Appropriate Use of DXA Scans in Women Under 65 Years Who Do Not Meet the Risk Factor Profile for Osteoporotic Fracture

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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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 smoking 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.

"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."

"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." 

"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%."

The National Institute for Health and Clinical Excellence’s Osteoporosis Guidelines:
"Consider assessment of fracture risk:
a. in all women aged 65 years and over and all men aged 75 years and over
b. in women aged under 65 years and men aged under 75 years in the presence of risk factors, for 
example:
*previous fragility fracture
*current use or frequent/ recent use of oral or systemic glucocorticoids
*history of falls
*family history of hip fracture
*other causes of secondary osteoporosis
*low body mass index (BMI) (less than 18.5 kg/m2)
*smoking
*alcohol intake of more than 14 units per week for women and more than 21 units per week for men."
"Do not routinely assess fracture risk in people aged under 50 years unless they have major risk 
factors (for example, current or frequent/recent use of oral or systemic glucocorticoids, untreated 
premature menopause or previous fragility fracture), because they are unlikely to be at high risk."

"Estimate absolute risk when assessing risk of fracture (for example, the predicted risk of major osteoporotic or hip fracture over 10 years, expressed as a percentage."

"Use either FRAX (without a bone mineral density [BMD] value if a dual energy X-ray absorptiometry [DXA] scan has not previously been undertaken) or QFracture, within their allowed age ranges, to estimate 10-year predicted absolute fracture risk when assessing risk of fracture."

"Do not routinely measure BMD to assess fracture risk without prior assessment using FRAX 
(without a BMD value) or QFracture."

"Take into account that risk assessment tools may underestimate fracture risk in certain 
circumstances, for example if a person:
*has a history of multiple fractures
*has had previous vertebral fracture(s)
*has a high alcohol intake
*is taking high-dose oral or high-dose systemic glucocorticoids (more than 7.5 mg prednisolone 
or equivalent per day for 3 months or longer)
*has other causes of secondary osteoporosis."

Lower score indicates better quality

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.

National Institute for Health and Clinical Excellence. (2012). Osteoporosis: Fragility fracture risk. Retrieved from https://www.nice.org.uk/guidance/cg146/chapter/1-Guidance

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 providers to use the Fracture Risk Assessment Tool (FRAX[R]) to calculate 10-year absolute fracture risk. The FRAX was developed by the World Health Organization in 2008 to evaluate 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.

There are two ways that a patient can be excluded from the measure:
1. The patient has a specific number of "combination" risk factors (the number of risk factors varies by age).
2. The patient has one or more of the "independent" risk factors, including a 10-year probability of major osteoporotic fracture of 8.4  percent or higher as determined by the FRAX.

TBD

Female patients ages 50 to 64 years with an encounter during the measurement period

Equals Initial Population

Exclude patients with a combination of risk factors (as determined by age) or one of the independent risk factors

Ages: 50-54 (>=4 combination risk factors) or 1 independent risk factor
Ages: 55-59 (>=3 combination risk factors) or 1 independent risk factor
Ages: 60-64 (>=2 combination risk factors) or 1 independent risk factor

COMBINATION RISK FACTORS [The following risk factors are all combination risk factors; they are grouped by when they occur in relation to the measurement period]:

The following risk factors may occur any time in the patient's history but must be active during the measurement period:
White (race)
BMI <= 20 kg/m2 (must be the first BMI of the measurement period)
Smoker (current during 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 factor may occur any time in the patient's history and must not start during the measurement period:
Osteopenia 

The following risk factors may occur at any time in the patient's history or during the measurement period:
Rheumatoid arthritis
Hyperthyroidism
Malabsorption Syndromes: celiac disease, inflammatory bowel disease, ulcerative colitis, Crohn's disease, cystic fibrosis, malabsorption
Chronic liver disease
Chronic malnutrition

The following risk factors may occur any time in the patient's history and do not need to be active at the start of the measurement period:
Documentation of history of hip fracture in parent
Osteoporotic fracture
Glucocorticoids  (>= 5 mg/per day   ) [cumulative medication duration >= 90 days]

INDEPENDENT RISK FACTORS (The following risk factors are all independent risk factors; they are grouped by when they occur in relation to the measurement period):

The following risk factors may occur at any time in the patient's history and must not start during the measurement period:
Osteoporosis  

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 
FRAX[R] ten-year probability of all major osteoporosis related fracture >= 8.4 percent
Aromatase inhibitors

The following risk factors may occur at any time in the patient's history or during the measurement period:
Type I Diabetes 
End stage renal disease
Osteogenesis imperfecta
Ankylosing spondylitis
Psoriatic arthritis
Ehlers-Danlos syndrome
Cushing's syndrome
Hyperparathyroidism
Marfan syndrome
Lupus

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

Not Applicable

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

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