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ABIM Osteoporosis PIM™ Practice Improvement Module Measures Catalogue

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Measures (8) http://www.abim.org/ …

Measures (8) http://www.abim.org/
This catalogue provides information related to the American Board of Internal Medicine’s Osteoporosis Practice
Improvement Module®. It is written in language that addresses the physician who might choose to complete this module, and it
details the specifics of the module. Included is information regarding:
• Purpose and structuring of the module
• Patient inclusion criteria
• Detailed description of the measures


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  • 1. ABIM Osteoporosis PIM™Practice Improvement Module Measures Catalogue
  • 2. Osteoporosis PIM Measures Catalogue September 2011 TABLE OF CONTENTS Introduction ............................................................................................................................................ 3 Processes of Care History.................................................................................................................................................................... 5 Physical Examination........................................................................................................................................... 6 Diagnostic Testing................................................................................................................................................ 8 Counseling .......................................................................................................................................................... 10 Treatment............................................................................................................................................................. 13Osteoporosis Measure Catalog September 2011 Page 2 of 13
  • 3. IntroductionThis catalogue provides information related to the American Board of Internal Medicine’s Osteoporosis PracticeImprovement Module®. It is written in language that addresses the physician who might choose to complete this module, and itdetails the specifics of the module. Included is information regarding: • Purpose and structuring of the module • Patient inclusion criteria • Detailed description of the measuresThis PIM examines the care you provide to your patients by addressing key processes and outcomes related to osteoporosis. These arebased primarily on guidelines from the American Association of Clinical Endocrinologists, the National Osteoporosis Foundation andthe Institute of Medicine.The PIM is divided into three parts, with multiple sections in each part.Part 1 -Performance DataProvide baseline data about your practices current performance by... • Reviewing your charts • Assessing your practice systemsThe 24 chart review measures are summarized below. ABIM requires a minimum of 25 chart reviews. The practice systemsassessment comprises questions covering various aspects of practice structure and protocols.  Osteoporosis Measure Catalog September 2011 Page 3 of 13
  • 4. Patients can be included in this module if all of the following are true: 1. Patients aged 18 and older with a diagnosis of osteoporosis, osteopenia or prior low impact fracture, or women age 65 and older or men age 70 and older regardless of diagnosis; 2. Management decisions regarding the diagnosis and treatment of osteoporosis are made primarily by providers in the practice; 3. They have been patients in the practice for at least one year; AND 4. They have been seen by the practice within the past 12 months. Patients should be excluded from this module if they have a terminal illness or treatment of their osteoporosis is not clinically relevant.Part 2 - Quality Improvement (QI) PlanDevelop a plan for improving one aspect of your practice after reviewing the analysis of your current performance data. The analysiswill include many aspects of care you provide to your patients. Ultimately, you will target only one of these to use in this qualityimprovement (QI) cycle.Part 3 - RemeasurementRemeasure your performance data after you have implemented your QI plan to see if you achieved your goal. Then, you will reflect onthe process of developing and implementing a QI plan.You may claim CME credit for completing this activity. The University of Pennsylvania School of Medicine designates thiseducational activity for a maximum of 20 AMA PRA Category 1 Credit(s)TM.Osteoporosis Measure Catalog September 2011 Page 4 of 13
