Percentage of female patients aged 18 to 64 without select risk factors for osteoporotic fracture who received an order for a dual-energy x-ray absorptiometry (DXA) scan during the measurement period or the prior year.

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Recent updates of osteoporosis guidelines underscore the importance of screening women older than 65 and postmenopausal women younger than 65 for osteoporosis, provided that they meet a risk factor profile. These risks include but are not limited to previous osteoporotic fracture, osteoporosis, rheumatoid arthritis and other conditions associated with secondary osteoporosis, parental history of fractures, body mass index (BMI) <21 kg/m2, long-term use of glucocorticoids, current smoking, or excessive alcohol intake (U.S. Department of Health & Human Services, 2011). While there is evidence to support the cost effectiveness of DXA screening in women older than 65, there is not enough evidence to support screening in women younger than 65 who do not meet a risk factor profile (Lim 2009). Additionally, there are potentially avoidable harms associated with screening asymptomatic patients who do not have risk factors for osteoporosis, including exposure to radiation, false positive exams, and resulting side effects from unnecessary osteoporosis medications, that also add costs to an already burdened health care system (Lim 2009).

United States Preventive Services Task Force (USPSTF) :

USPSTF recommends a list of indications for bone mineral density (BMD) testing, which includes the following: 

• All women 65 or older 

• FRAX score* >= 9.3 percent 10-year fracture risk 

• White women between the ages of 50 and 64 years with equivalent or greater 10-year fracture risks based on specific risk factors including, but not limited to the following examples: 

- A 50-year-old current smoker with a BMI less than 21 kg/m2, daily alcohol use, and parental fracture history 

- A 55-year-old woman with a parental fracture history 

- A 60-year-old woman with a BMI less than 21 kg/m2 and daily alcohol use 

- A 60-year-old current smoker with daily alcohol use 



o USPSTF recommends screening for osteoporosis in women ages 65 years or older and younger women whose fracture risk is equal to or greater than that of a 65-year-old white woman with no additional risk factors. 

Grade: B Recommendation. 

o USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of screening for osteoporosis in men. 

Grade: I Statement. 



* The FRAX(R) tool, developed by the World Health Organization, is a risk assessment tool that evaluates the 10-year probability of hip fracture or a major osteoporotic fracture.



American Association of Clinical Endocrinologists (AACE): 

AACE recommendations for screening include women 65 or older (Grade B; BEL 3) and younger postmenopausal women at increased risk based on fracture risk analysis (Grade C; BEL 2). 

A list of indications for BMD testing includes the following: 



• All women 65 or older

• All postmenopausal women: 

-With a history of fracture(s) without major trauma after ages 40 to 45 

-With osteopenia identified radiographically 

-Starting or taking long-term systemic glucocorticoid therapy (>= three months) 

• Other perimenopausal or postmenopausal women with risk factors for osteoporosis if willing to consider pharmacologic interventions 

- Low body weight (<127 lb or BMI <20 kg/m2) 

- Ever used long-term systemic glucocorticoid therapy (>= three months) 

- Family history of osteoporotic fracture 

- Early menopause 

- Current smoking 

- Excessive consumption of alcohol

- Secondary osteoporosis 



National Osteoporosis Foundation (NOF) [not graded]: 

NOF recommends testing all women 65 and older. NOF also recommends testing men 70 and older. BMD measurement is not recommended in children or adolescents and is not routinely indicated in healthy young men or premenopausal women. A list of indications for BMD testing includes the following: 

• Women 65 and older, and men 70 and older, regardless of clinical risk factors 

• Younger postmenopausal women and men ages 50 to 69 about whom there are concerns based on their clinical risk factor profiles 

• Women in the menopausal transition if there is a specific risk factor associated with increased fracture risk, such as low body weight, prior low-trauma fracture, or high-risk medication 

• Adults who have a fracture after age 50 

• Adults with a condition (e.g., rheumatoid arthritis) or taking a medication (e.g., glucocorticoids in a daily dose >= 5 mg prednisone or equivalent for >= three months) associated with low bone mass or bone loss 

• Anyone being considered for pharmacologic therapy for osteoporosis 

• Anyone being treated for osteoporosis, to monitor treatment effect 

• Anyone not receiving therapy for whom evidence of bone loss would lead to treatment 



North American Menopause Society (NAMS) [not graded]:

NAMS recommends that BMD be measured in the following populations: 



• All women 65 and older, regardless of clinical risk factors 

• Postmenopausal women with medical causes of bone loss (e.g., steroid use, hyperparathyroidism), regardless of age 

• Postmenopausal women 50 and older with additional risk factors (see below) 

• Postmenopausal women with a fragility fracture (e.g., fracture from a fall from standing height) 



Testing should be considered for postmenopausal women 50 and older when one or more of the following risk factors for fracture have been identified: 

• Postmenopausal women with a fragility fracture (e.g., fracture from a fall from standing height) 

• Fracture (other than skull, facial bone, ankle, finger, and toe) after menopause 

• Thinness (body weight <127 lb [57.7 kg] or BMI 21 kg/m2) 

• History of fracture in a parent 

• Current smoker 

• Rheumatoid arthritis 

• Alcohol intake of more than two units per day (one unit is 12 oz of beer, 4 oz of wine, or 1 oz of liquor)

Lower score indicates better quality.

U.S. Department of Health & Human Services: AHRQ, Agency for Healthcare Research and Quality, U.S. Preventive Services Task Force (USPSTF). Screening for osteoporosis in postmenopausal women. Rockville (MD): AHRQ; January 2011. Available at: http://www.uspreventiveservicestaskforce.org/uspstf/uspsoste.htm.

