Appropriate Use of DXA Scans in Women Under 65 Years Who Do Not Meet the Risk Factor Profile for Osteoporotic Fracture
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| Measure Information | 2023 Performance Period | 2024 Performance Period |
|---|---|---|
| Title | Appropriate Use of DXA Scans in Women Under 65 Years Who Do Not Meet the Risk Factor Profile for Osteoporotic Fracture | Appropriate Use of DXA Scans in Women Under 65 Years Who Do Not Meet the Risk Factor Profile for Osteoporotic Fracture |
| CMS eCQM ID | CMS249v5 | CMS249v6 |
| CBE ID* | 3475e | 3475e |
| MIPS Quality ID | 472 | 472 |
| Measure Steward | Centers for Medicare & Medicaid Services (CMS) | Centers for Medicare & Medicaid Services (CMS) |
| Description |
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 |
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 |
| Measure Scoring | Proportion | Proportion |
| Measure Type | Process | Process |
| Stratification | *See CMS249v5.html |
None |
| Risk Adjustment | *See CMS249v5.html |
None |
| Rationale | *See CMS249v5.html |
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). |
| Clinical Recommendation Statement | *See CMS249v5.html |
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 Fracture Risk Assessment (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%." |
| Improvement Notation |
Lower score indicates better quality |
Lower score indicates better quality |
| Definition | *See CMS249v5.html |
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. |
| Guidance |
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 QDM page for more information on the QDM. |
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 QDM page for more information on the QDM. |
| Initial Population |
Female patients ages 50 to 63 years at the start of the measurement period with an encounter during the measurement period |
Female patients ages 50 to 63 years at the start of the measurement period with an encounter during the measurement period |
| Denominator |
Equals Initial Population |
Equals Initial Population |
| Denominator Exclusions |
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 |
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 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 |
| Numerator |
Female patients who received an order for at least one DXA scan in the measurement period |
Female patients who received an order for at least one DXA scan in the measurement period |
| Numerator Exclusions |
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 |
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 |
| Denominator Exceptions |
None |
None |
| Telehealth Eligible | Yes | Yes |
| Next Version | No Version Available | |
| Previous Version | No Version Available |
Additional Resources for CMS249v5
Header
Updated copyright.
Measure Section: Copyright
Source of Change: Annual Update
Updated references.
Measure Section: Reference
Source of Change: Measure Lead
Removed National Institute for Health and Care Excellence (NICE) guidelines that are only applicable to the U.K. Population.
Measure Section: Clinical Recommendation Statement
Source of Change: Measure Lead
Updated version number of the Quality Data Model (QDM) used in the measure specification to v5.6.
Measure Section: Guidance
Source of Change: Standards/Technical Update
Added age anchor specification to the initial population description to clarify measure requirements.
Measure Section: Initial Population
Source of Change: Measure Lead
Updated the grouping category of glucocorticoids risk factor to reflect the timing requirement to improve readability and provide clarity.
Measure Section: Denominator Exclusions
Source of Change: Measure Lead
Added exclusion risk factors associated with increased risk for osteoporosis based on recent evidence and stakeholder support.
Measure Section: Denominator Exclusions
Source of Change: Measure Lead
Revised the timing requirement to align the onset of osteoporosis and osteopenia to prior to the measurement period.
Measure Section: Denominator Exclusions
Source of Change: Measure Lead
Added new osteoporosis risk assessment tools to identify patients with increased risk for osteoporosis to align with USPSTF clinical recommendations.
Measure Section: Multiple Sections
Source of Change: Measure Lead
Removed patients with qualifying risk assessment scores from the numerator exclusions instead of from the denominator exclusions to align with the measure intent.
Measure Section: Multiple Sections
Source of Change: Measure Lead
Removed age combination risk factors 'race' and 'smoking status' and retained all others as independent risk factors to simplify the measure specification per the addition of new risk assessment tools.
Measure Section: Multiple Sections
Source of Change: Measure Lead
Logic
Updated glucocorticoid active medication duration calculation to accurately capture total days covered by the period instead of 24-hour durations.
Measure Section: Definitions
Source of Change: Measure Lead
Updated the timing precision in the definitions from datetime to date by adding 'day of', 'date from', and/or function 'ToDateInterval' to align with the measure intent.
Measure Section: Definitions
Source of Change: Measure Lead
Updated the grouping category of glucocorticoids risk factor to reflect the timing requirement to improve readability.
Measure Section: Definitions
Source of Change: Measure Lead
Revised the timing requirement to align the onset of osteoporosis and osteopenia to prior to the measurement period.
Measure Section: Definitions
Source of Change: Measure Lead
Replaced value set Preventive Care Services Other (2.16.840.1.113883.3.464.1003.101.12.1030) with direct reference code CPT code (99429).
Measure Section: Definitions
Source of Change: Measure Lead
Added QDM datatypes 'Diagnosis' and 'Procedure, Performed' to capture additional exclusion risk factors associated with increased risk for osteoporosis based on recent evidence and stakeholder support.