  • 5. OSTEOPOROSIS - PROCESSES OF CAREHistoryMeasure Title Description Numerator Denominator RationaleSmoking status Patients in the sample whose Number of patients in the sample Number of patients Several research studies have current smoking status was whose current smoking status in the sample identified smoking as a risk factor documented was documented for osteoporosis and bone fracture. Cigarette smokers have increased catabolism of endogenous estrogen, and experience more fractures.Medical record Patients in the sample whose Number of patients in the sample Number of patients Good evidence has been found thatdocuments information status regarding participation in whose medical record indicated in the sample physical activity is important forabout patient’s exercise a weight-bearing exercise whether or not patient maintaining bone density. Weight-level within the past 12 program was documented within participated in a weight-bearing bearing exercise may slow bonemonths the past 12 months exercise program within the past loss attributable to disuse in elderly 12 months persons. In addition, regular exercise promotes mobility, agility, and muscle strength, all of which may help prevent falls. In addition, exercise may modestly increase bone density. Current level of alcohol Patients in the sample whose Number of patients in the sample Number of patients Good evidence has been found thatuse current level of alcohol use was whose current level of alcohol in the sample screening regarding alcohol use can documented use was documented accurately identify patients whose levels or patterns of alcohol consumption place them at risk for increased morbidity and mortality. Heavy alcohol use is detrimental to bone health, increases the risk of falling and requires treatment when identified.Osteoporosis Measure Catalog September 2011 Page 5 of 13
  • 6. HistoryMeasure Title Description Numerator Denominator RationaleScreen for falls risk Patients in the sample whose Number of patients in the sample Number of patients Studies have shown that the risk forevaluation screen for falls risk evaluation whose screen for falls risk in the sample falling increases in the older was documented. evaluation was documented population, resulting in an increase in serious outcomes and associated health care costs. Incorporating a falls assessment measure into the routine clinical evaluation is important for early identification of elders who are at greater risk for falls and provide information that can guide interventions.Physical ExaminationMeasure Title Description Numerator Denominator RationaleHeight Patients in the sample with Number of patients in the sample Number of patients Studies have shown that height loss height documented who have height documented in the sample increases the likelihood of osteoporosis of the hip and increases with the amount of height lost.Young-adult height Patients in the sample who have Number of patients in the sample Number of patients During youth, bones grow in length young-adult height documented who have young-adult height in the sample and density. During the teen years, documented maximum height is reached, but bones continue to grow more dense until about age 30 when peak bone mass is attained. After that point, bones slowly start to lose density or strength. Throughout life, bone density is affected by heredity, diet, sex hormones, physical activity, lifestyle choices and the use of certain medications. Men have larger, stronger bones than women which explains, in part, why osteoporosis affects fewer men than women.Osteoporosis Measure Catalog September 2011 Page 6 of 13
  • 7. Physical ExaminationMeasure Title Description Numerator Denominator RationaleWeight Patients in the sample with Number of patients in the sample Number of patients Epidemiological evidence shows weight documented who have weight documented in the sample that obesity is correlated with increased bone mass. A high- quality meta-analysis showed that low body weight (body mass index 20 to 25 kg/m2 or lower) and/or weight loss (10% [compared with the usual young or adult weight or weight loss in recent years]) are important risk factors for osteoporosis in men age 70 and older. Underweight people tend to have lower bone mass than people of a healthy weight.Height stability or loss Medical record documents Number of patients in the sample Number of patients Studies have shown that height loss whether or not patient has lost with documentation that they in the sample greater than 1.5 inches (3.8 cm) one and half inches in height or have or have not lost one and increases the likelihood that a more half inches in height or more vertebral fracture is present. Loss of 1.5 inches (3.8 cm) or more calls for evaluation by a lateral thoracolumbar radiograph or vertebral fracture assessment (VFA) by DXA to identify vertebral fractures.Osteoporosis Measure Catalog September 2011 Page 7 of 13
