ABIM Osteoporosis PIM™Practice Improvement ModuleMeasures Catalogue - American Board of Internal Medicine by ds.abimorg

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									  ABIM Osteoporosis PIM™
Practice Improvement Module
    Measures Catalogue
                                                                                     Osteoporosis PIM
                                                                                    Measures Catalogue
                                                                                      September 2010




                TABLE OF CONTENTS

                Introduction ............................................................................................................................................ 3

                Processes of Care

                  History.................................................................................................................................................................... 5

                  Physical Examination........................................................................................................................................... 5

                  Diagnostic Testing................................................................................................................................................ 7

                  Counseling ............................................................................................................................................................ 7

                  Treatment............................................................................................................................................................... 9




Osteoporosis Measure Catalog                                                               September 2010                                                                                         Page 2 of 9
Introduction
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

This PIM examines the care you provide to your patients by addressing key processes and outcomes related to osteoporosis. These are
based primarily on guidelines from the American Association of Clinical Endocrinologists, the National Osteoporosis Foundation, the
U.S. Preventive Services Task Force, and the World Health Organization.

The PIM is divided into three parts, with multiple sections in each part.

Part 1 -Performance Data
Provide baseline data about your practice's current performance by...

    •       Reviewing your charts
    •       Assessing your practice systems

The 21 chart review measures are summarized below. ABIM requires a minimum of 25 chart reviews. The practice systems
assessment comprises questions covering various aspects of practice structure and protocols.

Patients can be included in this module if all of the following are true:

               1. They are between the ages of 18 and 110 (inclusive);
               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.



Osteoporosis Measure Catalog                                  September 2010                                                 Page 3 of 9
            Types of Patients:

            o   Women age 65 and older
            o   Men age 70 and older
            o   Patients with osteopenia or prior low-impact fracture
            o   Patients on chronic oral or parenteral corticosteroid therapy
            o   Patients taking other medications associated with secondary osteoporosis
            o   Transplant recipients
            o   Women with a history of breast cancer
            o   Men with a history of prostate cancer
            o   Patients with other conditions associated with an increased risk for osteoporosis
            o   Patients with other risk factors for osteoporosis

Part 2 - Quality Improvement (QI) Plan
Develop a plan for improving one aspect of your practice after reviewing the analysis of your current performance data. The analysis
will include many aspects of care you provide to your patients. Ultimately, you will target only one of these to use in this quality
improvement (QI) cycle.

Part 3 - Remeasurement
Remeasure your performance data after you have implemented your QI plan to see if you achieved your goal. Then, you will reflect on
the 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 this
educational activity for a maximum of 20 AMA PRA Category 1 Credit(s)TM.




Osteoporosis Measure Catalog                                  September 2010                                                Page 4 of 9
OSTEOPOROSIS - PROCESSES OF CARE

History

Measure Title              Description                         Numerator                          Denominator          Rationale

Smoking status             Patients in the sample whose        Number of patients in the sample   Number of patients   Cigarette smokers have increased
                           current smoking status was          whose current smoking status       in the sample        catabolism of endogenous
                           documented                          was documented                                          estrogen, and experience more
                                                                                                                       fractures.

Medical record             Patients in the sample whose        Number of patients in the sample   Number of patients   Weight-bearing exercise may slow
documents information      status regarding participation in   whose medical record indicated     in the sample        bone loss attributable to disuse in
about patient’s exercise   a weight-bearing exercise           whether or not patient                                  elderly persons. In addition, regular
level                      program was documented              participated in a weight-bearing                        exercise promotes mobility, agility,
                                                               exercise program                                        and muscle strength, all of which
                                                                                                                       may help prevent falls.

Current level of alcohol   Patients in the sample whose        Number of patients in the sample   Number of patients   Good evidence has been found that
use                        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.

Screen for falls risk      Patients in the sample whose        Number of patients in the sample   Number of patients   A prospective study of elderly,
evaluation                 screen for falls risk evaluation    whose screen for falls risk        in the sample        ambulatory women identified a
                           was documented.                     evaluation was documented                               slower gait, difficulty in performing a
                                                                                                                       heel-to-toe walk and reduced visual
                                                                                                                       acuity as significantly predictive of
                                                                                                                       risk for subsequent hip fracture.


