Public Comment for Proposed Eligible Professionals Electronic Health Record (EHR) Incentive Program Measure: Appropriate Use of Dual-energy X-ray Absorptiometry (DXA) Scans in Women Under 65 Years Who Do Not Meet the Risk Factor Profile

These comments are on behalf of the National Bone Health Alliance (NBHA, www.nbha.org), a public-private partnership on bone health that includes 51 organizational members and 4 government agencies, in response to the proposed new clinical quality measure (CQM) for potential use by eligible professionals in the EHR Incentive Program, “Appropriate Use of Dual-energy X-ray Absorptiometry (DXA) Scans in Women Under 65 Years Who Do Not Meet the Risk Factor Profile” (which Mathematica and its subcontractors, the National Committee for Quality Assurance and the Lewin Group are developing on behalf of The Centers for Medicare & Medicaid Services, per HHS Contract: HHSM-500-2008-00020I; Task Order HHSM-500-TO003).

NBHA wishes to emphasize that BMD screening is necessary in women over 65 and men over 70, as well as those younger individuals with recognized risk factors. While utilization in younger women without formally listed risk factors should not be universally recommended, it is clearly not excessive and may well be useful in instances. We feel this proposed program measure is unnecessary, as DXA and other bone density screening modalities are not being overused in women under 65. In fact, only 1.4% of DXA tests in women 40-65 were inappropriate based on absence of risk factors. In our view, it would be unwise to broadly label such use as “unnecessary” or to conclude that all such use constitutes overutilization.

Further, this measure does not include common known risk factors and has the potential to exclude other risk factors identified in the future, even though there are a number of conditions and risk factors that can increase fracture risk in younger individuals and a thorough dialogue between the patient and their health care professional(s) is critical in adequately assessing this risk.

The proposed program measure appears to define the last set of denominator exclusions for DXA testing in women younger than 65 years of age based on the NOF recommendations for treatment in the United States (10 y probability of major osteoporotic fracture >20% and hip fracture >3%) rather than the USP recommendation for DXA testing if 10 year major osteoporotic fracture risk.

In developing and implementing this particular “overuse” measure, it is also important to consider that bone density tests are widely underutilized among women older than age 65 – the population at highest risk for osteoporosis and fractures. In fact, only 11 percent of women in this age group have ever had a bone density test, leaving those at the highest risk the most vulnerable to fracture.

We are hopeful that the committee will be thoughtful in determining how best to draw attention to the need for osteoporosis screening in those sub-populations that are at heightened risk for fracturing, while continuing to caution clinicians against screening those patients who do not present an appropriate fracture risk.