  • 8. Diagnostic TestingMeasure Title Description Numerator Denominator RationaleDXA scan performed Patients in the sample who have Number of patients in the Number of patients Measurement of bone density byand result documented had a DXA scan and result sample, excluding those who are in the sample, dual energy X-ray absorptiometry documented (Normal, already on therapy and for whom excluding those who (DXA) remains the “gold standard” Osteopenia, or Osteoporosis) imaging would not be likely to are already on for the diagnosis of osteoporosis add benefit, or those with therapy and for and, where available, will clearly documented refusal, or could not whom imaging would define need for specific therapy in be done due to healthcare not be likely to add the individual patient. DXA is also system delivery reason, who benefit, or those with effective in tracking the effects of have had a DXA scan and result documented refusal, treatment for osteoporosis and documented (Normal, or could not be done other conditions that cause bone Osteopenia, or Osteoporosis) due to healthcare loss. DXA is the most validated and system delivery population specific information that reason, who have helps predict fracture risk and can had a DXA scan and also help to diagnose normal bones result documented as well as osteopenia. (Normal, Osteopenia, or Osteoporosis)Formal fracture risk Patients in the sample with Number of patients in the sample Number of patients The web-based tool called FRAX®assessment (such as a osteopenia (i.e. osteopenia was with osteopenia (i.e. osteopenia in the sample with was developed by The World HealthFRAX score) identified as a risk factor or a T- was identified as a risk factor or osteopenia (i.e. Organization (WHO) to evaluate score between -1.0 and -2.5) a T-score between -1.0 and -2.5) osteopenia was fracture risk of patients. It is based who have had a formal fracture who have had a formal fracture identified as a risk on individual patient models that risk assessment, excluding risk assessment, excluding factor or a T-score integrate the risks associated with patients who are on patients who are on between -1.0 and - clinical risk factors as well as bone pharmacologic therapy for pharmacologic therapy for 2.5), excluding mineral density (BMD) at the osteoporosis or have had a hip osteoporosis or have had a hip patients who are on femoral neck. or spine fracture or spine fracture pharmacologic The FRAX® models have been therapy for developed from studying osteoporosis or have population-based cohorts from had a hip or spine Europe, North America, Asia and fracture Australia. The FRAX® algorithms give the ten-year probability of fracture. The output is a ten-year probability of hip fracture and the ten-year probability of a major osteoporotic fracture (clinical spine, forearm, hip or shoulder fracture).Osteoporosis Measure Catalog September 2011 Page 8 of 13
  • 9. Diagnostic TestingMeasure Title Description Numerator Denominator Rationale25-hydroxy vitamin D Patients in the sample reported Number of patients in the sample Number of patients Blood levels of 25(OH)D provide thelevel as taking a pharmacologic reported as taking a in the sample best index of vitamin D stores. A therapy for osteoporosis whose pharmacologic therapy for reported as taking a desirable range is between 30 and 25-hydroxy vitamin D level has osteoporosis whose 25-hydroxy pharmacologic 60 ng/mL. 25-hydroxy vitamin D is been documented vitamin D level has been therapy for used to determine if bone documented osteoporosis weakness, bone malformation, or abnormal metabolism of calcium (reflected by abnormal calcium, phosphorus, PTH) is occurring as a result of a deficiency or excess of vitamin D.Complete falls risk Patients in the sample who were Number of patients in the sample Number of patients Since the majority of osteoporosis-assessment reported as having a history of who were reported as having a in the sample related fractures result from falls, it two or more falls, or fall-related history of two or more falls, or reported as having a is also important to evaluate risk injury and had a complete risk fall-related injury and had a history of two or factors for falling. A falls risk assessment for falls complete risk assessment for more falls, or fall- assessment should be performed falls related injury for older persons who present for medical attention because of a fall, report recurrent falls in the past year, report difficulties in walking or balance or fear of falling, or demonstrate unsteadiness or difficulty performing a gait and balance test.Falls plan of care Patients in the sample who were Number of patients in the sample Number of patients A falls plan of care must include reported as having a history of who were reported as having a in the sample consideration of appropriate two or more falls, or fall-related history of two or more falls, or reported as having a assistance device and balance, injury and had a falls plan of care fall-related injury and had a falls history of two or strength, and gait training. plan of care more falls, or fall- Interventions to prevent future falls related injury should be documented for the patient with 2 or more falls or injurious falls.Osteoporosis Measure Catalog September 2011 Page 9 of 13