Physical Examination

Measure Title              Description                         Numerator                          Denominator          Rationale

Height                     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        of 2 to 3 inches increases more
                                                                                                                       than fourfold the chances of women
                                                                                                                       having osteoporosis of the hip.
                                                                                                                       Odds of osteoporosis in the hip are
                                                                                                                       nearly 10 times greater in women
                                                                                                                       with 3 or more inches of height loss,
                                                                                                                       compared with women with less
                                                                                                                       than an inch of loss.



Osteoporosis Measure Catalog                                            September 2010                                                               Page 5 of 9
Physical Examination

Measure Title              Description                       Numerator                           Denominator          Rationale

Weight                     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.

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        of between 2 inches and 3 inches
                           one inch in height or more        have or have not lost one inch in                        increases more than fourfold the
                                                             height or more                                           chances of women having
                                                                                                                      osteoporosis of the hip. Odds of
                                                                                                                      osteoporosis in the hip are nearly
                                                                                                                      10 times greater in women with 3 or
                                                                                                                      more inches of height loss
                                                                                                                      compared to women with less than
                                                                                                                      an inch of loss.

Presence or absence of     Medical record documents          Number of patients in the sample    Number of patients   Older adults with osteoporosis are
kyphosis                   whether or not patient has        whose medical record                in the sample        at greater risk of spinal fractures
                           acquired kyphosis                 documents whether or not                                 that can contribute to kyphosis.
                                                             patient has acquired kyphosis




Osteoporosis Measure Catalog                                          September 2010                                                              Page 6 of 9
Diagnostic Testing

Measure Title            Description                         Numerator                            Denominator            Rationale

Bone mineral density     Patients in the sample (excluding   Number of patients in the sample     Number of patients     BMD testing is a vital component in
testing performed and    those who refuse to consider any    (excluding those who refuse to       in the sample,         the diagnosis and management of
results documented       pharmacologic therapy) who          consider any pharmacologic           excluding those who    osteoporosis. BMD has been shown
                         have had bone mineral density       therapy) who have had bone           refuse to consider     to correlate with bone strength and
                         testing and result documented       mineral density testing and result   any pharmacologic      is an excellent predictor of future
                                                             documented (Normal,                  therapy                fracture risk.
                                                             Osteopenia, or Osteoporosis)

Vitamin D level          Patients in the sample whose        Number of patients in the sample     Number of patients     According to a large body of
                         vitamin D level has been            whose vitamin D level has been       in the sample          literature, vitamin D had varying
                         documented                          documented                                                  effects on fracture prevention,
                                                                                                                         depending on dose, analogs, and
                                                                                                                         population. One meta-analysis
                                                                                                                         found that 700 to 800 IU daily was
                                                                                                                         necessary to reduce hip and
                                                                                                                         nonvertebral fractures.

Complete falls           Patients in the sample who were     Number of patients in the sample     Number of patients     Since the majority of osteoporosis-
evaluation               reported as having a complete       who were report as having a          in the sample          related fractures result from falls, it
                         falls evaluation performed          history of two or more falls, or     reported as having a   is also important to evaluate risk
                                                             fall-related injury and had a        history of two or      factors for falling.
                                                             complete falls evaluation            more falls, or fall-
                                                             performed                            related injury


Counseling

Measure Title            Description                         Numerator                            Denominator            Rationale

Estimated dietary        Patients in the sample whose        Number of patients in the sample     Number of patients     Lifelong adequate calcium intake is
calcium 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.

Calcium                  Patients in the sample whose        Number of patients in the sample     Number of patients     Calcium and vitamin D are essential
supplementation status   medical record indicates whether    with documentation of whether        in the sample          as adjunctive therapies to the more
                         or not they take calcium            or not they take calcium                                    potent antiresorptive therapies.
                         supplementation                     supplementation                                             Calcium supplementation should be
                                                                                                                         prescribed whenever it is needed to
                                                                                                                         achieve the recommended daily
                                                                                                                         intake levels.



Osteoporosis Measure Catalog                                          September 2010                                                                    Page 7 of 9
Counseling

Measure Title           Description                       Numerator                          Denominator          Rationale

Calcium intake          Patients in the sample with       Number of patients in the sample   Number of patients   Lifelong adequate calcium intake is
assessment              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.

