eCQM Title | 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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eCQM Identifier (Measure Authoring Tool) | 249 | eCQM Version Number | 7.0.000 |
CBE Number | 3475e | GUID | a3ce125d-c238-42ce-862e-dba0055dfc66 |
Measurement Period | January 1, 20XX through December 31, 20XX | ||
Measure Steward | Centers for Medicare & Medicaid Services (CMS) | ||
Measure Developer | National Committee for Quality Assurance | ||
Endorsed By | CMS Consensus Based Entity | ||
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 |
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Copyright |
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) codes, descriptions and other data are copyright 2024. American Medical Association. All rights reserved. CPT is a trademark of the American Medical Association. Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT, and the AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability for data contained or not contained herein. Applicable FARS/DFARS restrictions apply to government use. The measure specifications contain coding from LOINC(R) (http://loinc.org). The LOINC table, LOINC codes, LOINC panels and form file, LOINC linguistic variants file, LOINC/RSNA Radiology Playbook, and LOINC/IEEE Medical Device Code Mapping Table are copyright 2004-2024 Regenstrief Institute, Inc. and the Logical Observation Identifiers Names and Codes (LOINC) Committee, and are available at no cost under the license at http://loinc.org/terms-of-use. This material contains SNOMED Clinical Terms(R) (SNOMED CT[R]) copyright 2004-2023 International Health Terminology Standards Development Organisation. ICD-10 copyright 2024 World Health Organization. All Rights Reserved. The Measure uses RxNorm, a standardized nomenclature and coding for clinical drugs and drug delivery devices, which is made publicly available courtesy of the U.S. National Library of Medicine (NLM), National Institutes of Health, Department of Health and Human Services. NLM is not responsible for the Measure and does not endorse or recommend this or any other product. “HL7” is the registered trademark of Health Level Seven International. |
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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 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]. |
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Measure Scoring | Proportion | ||
Measure Type | Process | ||
Stratification |
None |
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Risk Adjustment |
None |
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Rate Aggregation |
None |
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Rationale |
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). |
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Clinical Recommendation Statement |
USPSTF 2018: "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%." |
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Improvement Notation |
Lower score indicates better quality |
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Reference |
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.' |
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Reference |
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.' |
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Definition |
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. |
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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 eCQI resource center (https://ecqi.healthit.gov/qdm) for more information on the QDM. |
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Transmission Format |
TBD |
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Initial Population |
Female patients ages 50 to 63 years at the start of the measurement period with an encounter during the measurement period |
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Denominator |
Equals Initial Population |
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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 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 |