  • 10. Diagnostic TestingMeasure Title Description Numerator Denominator RationaleSerum chemistry panel Patients in the sample reported Number of patients in the sample Number of patients In general, biochemical testingperformed within 12 as taking pharmacologic therapy, reported as taking a in the sample (such as serum calcium, creatinine,months of initiating who had a serum chemistry pharmacologic therapy, who had reported as taking a etc.) should be considered intreatment for panel performed within 12 a serum chemistry panel pharmacologic patients with documentedosteoporosis months of initiating treatment for performed within 12 months of therapy, excluding osteoporosis prior to initiation of osteoporosis initiating treatment for those patients who treatment. The other purpose of osteoporosis were already on laboratory tests is to check for therapy and secondary causes of osteoporosis information is not such as cases of renal or hepatic available failure, anemia, acidosis, hypercalciuria, and abnormalities of calcium/phosphate and should be done as indicated and not routinely.CounselingMeasure Title Description Numerator Denominator RationaleEstimated dietary Patients in the sample whose Number of patients in the sample Number of patients Lifelong adequate calcium intake iscalcium intake current estimated dietary calcium whose current estimated dietary in the sample necessary for the acquisition of intake was reported as being calcium intake was reported as peak bone mass and subsequent documented being documented maintenance of bone health.Appropriate calcium Patients in the sample with Number of patients in the sample Number of patients Calcium and vitamin D are essentialsupplementation <1200 mg/day estimated dietary with <1200 mg/day estimated in the sample with a as adjunctive therapies to the more calcium intake who are currently dietary calcium intake who are documentation of potent antiresorptive therapies. taking calcium supplementation currently taking calcium estimated dietary Calcium supplementation should be with dosage documented, OR supplementation with dosage calcium intake prescribed whenever it is needed to patients in the sample with at documented, OR patients in the achieve the recommended daily least 1200 mg/day estimated sample with at least 1200 intake levels. dietary calcium intake and mg/day estimated dietary documented NOT currently calcium intake and documented taking calcium supplementation NOT currently taking calcium supplementationCalcium intake Patients in the sample with Number of patients in the sample Number of patients Lifelong adequate calcium intake isassessment assessment of adequacy of with assessment of adequacy of in the sample necessary for the acquisition of calcium intake through diet calcium through diet and/or peak bone mass and subsequent and/or supplementation calcium supplementation maintenance of bone health.Osteoporosis Measure Catalog September 2011 Page 10 of 13
  • 11. CounselingMeasure Title Description Numerator Denominator RationaleCalcium intake Applicable patients in the sample Number of patients in the Number of patients Adequate calcium intake is acounseling with documentation of receiving sample, excluding patients in the sample, fundamental element of any counseling about appropriate whose total estimated daily excluding patients osteoporosis prevention or calcium intake calcium intake is 1200-1500 mg, whose total treatment program. Patients should or whose total estimated daily estimated daily be counseled specifically on the calcium intake is >1500 mg but calcium intake is importance of calcium and vitamin not taking calcium 1200-1500 mg, or D as part of any treatment program supplementation, with whose total for osteoporosis. documentation of receiving estimated daily counseling about appropriate calcium intake is calcium intake >1500 mg but not taking calcium supplementationVitamin D intake Patients in the sample with Number of patients in the sample Number of patients According to several studies, 40%-assessment assessment of adequacy of with assessment of adequacy of in the sample 100% of U.S. community-dwelling vitamin D intake through diet and vitamin D intake either because seniors are vitamin D deficient. supplementation the patient uses supplementation or because an estimate of dietary vitamin D intake has been documentedVitamin D counseling Patients in the sample with Number of patients in the sample Number of patients Patients should be counseled documentation of receiving with documentation of receiving in the sample, specifically on the importance of counseling about vitamin D counseling about adequate excluding patients calcium and vitamin D as part of vitamin D, excluding patients