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

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............................................................................................................................................................. 13
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3. 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 and
the Institute of Medicine.
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 24 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.
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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) 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.
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5. 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 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 that
documents information status regarding participation in whose medical record indicated in the sample physical activity is important for
about 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 bone
months 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 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.
Heavy alcohol use is detrimental to
bone health, increases the risk of
falling and requires treatment when
identified.
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6. History
Measure Title Description Numerator Denominator Rationale
Screen for falls risk Patients in the sample whose Number of patients in the sample Number of patients Studies have shown that the risk for
evaluation 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 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 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.
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7. 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. 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.
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8. Diagnostic Testing
Measure Title Description Numerator Denominator Rationale
DXA scan performed Patients in the sample who have Number of patients in the Number of patients Measurement of bone density by
and 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 Health
FRAX 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).
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9. Diagnostic Testing
Measure Title Description Numerator Denominator Rationale
25-hydroxy vitamin D Patients in the sample reported Number of patients in the sample Number of patients Blood levels of 25(OH)D provide the
level 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.
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10. Diagnostic Testing
Measure Title Description Numerator Denominator Rationale
Serum chemistry panel Patients in the sample reported Number of patients in the sample Number of patients In general, biochemical testing
performed 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 in
treatment for panel performed within 12 a serum chemistry panel pharmacologic patients with documented
osteoporosis 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.
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.
Appropriate calcium Patients in the sample with Number of patients in the sample Number of patients Calcium and vitamin D are essential
supplementation <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
supplementation
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.
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11. Counseling
Measure Title Description Numerator Denominator Rationale
Calcium intake Applicable patients in the sample Number of patients in the Number of patients Adequate calcium intake is a
counseling 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
supplementation
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 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 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 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 demonstrated
exercise program within able to exercise but did not who are able to exercise but did in the sample who a beneficial effect on bone density
the 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.
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12. Counseling
Measure Title Description Numerator Denominator Rationale
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
Documentation of Patients in the sample reported Number of patients in the sample Number of patients Multiple studies have demonstrated
assessment/review of as taking a pharmacologic reported as taking a in the sample poor adherence to medications for
patient’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. Despite
therapies within the assessed/reviewed within the therapies was therapy for advances in therapeutic options
past 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.
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13. Treatment
Measure Title Description Numerator Denominator Rationale
Pharmacologic 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%
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