women (Guise, 2007). In preserving bone health, the goal is to prevent or treat osteopenia/osteoporosis for the patient on ADT and to prevent or delay skeletal related events. The National Osteoporosis Foundation recommendations including a baseline assessment of bone density with a dual energy X-ray absorptiometry (DEXA) scan and daily calcium and Vitamin D supplementation (Watts, 2012). The DEXA scan is the gold standard for bone density screening. Men at risk for adverse bone consequences from chronic ADT do not always receive care according to evidence-based guidelines. These findings call for improved processes that standardize evidence-based practice including baseline and follow up bone density assessment (Watts, 2012).
Clinical Recommendation Statement |
    Bone density screening should be performed at the start of Androgen Deprivation Therapy (ADT) for prostate cancer. It should also be performed every 2 years for the patient with continued ADT or for patients with known osteoporosis. Current insurance practice is to possibly cover the cost of bone density screening if osteoporosis is known or if there is a high-risk drug. Some patients choose to delay bone density screening until after ADT is started and they therefore have insurance authorization due to the administration of a high-risk drug.
Improvement Notation |
    A higher score indicates better quality
Reference |
    Reference Type: CITATION
    Reference Text: 'Cosman, F., deBeur, S., LeBoff, M., et al. (2014, June). Clinician’s guide to prevention and treatment of osteoporosis. Osteoporosis International, 25(10), 2359–2381. Retrieved from
    http://link.springer.com/article/10.1007/s00198-014-2794-2'
Reference |
    Reference Type: CITATION
    Reference Text: 'Finkelstein, J., & Yu, E. (2017). Clinical manifestations, diagnosis, and evaluation of osteoporosis in men. Retrieved from
    https://www.uptodate.com/contents/clinical-manifestations-diagnosis-and-evaluation-of-osteoporosis-in-men/print?source=see_link'
Reference |
    Reference Type: CITATION
    Reference Text: 'Guise, T., Oefelein, M., Eastham, J., et al. (2007). Estrogenic side effects of androgen deprivation therapy. Reviews in Urology, 9(4), 163-180. Retrieved from
    https://www.researchgate.net/profile/Celestia_Higano/publication/5619579_Estrogenic_side_effects_of_androgen_deprivation_therapy/links/0c960526434483fdfd000000.pdf'
Reference |
    Reference Type: CITATION
    Reference Text: 'Qaseem, A., Snow, V., Shekelle, P., et al. (2008). Annals of Internal Medicine. Screening for osteoporosis in men: A clinical practice guideline from the American College of Physicians, 2008. Annals of Internal Medicine, 148(9), 680-684. Retrieved from
    http://annals.org/aim/article/740825/screening-osteoporosis-men-clinical-practice-guideline-from-american-college-physicians'
Reference |
    Reference Type: CITATION
    Reference Text: 'Ward, R., Roberts, C., Bencardino, J., et al. (2016). American College of Radiology: ACR Appropriateness Criteria (R)—Osteoporosis and bone mineral density. Retrieved from
    https://www.jacr.org/article/S1546-1440(17)30198-9/pdf'
Reference |
    Reference Type: CITATION
    Reference Text: 'Watts, N., Adler, R., Bilezikian, J., et al. (2012, June). Osteoporosis in men: An Endocrine Society clinical practice guideline, Journal of Clinical Endocrinology & Metabolism, 97(6), 1802–1822. Retrieved from
    https://academic.oup.com/jcem/article-lookup/doi/10.1210/jc.2011-3045'
Definition |
    DEXA - Dual Energy X-ray Absorptiometry - A scan that measures the bone of the spine, hip or total body and measures bone mineral density. It is considered one of the most accurate measurements.
    PDXA - Peripheral Dual Energy X-ray Absorptiometry - Bone mineral density measurement of the wrist, heel or finger.

    First Androgen Deprivation Therapy - The first Androgen Deprivation Therapy (ADT) is measured as the first order or administration of ADT for an anticipated period of 12 months or greater to a patient with prostate cancer.
Guidance |
    In order to capture the practitioner's intent of androgen deprivation therapy (ADT) for a period of 12 months or greater, SNOMEDCT 456381000124102 which is Injection of leuprolide acetate for twelve month period (regime/therapy) is the correct code.