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Numerator |
Female patients who received an order for at least one DXA scan in the measurement period |
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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 |
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Denominator Exceptions |
None |
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Supplemental Data Elements |
For every patient evaluated by this measure also identify payer, race, ethnicity and sex |
AgeInYearsAt(date from start of "Measurement Period") in Interval[50, 63] and exists ( ["Patient Characteristic Sex": "Female"] ) and exists "Qualifying Encounter"
"Initial Population"
"Has Risk Factor Active During the Measurement Period" or "Has Risk Factor Any Time in History Prior to Measurement Period" or "Has Risk Factor Any Time in History or During Measurement Period"
exists "DXA Scan Order During Measurement Period"
exists "Osteoporosis Fracture Risk Assessment Prior to First DXA Scan"
None
None
"Initial Population"
"Has Risk Factor Active During the Measurement Period" or "Has Risk Factor Any Time in History Prior to Measurement Period" or "Has Risk Factor Any Time in History or During Measurement Period"
["Diagnostic Study, Order": "DXA (Dual energy Xray Absorptiometry) Scan"] DXA where DXA.authorDatetime during "Measurement Period" sort by authorDatetime asc
First(["Assessment, Performed": "Alcoholic drinks per day"] AverageDrinks where start of Global."NormalizeInterval"(AverageDrinks.relevantDatetime, AverageDrinks.relevantPeriod) during "Measurement Period" and AverageDrinks.result > 2 '{drinks}/d' sort by start of Global."NormalizeInterval"(relevantDatetime, relevantPeriod) )
First(["Physical Exam, Performed": "Body mass index (BMI) [Ratio]"] BMI where start of Global."NormalizeInterval"(BMI.relevantDatetime, BMI.relevantPeriod) during "Measurement Period" and BMI.result is not null sort by start of Global."NormalizeInterval"(relevantDatetime, relevantPeriod) )
"First BMI in Measurement Period" FirstBMI where FirstBMI.result <= 20 'kg/m2'
Sum("Glucocorticoid Active Medication Duration in Days")
( collapse ( ["Medication, Active": "Glucocorticoids (oral only)"] Glucocorticoid where Glucocorticoid.relevantPeriod starts before end of "Measurement Period" ).relevantPeriod per day ) GlucocorticoidIntervals return difference in days of ( GlucocorticoidIntervals intersect Interval[Patient.birthDatetime, end of "Measurement Period"] ) + 1
"Glucocorticoid Active Medication Days" >= 90
exists ( "ProcedureInPatientHistory"(["Procedure, Performed": "Bilateral Oophorectomy"]) ) or exists ( "ProcedureInPatientHistory"(["Procedure, Performed": "Evidence of Bilateral Oophorectomy"]) ) or ( exists ( "ProcedureInPatientHistory"((["Procedure, Performed": "Unilateral Oophorectomy, Unspecified Laterality"] UnilateralOophorectomy where UnilateralOophorectomy.anatomicalLocationSite ~ "Right (qualifier value)" ) union ["Procedure, Performed": "Unilateral Oophorectomy Right"] ) ) and exists ( "ProcedureInPatientHistory"((["Procedure, Performed": "Unilateral Oophorectomy, Unspecified Laterality"] UnilateralOophorectomy where UnilateralOophorectomy.anatomicalLocationSite ~ "Left (qualifier value)" ) union ["Procedure, Performed": "Unilateral Oophorectomy Left"] ) ) )
exists "ProcedureInPatientHistory"(["Procedure, Performed": "Major Transplant"] union ["Procedure, Performed": "Kidney Transplant"] union ["Procedure, Performed": "Bone Marrow Transplant"] )
"First BMI in Measurement Period Less Than or Equal to 20 kg m2" is not null or "First Average Number of Drinks Assessment Indicating More Than Two Per Day" is not null
