Measures Aim to Enhance Osteoporosis E&M

Challenges Ahead

It is hoped “that there can be some blending or melding [of the two sets of performance measures] so that we can talk about similar outcomes or processes and numerators, and similar target populations,” Dr. Silverman said.

He added that he thought that because the “measures were based on referring to fracture only,” the target population of the measures may need to change, perhaps to those defined in the new National Osteoporosis Foundation (NOF) guidelines as having low bone mass and high risk on the World Health Organization Fracture Risk Assessment Tool (FRAX).

“Should we change the wording in some of these performance measures to include these target populations as well?” Dr. Silverman asked.

The implementation of the measures as standards faces potential problems because they are not mandatory and the financial incentives for reporting them may not be worth the cost and time that is required, Dr. Silverman said. Not only may the data be hard to locate across different electronic health record systems, but the lack of reimbursement to individual hospitals for diagnosis-related groups that have been assigned for treating and diagnosing a fracture may make the measures harder to implement. The NOF has raised only $60,000 of the $380,000 that will be required to validate the Joint Commission's measures, he added.

All of the speakers disclosed relationships with companies that manufacture osteoporosis medications, including speakers bureau, consulting fees, performing paid research, and/or being on an advisory committee or other paid committee.

Proposed Osteoporosis Performance Measures

Many measures proposed by the Joint Commission are similar to those suggested by the AMA's Physician Consortium for Performance Improvement (PCPI):

▸ Screening women at risk. How many women patients aged 60–64 years with one or more risk factors, and those older than 65 years, have had at least one central DXA exam?

PCPI measurement: What percentage of female patients aged 65 years and older have had a central DXA exam ordered or performed at least once since age 60 or pharmacologic therapy prescribed within 12 months?

▸ Secondary causes. For all patients with a new diagnosis of osteoporosis, how many have had an appropriate, minimal laboratory investigation ordered or performed prior to discharge within 3 months of the initial diagnosis?

PCPI measurement: What percentage of patients aged 18 years and older with one of the following conditions or therapies has had a central DXA ordered or performed or pharmacologic therapy prescribed within 12 months: use of oral glucocorticoid therapy for greater than 3 months; aromatase therapy for breast cancer; hypogonadism; fracture history; transplant history; obesity surgery; malabsorption disease?

▸ BMD testing of glucocorticoid patients. How many patients older than 18 years who have taken oral glucocorticoids for at least 3 months have had a DXA exam ordered or performed since the initiation of therapy?

▸ Dietary education. How many patients with a diagnosis of osteoporosis or their caregivers have received information about calcium and vitamin D within the past year?

PCPI measurement: What percentage of patients, regardless of age, with a diagnosis of osteoporosis have either received both calcium and vitamin D or had documented counseling regarding both calcium and vitamin D intake, and exercise at least once within 12 months?

▸ Osteoporosis activity counseling. How many patients have received documented, age-appropriate activity information or referral for activity counseling within 36 months?

▸ Pharmacotherapy. How many patients at least 50 years old with a diagnosis of osteoporosis have been provided with pharmacotherapy within the most recent 12 months?

PCPI measurement: What percentage of patients aged 50 years and older with a diagnosis of osteoporosis were prescribed pharmacologic therapy within 12 months?

▸ Risk assessment or treatment for osteoporosis after fracture in an acute care setting. What percentage of patients aged 50 years or older with new fracture in an emergency department or a mental hospital have received a central DXA exam or a prescription for pharmacotherapy for osteoporosis prevention or treatment? (This is a potential core measure that “would have teeth,” Dr. Siris said.)

PCPI measurement: In what percentage of patients aged 50 years and older treated for a hip, spine, or distal radial fracture is there documentation of communication with the physician managing the patient's ongoing care that a fracture occurred and that the patient was or should be tested or treated for osteoporosis? (Dr. Saag noted that this is the only measure that differs from the Joint Commission's recommendations.)

▸ Risk assessment or treatment for osteoporosis after fracture in a nonacute care setting. What percentage of patients aged 50 years or older who have a documented history of a fracture within the past 3 months have received a central DXA exam or a prescription for pharmacotherapy for osteoporosis prevention or treatment?