    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.
Transmission Format |
    TBD
Initial Population |
    Male patients with a qualifying encounter in the measurement period AND with a diagnosis of prostate cancer AND with an order for ADT or an active medication of ADT with an intent for treatment greater than or equal to 12 months during the measurement period
Denominator |
    Equals Initial Population
Denominator Exclusions |
    None
Numerator |
    Patients with a bone density evaluation within the two years prior to the start of or less than three months after the start of ADT treatment
Numerator Exclusions |
    Not Applicable
Denominator Exceptions |
    Patient refused the bone density evaluation at the time ordered or did not have it performed within 3 months after the start of ADT
Supplemental Data Elements |
    For every patient evaluated by this measure also identify payer, race, ethnicity and sex

## Table of Contents

- Population Criteria
- Definitions
- Functions
- Terminology
- Data Criteria (QDM Data Elements)
- Supplemental Data Elements
- Risk Adjustment Variables

### Population Criteria

- - Initial Population

    - -     "Patient is Male"
              and "Has Qualifying Encounter"
              and exists "Order for 12 Months of ADT in 3 Months Before to 9 Months After Start of Measurement Period"

- - Denominator

    - -     "Initial Population"

- - Denominator Exclusions

    - -     None

- - Numerator

    - -     "Has Baseline DEXA Scan Two Years Prior to the Start of or Less than Three Months After the Start of ADT"

- - Numerator Exclusions

    - -     None

- - Denominator Exceptions

    - -     exists ( "No Bone Density Scan Ordered Due to Patient Refusal" )
              or exists ( "No Bone Density Scan Performed Due to Patient Refusal" )

- - Stratification

    - -     None

### Definitions

- - Androgen Deprivation Therapy for Urology Care Medication Active Start Dates

    - -     ["Medication, Active": "Androgen deprivation therapy for Urology Care"] ADTActive
              where Global."NormalizeInterval" ( ADTActive.relevantDatetime, ADTActive.relevantPeriod ) starts during day of Interval[start of "Measurement Period" - 12 months,
              end of "Measurement Period"]
              return Global.EarliestOf ( ADTActive.relevantDatetime, ADTActive.relevantPeriod )

  - Androgen Deprivation Therapy for Urology Care Medication Order Start Dates

    - -     ["Medication, Order": "Androgen deprivation therapy for Urology Care"] ADTOrder
              where Global."NormalizeInterval" ( ADTOrder.authorDatetime, ADTOrder.relevantPeriod ) starts during day of Interval[start of "Measurement Period" - 12 months,
              end of "Measurement Period"]
              return Global.EarliestOf ( ADTOrder.authorDatetime, ADTOrder.relevantPeriod )

  - Denominator

    - -     "Initial Population"

  - Denominator Exception

    - -     exists ( "No Bone Density Scan Ordered Due to Patient Refusal" )
              or exists ( "No Bone Density Scan Performed Due to Patient Refusal" )

  - First ADT in 3 Months Before to 9 Months After Start of Measurement Period

    - -     First(("Androgen Deprivation Therapy for Urology Care Medication Active Start Dates"
                union "Androgen Deprivation Therapy for Urology Care Medication Order Start Dates")ADTDate
                with "Prostate Cancer Diagnosis" ProstateCancer
                  such that ADTDate during ProstateCancer.prevalencePeriod
                    and ADTDate during Interval[start of "Measurement Period" - 3 months, start of "Measurement Period" + 9 months]
                sort ascending
            )

  - Has Baseline DEXA Scan Two Years Prior to the Start of or Less than Three Months After the Start of ADT