Measure Section: Multiple Sections
Source of Change: Measure Lead
Updated the version number of the Measure Authoring Tool (MAT) Global Common Functions Library to v7.0.000.
Measure Section: Multiple Sections
Source of Change: Standards/Technical Update
Updated the timing precision in the definitions to align with the measure intent by replacing 'starts before' to 'starts on or before'.
Measure Section: Multiple Sections
Source of Change: Measure Lead
Revised logic to remove patients with qualifying risk assessment scores from numerator exclusions instead of from denominator exclusions to align with revised narrative and clinical recommendations.
Measure Section: Multiple Sections
Source of Change: Measure Lead
Updated the version of the Quality Data Model (QDM) to 5.6 and Clinical Quality Language (CQL) to 1.5.
Measure Section: Multiple Sections
Source of Change: Standards/Technical Update
Replaced the Global.CalendarAgeInYearsAt function with the native CQL function AgeInYearsAt to take advantage of existing CQL features and increase human readability. As a result of this change, the LOINC code 21112-8 is no longer required and has been removed from the Terminology section of the human readable specification.
Measure Section: Multiple Sections
Source of Change: Measure Lead
Revised the age interval to use closed intervals within the logic to align with CQL style best practices.
Measure Section: Multiple Sections
Source of Change: Measure Lead
Removed age combination risk factors logic and retained all as independent risk factors except for 'race' and 'smoking status' to reflect the revised narrative.
Measure Section: Multiple Sections
Source of Change: Measure Lead
Added new 'Assessment, Performed' logic to account for new osteoporosis risk assessment tools to align with revised narrative and clinical recommendations.
Measure Section: Multiple Sections
Source of Change: Measure Lead
Updated the names of CQL definitions, functions, and/or aliases for clarification and to align with the CQL Style Guide.
Measure Section: Multiple Sections
Source of Change: Standards/Technical Update
Value set
The VSAC is the source of truth for the value set content, please visit the VSAC for downloads of current value sets.
Value set Chronic Liver Disease (2.16.840.1.113883.3.464.1003.199.12.1035): Added 1 SNOMED CT code (1010616001) based on review by technical experts, SMEs, and/or public feedback. Deleted 1 ICD-10-CM code (K74.0) based on validity of code during timing of look back period.
Measure Section: Terminology
Source of Change: Measure Lead
Value set Osteoporosis (2.16.840.1.113883.3.464.1003.113.12.1038): Added 39 SNOMED CT codes based on review by technical experts, SMEs, and/or public feedback.
Measure Section: Terminology
Source of Change: Measure Lead
Value set Hyperparathyroidism (2.16.840.1.113883.3.464.1003.117.12.1016): Added 1 SNOMED CT code (190045361000119101) based on review by technical experts, SMEs, and/or public feedback.
Measure Section: Terminology
Source of Change: Measure Lead
Value set Malabsorption Syndromes (2.16.840.1.113883.3.464.1003.199.12.1050): Added 5 SNOMED CT codes (453720571000119100, 721702009, 880001008, 966011731000119103, 969688801000119108) based on review by technical experts, SMEs, and/or public feedback. Deleted 1 ICD-10-CM code (K90.4) based on validity of code during timing of look back period.
Measure Section: Terminology
Source of Change: Measure Lead
Value set Marfan's Syndrome (2.16.840.1.113883.3.464.1003.113.12.1048): Added 1 SNOMED CT code (1003407000) based on review by technical experts, SMEs, and/or public feedback.
Measure Section: Terminology
Source of Change: Measure Lead
Value set Osteogenesis Imperfecta (2.16.840.1.113883.3.464.1003.113.12.1044): Added 1 SNOMED CT code (1003379004) based on review by technical experts, SMEs, and/or public feedback.
Measure Section: Terminology
Source of Change: Measure Lead
Value set Rheumatoid Arthritis (2.16.840.1.113883.3.464.1003.113.12.1005): Added 65 SNOMED CT codes based on review by technical experts, SMEs, and/or public feedback.
Measure Section: Terminology
Source of Change: Measure Lead
Added direct reference code SNOMED CT code (7771000) based on review by technical experts, SMEs, and/or public feedback.
Measure Section: Terminology
Source of Change: Measure Lead
Value set Type 1 Diabetes (2.16.840.1.113883.3.464.1003.103.12.1020): Deleted 8 ICD-10-CM codes (E10.321, E10.329, E10.331, E10.339, E10.341, E10.349, E10.351, E10.359) based on validity of code during timing of look back period.
Measure Section: Terminology
Source of Change: Measure Lead
Removed direct reference code LOINC code (21112-8) based on review by technical experts, SMEs, and/or public feedback.
Measure Section: Terminology
Source of Change: Measure Lead
Replaced value set Female (2.16.840.1.113883.3.560.100.2) with direct reference code AdministrativeGender code (F) based on review by technical experts, SMEs, and/or public feedback.
Measure Section: Terminology
Source of Change: Measure Lead
Added direct reference code LOINC code (98133-2) based on review by technical experts, SMEs, and/or public feedback.
