Screening for Osteoporosis

WCHQ Ambulatory Measure Specification

Screening For Osteoporosis

Measurement Period 07/01/16 - 06/30/17

Submission Period: 09/05/17 - 10/20/17

Measure Description

The percentage of women age 65 through 85 who had a minimum of one bone densitometry test atage 60 or above or have a diagnosis of osteoporosis or osteopenia.

Disclaimer: Measures reported by WCHQ healthcare organizations represent a specific aspect of care in relation to an evidence-based standard, but are not clinical guidelines and do not establish standards of care. All providers should have an individual care plan established with their patient.

General Information/Rationale

The USPSTF found good evidence that the risk for osteoporosis and fracture increases with age (and other factors). They also found that bone density measurements accurately predict the risk for fractures in the short-term and that treating asymptomatic women with osteoporosis reduces their risk for fracture. The benefits of screening and treatment are of at least moderate magnitude for women at increased risk by virtue of age or the presence of other risk factors. No recommendation has been made by the USPSTF for or against screening for osteoporosis in postmenopausal women younger than 60 or in women 60-64 who are not at increased risk for an osteoporotic fracture1. The National Osteoporosis Foundation recommends a bone density screening for all women at 65 years and older regardless of their risk factors 2.

Reference 1. Screening for Osteoporosis. U.S. Preventive Services Task Force. September, 2002. 2. NOF Guidelines. National Osteoporosis Foundation. 2007.

Definitions

12 Months: Measurement Period

24 Months: Measurement Period + Prior Year

36 Months: Measurement Period plus Prior Two Years

Office Visit: Office visit in an outpatient, non-urgent care setting

Encounter: Any type of visit to any type of service

PCP: For WCHQ measure purposes, a primary care provider is defined as any General Practice, Internal Medicine, Family Medicine, Pediatrics provider withthe following degree types (MD, DO, PA, and NP),and any other practitioners identified by the healthcare system as primary care practitioners. The rationale for the additional practitioner(s) must be documented and must be applied consistently across all preventive care and chronic care measures by the organization.

Measure Specific Specialist: For this measure, visits to an OB-GYN qualifyas office visitsfor the denominator population.

Age Range 65-85: Patients born between 07/01/1931 and 07/01/1951.

Denominator Description

Women whose age at the beginning of the one year measurement period is at least 65 and whose age at the end of the one year measurement period is less than 86 and who are alive as of the last day of the Measurement Period. Expired patients for whom a specific date of expiration cannot be found are excluded from the denominator population.

The rationale for the denominator population is built from the following criteria (See Figure O-1)

[Question 1] – Is this patient whose care is managed within the physician group?

[Question 2] - Is this a patient currently managed in our system?

[Question 3] – Is this patient eligible for a bone densitometry test?

Organization Level Reporting:

For every WCHQ Ambulatory Measure, each organization must calculate the total denominator population for this measure, not a sample (see Encounter Data section). If the Denominator for any given measure is less than 50 patients, the organization does not have to report the Numerator for the measure to WCHQ. To allow for appropriate comparisons of performance across organizations, a minimum population of 50 patients ensures a maximum of a 2% incremental scale on proportional measures.

Publication on the Website: If the Denominator is less than 50, only the Physician Group Name, Population Size (N), and the following statement will display on

• The patient population is too small (N<50) for purposes of reliably predicting Physician Group performance.

Historical Trend for Low Population Sizes: The historical trend display of Physician Group performance will not include measurement periods with population sizes less than 50. For each measurement period with insufficient data, there will be no display for that period.

Site Level Reporting:

Denominator Minimum: For site level reporting there must be a minimum of 100 patients per clinic in the denominator for each measure. If the clinic denominator for any given measure is less than 100 patients the organization does not publicly report the results for the measure. The results will still be included in the organization level data.

Provider Minimum per Clinic: For site level reporting there are two options as follows:

• A minimum of 3 providers per clinic who have patients in the measure denominator. There could be a provider or providers in a given clinic who do not get counted because they have no patients in the measure denominator.
• If an organization desires, they can report site level data for a clinic with fewer than 3 providers as long as the clinic meets the 100 patient threshold. If your organization is planning to report results publicly for clinics with less than 3 providers, all clinics that meet this criteria will need to be reported.