    - -     exists ( ( ["Diagnostic Study, Order": "DEXA Dual Energy Xray Absorptiometry, Bone Density for Urology Care"] DEXAOrdered
                  with "Order for 12 Months of ADT in 3 Months Before to 9 Months After Start of Measurement Period" OrderTwelveMonthsADT
                    such that DEXAOrdered.authorDatetime 3 months or less on or after day of OrderTwelveMonthsADT.authorDatetime
                      or DEXAOrdered.authorDatetime 2 years or less before day of OrderTwelveMonthsADT.authorDatetime
              )
                union ( ["Diagnostic Study, Performed": "DEXA Dual Energy Xray Absorptiometry, Bone Density for Urology Care"] DEXAPerformed
                    with "Order for 12 Months of ADT in 3 Months Before to 9 Months After Start of Measurement Period" OrderTwelveMonthsADT
                      such that Global."NormalizeInterval" ( DEXAPerformed.relevantDatetime, DEXAPerformed.relevantPeriod ) 3 months or less on or after day of OrderTwelveMonthsADT.authorDatetime
                        or Global."NormalizeInterval" ( DEXAPerformed.relevantDatetime, DEXAPerformed.relevantPeriod ) 2 years or less before OrderTwelveMonthsADT.authorDatetime
                )
            )

  - Has Qualifying Encounter

    - -     exists ["Encounter, Performed": "Office Visit"] Encounter
              where Encounter.relevantPeriod during "Measurement Period"

  - Initial Population

    - -     "Patient is Male"
              and "Has Qualifying Encounter"
              and exists "Order for 12 Months of ADT in 3 Months Before to 9 Months After Start of Measurement Period"

  - No Bone Density Scan Ordered Due to Patient Refusal

    - -     ["Diagnostic Study, Not Ordered": "DEXA Dual Energy Xray Absorptiometry, Bone Density for Urology Care"] DEXANotOrdered
              with "Order for 12 Months of ADT in 3 Months Before to 9 Months After Start of Measurement Period" OrderTwelveMonthsADT
                such that DEXANotOrdered.authorDatetime 3 months or less on or after day of OrderTwelveMonthsADT.authorDatetime
                  and DEXANotOrdered.negationRationale in "Patient Declined"

  - No Bone Density Scan Performed Due to Patient Refusal

    - -     ["Diagnostic Study, Not Performed": "DEXA Dual Energy Xray Absorptiometry, Bone Density for Urology Care"] DEXANotPerformed
              with "Order for 12 Months of ADT in 3 Months Before to 9 Months After Start of Measurement Period" OrderTwelveMonthsADT
                such that DEXANotPerformed.authorDatetime 3 months or less on or after day of OrderTwelveMonthsADT.authorDatetime
                  and DEXANotPerformed.negationRationale in "Patient Declined"

  - Numerator

    - -     "Has Baseline DEXA Scan Two Years Prior to the Start of or Less than Three Months After the Start of ADT"

  - Order for 12 Months of ADT in 3 Months Before to 9 Months After Start of Measurement Period

    - -     ["Procedure, Order": "Injection of leuprolide acetate for twelve month period (regime/therapy)"] OrderTwelveMonthADT
              with "First ADT in 3 Months Before to 9 Months After Start of Measurement Period" FirstADTMP
                such that OrderTwelveMonthADT.authorDatetime on or after FirstADTMP
                  and OrderTwelveMonthADT.authorDatetime during Interval[start of "Measurement Period" - 3 months, start of "Measurement Period" + 9 months]

  - Patient is Male

    - -     exists ["Patient Characteristic Sex": "Male"]

  - Prostate Cancer Diagnosis

    - -     ["Diagnosis": "Prostate Cancer"] ProstateCancer
              where ProstateCancer.prevalencePeriod overlaps "Measurement Period"

  - SDE Ethnicity

    - -     ["Patient Characteristic Ethnicity": "Ethnicity"]

  - SDE Payer

    - -     ["Patient Characteristic Payer": "Payer"]

  - SDE Race

    - -     ["Patient Characteristic Race": "Race"]

  - SDE Sex

    - -     ["Patient Characteristic Sex": "ONC Administrative Sex"]

### Functions

- - Global.Earliest(period Interval<DateTime>)

    - -     if ( HasStart(period)) then start of period
              else
            end of period

  - Global.EarliestOf(pointInTime DateTime, period Interval<DateTime>)

    - -     Earliest(NormalizeInterval(pointInTime, period))

  - Global.HasStart(period Interval<DateTime>)

    - -     not ( start of period is null
                or start of period = minimum DateTime
            )

  - Global.NormalizeInterval(pointInTime DateTime, period Interval<DateTime>)