Lim LS, Hoeksema LJ, Sherin K. Screening for osteoporosis in the adult U.S. population. ACPM Position Statement on Preventive Practice. Am J Prev Med 2009;36(4):366–75.

American Association of Clinical Endocrinologists. Available at https://www.aace.com/files/osteo-guidelines-2010.pdf

National Osteoporosis Foundation. Clinician’s guide to prevention and treatment of osteoporosis. Washington, DC: National Osteoporosis Foundation; 2010. Available at: http://www.nof.org/professionals/clinical-guidelines.

North American Menopause Society. Management of osteoporosis in postmenopausal women: 2006 position statement of The North American Menopause Society. Menopause 2006;13(3):340-367.

North American Menopause Society. Management of osteoporosis in postmenopausal women: 2010 position statement of The North American Menopause Society. Menopause 2010;17(1):25-54.

The measure allows for providers to use fracture risk assessment tools in women over 40 to assess fracture risk to estimate absolute risk for major osteoporotic or hip fracture over 10 years, expressed as a percentage. 



Women whose fracture risk is near an intervention threshold for proposed treatment will be excluded from the measure denominator, as these women would not meet the criteria for an inappropriate DXA scan. 



The following is a list of fracture risk assessment tools in use that can be used to calculate absolute fracture risk.

1. The Fracture Risk Assessment Tool (FRAX[R]) 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.

2. QFracture was developed in 2009, validated based on large primary care populations in the UK (QResearch and THIN clinical databases). It estimates an individual’s 10-year risk of developing both hip and major osteoporotic fractures (including hip, spine and wrist), without BMD measurement. It is applicable to people aged 30–85 years.

3. The FORE 10-Year Fracture Risk Calculator™ (FORE FRC) Version 2.0 published in 2012 estimates 10-year fracture risk for postmenopausal women and men age 45 and older who are not receiving treatment for osteoporosis. The FORE FRC closely aligns to the FRAX tool and also calculates a 10-year risk for hip and osteoporotic fractures without BMD measurement. 

4. The Garavan Fracture Risk Calculator was developed using data collected in the Dubbo Osteoporosis Epidemiology Study conducted by the Bone and Mineral Research Program of Sydney's Garvan Institute of Medical Research. It estimates an individual’s 5- and 10-year risk of developing both hip and major osteoporotic fractures (including hip, spine and wrist), without BMD measurement.

CUMULATIVE MEDICATION DURATION is an individual’s total number of medication days over a specific period; the period counts multiple prescriptions with gaps in between, but does not count the gaps during which a medication was not dispensed.

To determine the cumulative medication duration, determine first the number of the Medication Days for each prescription in the period: the number of doses divided by the dose frequency per day. Then add the Medication Days for each prescription without counting any days between the prescriptions.

For example, there is an original prescription for 30 days with 2 refills for thirty days each. After a gap of 3 months, the medication was prescribed again for 60 days with 1 refill for 60 days. The cumulative medication duration is (30 x 3) + (60 x 2) = 210 days over the 10 month period.

TBD

Female patients ages 18 to 64 years with an encounter during the measurement period.

Equals Initial Patient Population

Combination Risk Factors [>= 2 of the following]

BMI <= 21 kg/m2

Smoker (current)

Alcohol Consumption (> two units per day (one unit is 12 oz. of beer, 4 oz. of wine, or 1 oz. of liquor)

Family History of Osteoporotic Fracture 



Independent Risk Factors [Any one of the following categories]

Diagnosis [In the past 2 years] 

Osteoporosis;

Rheumatoid Arthritis;

Type I Diabetes;

Hyperthyroidism;

Malabsorption Syndromes: Celiac Disease, Inflammatory Bowel Disease, Ulcerative colitis, Chron’s disease, Cystic Fibrosis, Malabsorption;

End Stage Renal Disease;

Chronic Liver Disease

Hyperparathyroidism

Chronic Malnutrition 

Osteogenesis Imperfecta

Ankylosing Spondylitis

Psoriatic Arthritis 

Ehlers-Danlos Syndrome

Marfan’s Syndrome

Cushings Syndrome

Lupus

Ostopenia

Diagnosis [Any time during medical history]

Prior Osteoporotic Fracture

Procedure [Anytime during medical history] 

Gastric Bypass



Medications [cumulative medication duration of equal to or more than 90 days, anytime during the last 2 years]

Corticosteroids (>= 5 mg/per day);

Immunosuppressive Drugs (>= 5 mg/per day)



Probability of Fracture Based on Fracture Risk Assessment Tool Result [Any time during medical history]

The FRAX[R], Ten-year probability of hip fracture (>= 3%)

The FRAX[R], Ten-year probability of all major osteoporosis related fracture (>= 20%)

The Fracture Risk Calculator (FORE), Ten-year probability of hip fracture (>= 3%)

The Fracture Risk Calculator (FORE), Ten-year probability of all major osteoporosis related fracture (>= 20%)

The Garvan fracture risk calculator, Ten-year probability of hip fracture (>= 3%)

The Garvan fracture risk calculator, Ten-year probability of all major osteoporosis related fracture (>= 20%)

The Qfracture, Ten-year probability of hip fracture (>= 3%)

The Qfracture, Ten-year probability of all major osteoporosis related fracture (>= 20%)

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

Not Applicable

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Not Applicable

Not Applicable

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