Measure Section: Terminology
Source of Change: Measure Lead
Added direct reference code LOINC code (98139-9) based on review by technical experts, SMEs, and/or public feedback.
Measure Section: Terminology
Source of Change: Measure Lead
Removed value set White (2.16.840.1.113883.3.464.1003.123.12.1007) based on review by technical experts, SMEs, and/or public feedback.
Measure Section: Terminology
Source of Change: Measure Lead
Value set Ehlers Danlos Syndrome (2.16.840.1.113883.3.464.1003.113.12.1047): Deleted 1 ICD-10-CM code (Q79.6) based on validity of code during timing of look back period.
Measure Section: Terminology
Source of Change: Measure Lead
Removed value set Current Tobacco Smoker (2.16.840.1.113883.3.600.2390) based on review by technical experts, SMEs, and/or public feedback.
Measure Section: Terminology
Source of Change: Measure Lead
Added value set Major Transplant (2.16.840.1.113883.3.464.1003.198.12.1075) based on review by technical experts, SMEs, and/or public feedback.
Measure Section: Terminology
Source of Change: Measure Lead
Added value set Chemotherapy (2.16.840.1.113883.3.526.3.485) based on review by technical experts, SMEs, and/or public feedback.
Measure Section: Terminology
Source of Change: Measure Lead
Replaced value set BMI Ratio (2.16.840.1.113883.3.600.1.1490) with direct reference code LOINC code (39156-5) based on applicability of a single code to represent clinical data.
Measure Section: Terminology
Source of Change: Measure Lead
Replaced value set Average Number of Drinks per Drinking Day (2.16.840.1.113883.3.464.1003.106.12.1018) with direct reference code LOINC code (11287-0) based on applicability of a single code to represent clinical data.
Measure Section: Terminology
Source of Change: Measure Lead
Replaced value set Preventive Care Services Other (2.16.840.1.113883.3.464.1003.101.12.1030) with direct reference code CPT code (99429) based on review by technical experts, SMEs, and/or public feedback.
Measure Section: Terminology
Source of Change: Measure Lead
Added direct reference code LOINC code (98146-4) based on review by technical experts, SMEs, and/or public feedback.
Measure Section: Terminology
Source of Change: Measure Lead
Added value set Amenorrhea (2.16.840.1.113883.3.464.1003.1022) based on review by technical experts, SMEs, and/or public feedback.
Measure Section: Terminology
Source of Change: Measure Lead
Added value set Bone Marrow Transplant (2.16.840.1.113883.3.666.5.336) based on review by technical experts, SMEs, and/or public feedback.
Measure Section: Terminology
Source of Change: Measure Lead
Added value set Evidence of Bilateral Oophorectomy (2.16.840.1.113883.3.464.1003.1048) based on review by technical experts, SMEs, and/or public feedback.
Measure Section: Terminology
Source of Change: Measure Lead
Added value set Unilateral Oophorectomy Left (2.16.840.1.113883.3.464.1003.1028) based on review by technical experts, SMEs, and/or public feedback.
Measure Section: Terminology
Source of Change: Measure Lead
Added value set Bilateral Oophorectomy (2.16.840.1.113883.3.526.3.471) based on review by technical experts, SMEs, and/or public feedback.
Measure Section: Terminology
Source of Change: Measure Lead
Added value set Kidney Transplant (2.16.840.1.113883.3.464.1003.109.12.1012) based on review by technical experts, SMEs, and/or public feedback.
Measure Section: Terminology
Source of Change: Measure Lead
Added value set Unilateral Oophorectomy Right (2.16.840.1.113883.3.464.1003.1032) based on review by technical experts, SMEs, and/or public feedback.
Measure Section: Terminology
Source of Change: Measure Lead
Added value set Multiple Myeloma (2.16.840.1.113883.3.464.1003.1011) based on review by technical experts, SMEs, and/or public feedback.
Measure Section: Terminology
Source of Change: Measure Lead
Added value set Unilateral Oophorectomy, Unspecified Laterality (2.16.840.1.113883.3.464.1003.1035) based on review by technical experts, SMEs, and/or public feedback.
Measure Section: Terminology
Source of Change: Measure Lead
Added value set Premature Menopause (2.16.840.1.113883.3.464.1003.1013) based on review by technical experts, SMEs, and/or public feedback.
Measure Section: Terminology
Source of Change: Measure Lead
Added value set Eating Disorders (2.16.840.1.113883.3.464.1003.1039) based on review by technical experts, SMEs, and/or public feedback.
Measure Section: Terminology
Source of Change: Measure Lead
Removed value set Tobacco Use Screening (2.16.840.1.113883.3.526.3.1278) based on review by technical experts, SMEs, and/or public feedback.
Measure Section: Terminology
Source of Change: Measure Lead
Added direct reference code SNOMED CT code (24028007) based on review by technical experts, SMEs, and/or public feedback.
Measure Section: Terminology
Source of Change: Measure Lead