    - -     if pointInTime is not null then Interval[pointInTime, pointInTime]
              else if period is not null then period
              else null as Interval<DateTime>

### Terminology

- code "Injection of leuprolide acetate for twelve month period (regime/therapy)" ("SNOMEDCT Code (456381000124102)")
- code "Male" ("AdministrativeGender Code (M)")
- valueset "Androgen deprivation therapy for Urology Care" (2.16.840.1.113762.1.4.1151.48)
- valueset "DEXA Dual Energy Xray Absorptiometry, Bone Density for Urology Care" (2.16.840.1.113762.1.4.1151.38)
- valueset "Ethnicity" (2.16.840.1.114222.4.11.837)
- valueset "Office Visit" (2.16.840.1.113883.3.464.1003.101.12.1001)
- valueset "ONC Administrative Sex" (2.16.840.1.113762.1.4.1)
- valueset "Patient Declined" (2.16.840.1.113883.3.526.3.1582)
- valueset "Payer" (2.16.840.1.114222.4.11.3591)
- valueset "Prostate Cancer" (2.16.840.1.113883.3.526.3.319)
- valueset "Race" (2.16.840.1.114222.4.11.836)

### Data Criteria (QDM Data Elements)

- "Diagnosis: Prostate Cancer" using "Prostate Cancer (2.16.840.1.113883.3.526.3.319)"
- "Diagnostic Study, Not Ordered: DEXA Dual Energy Xray Absorptiometry, Bone Density for Urology Care" using "DEXA Dual Energy Xray Absorptiometry, Bone Density for Urology Care (2.16.840.1.113762.1.4.1151.38)"
- "Diagnostic Study, Not Performed: DEXA Dual Energy Xray Absorptiometry, Bone Density for Urology Care" using "DEXA Dual Energy Xray Absorptiometry, Bone Density for Urology Care (2.16.840.1.113762.1.4.1151.38)"
- "Diagnostic Study, Order: DEXA Dual Energy Xray Absorptiometry, Bone Density for Urology Care" using "DEXA Dual Energy Xray Absorptiometry, Bone Density for Urology Care (2.16.840.1.113762.1.4.1151.38)"
- "Diagnostic Study, Performed: DEXA Dual Energy Xray Absorptiometry, Bone Density for Urology Care" using "DEXA Dual Energy Xray Absorptiometry, Bone Density for Urology Care (2.16.840.1.113762.1.4.1151.38)"
- "Encounter, Performed: Office Visit" using "Office Visit (2.16.840.1.113883.3.464.1003.101.12.1001)"
- "Medication, Active: Androgen deprivation therapy for Urology Care" using "Androgen deprivation therapy for Urology Care (2.16.840.1.113762.1.4.1151.48)"
- "Medication, Order: Androgen deprivation therapy for Urology Care" using "Androgen deprivation therapy for Urology Care (2.16.840.1.113762.1.4.1151.48)"
- "Patient Characteristic Ethnicity: Ethnicity" using "Ethnicity (2.16.840.1.114222.4.11.837)"
- "Patient Characteristic Payer: Payer" using "Payer (2.16.840.1.114222.4.11.3591)"
- "Patient Characteristic Race: Race" using "Race (2.16.840.1.114222.4.11.836)"
- "Patient Characteristic Sex: Male" using "Male (AdministrativeGender Code M)"
- "Patient Characteristic Sex: ONC Administrative Sex" using "ONC Administrative Sex (2.16.840.1.113762.1.4.1)"
- "Procedure, Order: Injection of leuprolide acetate for twelve month period (regime/therapy)" using "Injection of leuprolide acetate for twelve month period (regime/therapy) (SNOMEDCT Code 456381000124102)"

### Supplemental Data Elements

- SDE Ethnicity

  - -     ["Patient Characteristic Ethnicity": "Ethnicity"]

- SDE Payer

  - -     ["Patient Characteristic Payer": "Payer"]

- SDE Race

  - -     ["Patient Characteristic Race": "Race"]

- SDE Sex

  - -     ["Patient Characteristic Sex": "ONC Administrative Sex"]

### Risk Adjustment Variables

- None

Measure Set |
    None