whose total any treatment program for whose total estimated daily estimated daily osteoporosis. Dietary instruction vitamin D intake is 600-800 IU vitamin D intake is should be given to the patient 600-800 IU and/or caregiver to ensure adequate understanding of dietary requirements.Weight-bearing Patients in the sample who are Number of patients in the sample Number of patients Multiple studies have demonstratedexercise program within able to exercise but did not who are able to exercise but did in the sample who a beneficial effect on bone densitythe past 12 months participate regularly in a weight- not participate regularly in a are able to exercise from impact and non-impact bearing exercise program, who weight-bearing exercise but did not exercise. Randomized clinical trials have documentation of receiving program, who have participate regularly have shown that exercise can advice to participate in a weight- documentation of receiving in a weight-bearing reduce falls by up to 25% in older bearing exercise program within advice to participate in a weight- exercise program adults. Also, when combined with the past 12 months bearing exercise program within adequate calcium intake, exercise the past 12 months can have a moderating effect, slowing the loss of bone mass.Osteoporosis Measure Catalog September 2011 Page 11 of 13
  • 12. CounselingMeasure Title Description Numerator Denominator RationaleSmoking-cessation Patients in the sample who are Number of patients in this Number of patients A number of large randomizedsupport within past 12 smokers and who received sample who are smokers and for in this sample who clinical trials have demonstrated themonths smoking-cessation counseling or whom smoking-cessation are smokers efficacy and cost-effectiveness of treatment during the 12-month counseling or treatment was smoking-cessation counseling in period prior to the visit date, with documented during the 12- changing smoking behavior and a three-month grace period month abstraction period or reducing tobacco use. three months prior to the abstraction periodDocumentation of Patients in the sample reported Number of patients in the sample Number of patients Multiple studies have demonstratedassessment/review of as taking a pharmacologic reported as taking a in the sample poor adherence to medications forpatient’s adherence to therapy, whose adherence to pharmacologic therapy, whose reported as taking a conditions that are ‘asymptomatic’pharmacological pharmacological therapies was adherence to pharmacological pharmacologic such as osteoporosis. Despitetherapies within the assessed/reviewed within the therapies was therapy for advances in therapeutic optionspast 12 months past 12 months and documented assessed/reviewed within the osteoporosis fracture rates remain unacceptably past 12 months and documented high – often due to patients not adhering to the medications prescribed to them. Practices need to develop screening strategies for adherence that systematically are employed for patients with chronic, silent conditions.Osteoporosis Measure Catalog September 2011 Page 12 of 13
  • 13. TreatmentMeasure Title Description Numerator Denominator RationalePharmacologic therapy Patients in this sample with the Number of patients in this Number of patients Current FDA-approved diagnosis of osteoporosis, OR sample with the diagnosis of in this sample with pharmacologic options for the with the diagnosis of osteopenia osteoporosis, OR with the the diagnosis of prevention and/or treatment of AND a 10-year probability of a diagnosis of osteopenia AND a osteoporosis (i.e. a postmenopausal osteoporosis hip fracture ≥ 3% or a 10-year 10-year probability of a hip previous diagnosis include, bisphosphonates probability of a major fracture ≥ 3% or a 10-year of osteoporosis or a (alendronate, alendronate plus D, osteoporosis-related fracture ≥ probability of a major T-score of -2.5 or ibandronate, risedronate, 20%, who were reported as osteoporosis-related fracture ≥ less), OR with the risedronate with 500 mg of calcium taking pharmacologic therapy 20%, who were reported as diagnosis of carbonate and zoledronic acid), approved by the FDA taking a pharmacologic therapy osteopenia AND a calcitonin, estrogens (estrogen approved by the FDA 10-year probability of and/or hormone therapy), estrogen a hip fracture ≥ 3% agonist/antagonist (raloxifene), or a 10-year parathyroid hormone [PTH(1-34), probability of a major teriparatide and denosumab osteoporosis-related (prolia). fracture ≥ 20%© 2011 American Board of Internal Medicine. All rights reserved. ABIM publications are protected by United States and international copyright laws. Written permission for any reproduction oradaptation, in whole or in part, in any format or medium must be obtained from ABIM. Contact request@abim.org.Osteoporosis Measure Catalog September 2011 Page 13 of 13