Calcium intake          Patients in the sample with       Number of patients in the sample   Number of patients   Adequate calcium intake is a
counseling              documentation of receiving        with documentation of receiving    in the sample        fundamental element of any
                        counseling about appropriate      counseling about appropriate                            osteoporosis prevention or
                        calcium intake                    calcium intake                                          treatment program. Patients should
                                                                                                                  be counseled specifically on the
                                                                                                                  importance of calcium, vitamin D
                                                                                                                  and exercise as part of any
                                                                                                                  treatment program for osteoporosis.

Vitamin 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 vitamin    with assessment of adequacy of     in the sample        100% of U.S. community-dwelling
                        D intake through diet,            vitamin D intake either because                         seniors are vitamin D deficient.
                        supplementation and sun           the patient uses supplementation
                        exposure                          or because an estimate of
                                                          dietary vitamin D intake has
                                                          been documented

Vitamin 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                               calcium, vitamin D and exercise as
                                                          vitamin D                                               part of any treatment program for
                                                                                                                  osteoporosis. Dietary instruction
                                                                                                                  should be given to the patient
                                                                                                                  and/or caregiver to ensure
                                                                                                                  adequate understanding of dietary
                                                                                                                  requirements.

Weight-bearing          Patients in the sample with       Number of patients in the sample   Number of patients   Multiple studies have demonstrated
exercise program        documentation of receiving        with documentation of receiving    in the sample        a beneficial effect on bone density
                        advice to start, increase, or     advice to start, increase, or                           from impact and non-impact
                        maintain participation in a       maintain participation in a                             exercise. Randomized clinical trials
                        weight-bearing exercise program   weight-bearing exercise program                         have shown that exercise can
                                                                                                                  reduce falls by up to 25% in older
                                                                                                                  adults. Also, when combined with
                                                                                                                  adequate calcium intake, exercise
                                                                                                                  can have a moderating effect,




Osteoporosis Measure Catalog                                       September 2010                                                             Page 8 of 9
Counseling

Measure Title                  Description                                Numerator                                 Denominator                 Rationale

                                                                                                                                                slowing the loss of bone mass.
Smoking-cessation              Patients in the sample who are             Number of patients in this                Number of patients           A number of large randomized
support within past 12         smokers and who received                   sample who are smokers and for            in this sample who          clinical trials have demonstrated the
months                         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 period


Treatment
Measure Title                  Description                                Numerator                                 Denominator                 Rationale

Pharmacologic therapy          Patients in the sample with                Number of patients in the sample          Number of patients          FDA-approved drug therapies are
                               osteopenia, osteoporosis, prior            with osteopenia, osteoporosis,            in this sample with         effective, safe, and proven to
                               low-impact fracture, transplant,           prior low-impact fracture,                osteopenia,                 reduce the risk of fracture. Agents
                               or chronic steroid use, who were           transplant, or chronic steroid            osteoporosis, prior         approved by the FDA for
                               reported as taking                         use, who were reported as                 low-impact fracture,        osteoporosis prevention and/or
                               pharmacologic therapy                      taking pharmacologic therapy              transplant, or chronic      treatment include bisphosphonates,
                                                                                                                    steroid use                 salmon calcitonin, estrogen,
                                                                                                                                                raloxifene, and teriparatide.

Calcium                        Patients in the sample who were            Number of patients in the sample          Number of patients          A meta-analysis of controlled trials
supplementation                reported as taking calcium                 who were reported as taking               in the sample               of the effects of calcium
                               supplementation                            calcium supplementation                                               supplementation on bone density
                                                                                                                                                and fractures in postmenopausal
                                                                                                                                                women shows that calcium
                                                                                                                                                supplementation had a small
                                                                                                                                                positive effect on BMD, and there
                                                                                                                                                was a trend toward reduction in
                                                                                                                                                vertebral fractures.

© 2010 American Board of Internal Medicine. All rights reserved. ABIM publications are protected by United States and international copyright laws. Written permission for any reproduction or
adaptation, in whole or in part, in any format or medium must be obtained from ABIM. Contact request@abim.org.




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