"Has 90 or More Active Glucocorticoid Medication Days" or exists ( "DiagnosisInPatientHistory"(["Diagnosis": "Osteoporosis With Current Fracture"] union ["Diagnosis": "Malabsorption Syndromes"] union ["Diagnosis": "Chronic Malnutrition"] union ["Diagnosis": "Chronic Liver Disease"] union ["Diagnosis": "Rheumatoid Arthritis"] union ["Diagnosis": "Hyperthyroidism"] union ["Diagnosis": "Type 1 Diabetes"] union ["Diagnosis": "End Stage Renal Disease"] union ["Diagnosis": "Osteogenesis Imperfecta"] union ["Diagnosis": "Ankylosing Spondylitis"] union ["Diagnosis": "Psoriatic Arthritis"] union ["Diagnosis": "Ehlers Danlos Syndrome"] union ["Diagnosis": "Cushings Syndrome"] union ["Diagnosis": "Hyperparathyroidism"] union ["Diagnosis": "Marfan's Syndrome"] union ["Diagnosis": "Lupus"] union ["Diagnosis": "Multiple Myeloma"] union ["Diagnosis": "Premature Menopause"] union ["Diagnosis": "Eating Disorders"] union ["Diagnosis": "Amenorrhea"] ) ) or exists "ProcedureInPatientHistory"(["Procedure, Performed": "Chemotherapy"]) or "Has Double or Bilateral Oophorectomy" or "Has Organ Transplants"
exists ( ( ["Diagnosis": "Osteoporosis Without Current Fracture"] OsteoporosisDiagnosis where OsteoporosisDiagnosis.prevalencePeriod starts before start of "Measurement Period" ) union ( ["Diagnosis": "Osteopenia"] OsteopeniaDiagnosis where OsteopeniaDiagnosis.prevalencePeriod starts before start of "Measurement Period" ) union ( ["Procedure, Performed": "Gastric Bypass Surgery"] GastricBypass where Global."NormalizeInterval" ( GastricBypass.relevantDatetime, GastricBypass.relevantPeriod ) ends before start of "Measurement Period" ) union ( ["Medication, Active": "Aromatase Inhibitors"] AromataseInhibitorActive where Global."NormalizeInterval" ( AromataseInhibitorActive.relevantDatetime, AromataseInhibitorActive.relevantPeriod ) starts before start of "Measurement Period" ) union ( ["Medication, Order": "Aromatase Inhibitors"] AromataseInhibitorOrder where AromataseInhibitorOrder.authorDatetime before start of "Measurement Period" ) union ( ["Assessment, Performed": "History of hip fracture in parent"] ParentFractureHistory where start of Global."NormalizeInterval" ( ParentFractureHistory.relevantDatetime, ParentFractureHistory.relevantPeriod ) before start of "Measurement Period" ) )
AgeInYearsAt(date from start of "Measurement Period") in Interval[50, 63] and exists ( ["Patient Characteristic Sex": "Female"] ) and exists "Qualifying Encounter"
exists "DXA Scan Order During Measurement Period"
exists "Osteoporosis Fracture Risk Assessment Prior to First DXA Scan"
( ( ["Assessment, Performed": "Major osteoporotic fracture 10-year probability [Likelihood] Fracture Risk Assessment"] FRAX where FRAX.result >= 8.4 '%' ) union ( ["Assessment, Performed": "Osteoporosis Risk Assessment Instrument"] ORAI where ORAI.result >= 9 ) union ( ["Assessment, Performed": "Osteoporosis Index of Risk panel"] OSIRIS where OSIRIS.result < 1.0 ) union ( ["Assessment, Performed": "Osteoporosis Self-Assessment Tool"] OST where OST.result < 2.0 ) ) RiskAssessment where start of Global."NormalizeInterval" ( RiskAssessment.relevantDatetime, RiskAssessment.relevantPeriod ) before First("DXA Scan Order During Measurement Period").authorDatetime
( ["Encounter, Performed": "Office Visit"] union ["Encounter, Performed": "Preventive Care Services Established Office Visit, 18 and Up"] union ["Encounter, Performed": "Unlisted preventive medicine service"] union ["Encounter, Performed": "Preventive Care Services Initial Office Visit, 18 and Up"] union ["Encounter, Performed": "Outpatient Consultation"] union ["Encounter, Performed": "Virtual Encounter"] union ["Encounter, Performed": "Telephone Visits"] ) ValidEncounters where ValidEncounters.relevantPeriod during day of "Measurement Period"
["Patient Characteristic Ethnicity": "Ethnicity"]
["Patient Characteristic Payer": "Payer Type"]
["Patient Characteristic Race": "Race"]
["Patient Characteristic Sex": "ONC Administrative Sex"]
Diagnosis Dx where Dx.prevalencePeriod starts on or before day of end of "Measurement Period"
if pointInTime is not null then Interval[pointInTime, pointInTime] else if period is not null then period else null as Interval<DateTime>
Procedure Proc where Global."NormalizeInterval" ( Proc.relevantDatetime, Proc.relevantPeriod ) ends on or before day of end of "Measurement Period"
["Patient Characteristic Ethnicity": "Ethnicity"]
["Patient Characteristic Payer": "Payer Type"]
["Patient Characteristic Race": "Race"]
["Patient Characteristic Sex": "ONC Administrative Sex"]
Measure Set |
None |
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