Publication on the Website: Clinics who do not have enough providers or patients to be publicly reported for a given measure or measures will still display on the website by name but without results and with a caveat indicating that data was reported but did not meet the minimum provider or population size.

Provider and /or Clinic Attrition Recommendation:

1. If a provider or clinic has left the organization prior to the end of the measurement period and if the organization can track the provider termination date, the provider will not be included in the site level reporting results. The provider or clinic is still included in the group level results.
2. If a clinic closes or is no longer affiliated with a health care system after the end of the measurement period and prior to next year’s data being published a terminationdate and verbiage will be added next to that clinic’s name on the website. This will require website updating throughout the year.

Assignment of Provider to Clinic:

Organizations can use their current internal site level reporting methodology to assign a provider to a clinic. A provider must be assigned to a “home” clinic. Organizations who are not already doing internal site level reporting can work with WCHQ for assistance.

Assignment of Patient to Provider:

For purposes of WCHQ site level reporting a patient must be attributed to one provider. Organizations can use their own internal algorithm to assign a patient to a provider. Those who are not already doing this can work with WCHQ for assistance.

Patients eligible for inclusion in the denominator include (See Figure O-1):

[Question 1] –Is this a patient whose care is managed within the physician group?

Women who had at least two Primary Care office visits (Table O -1), regardless of diagnosis code, on different dates of service, to a PCPand/or OB/GYN in the past 36 months (Measurement Period plus Prior Two Years). If OB/GYN is not considered a PCP, at least one of the two office visits must be to a PCP.

[Question 2] –Is this a patient currently managed in our system?

Women who had at least one Primary Care office visit (Table O-1) regardless of diagnosis code, with a PCPand/or OB/GYN in the most recent 24 months (Measurement Period plus Prior Year).

[Question 3] –Is this a patient that is eligible for a bone densitometry test?

No exclusions apply.

The number of eligible women in the denominator who have had a bone densitometry test performed at age 60 or above or who have a diagnosis of osteoporosis or osteopenia prior to the end of the Measurement Period.

• Administrative datawhich can include:
• Table O-2 – Codes to identify bone densitometry testing requiring date of service.
• Documentation indicating bone densitometry testing was done requiring year or date range that test was performed. The date range must have occurred after the age of 60 and before the end of the measurement period.
• Table O-3 – Codes to identify osteoporosis or osteopenia requiring date of service with an unlimited look back.
• An osteoporosis or osteopenia diagnosis from an ICD-9 or ICD-10 based problem list requiring date of documentation with an unlimited look back.

NOTE: This data can include internal, external and/or patient reported data extracted electronically from an Electronic Medical Record (EMR).

• Medical Record Review (Refer to Medical Record Review for Numerator Inclusion/Denominator Exclusion section)

Screening for Osteoporosis–Final 2017_Fall

This specification is updated annually; refer to previous versions for coding and other changes

1

WCHQ Ambulatory Measure Specification

Screening For Osteoporosis

Measurement Period 07/01/16 - 06/30/17

Submission Period: 09/05/17 - 10/20/17

Screening for Osteoporosis–Final 2017_Fall

This specification is updated annually; refer to previous versions for coding and other changes

1

WCHQ Ambulatory Measure Specification

Screening For Osteoporosis

Measurement Period 07/01/16 - 06/30/17

Submission Period: 09/05/17 - 10/20/17

Organizations unable to collect numerator databy electronic means can do so by using the following criteria for chart review;

The Sample size for chart review is determined based in the following criteria:

• c = 95% Confidence Interval
• E = 5% Margin of Error
• N = Total number of patients in the denominator pool
• Use the “Sample Size Generator” at the Wisconsin Collaborative for Healthcare Quality website ( and enter values to generate the sample size appropriate for your organization
• A 10% over sample is recommended beyond the generated sample size.

If a medical group utilizes internally generated codes to identify specific services or events required for a given WCHQ performance measure, the group may translate or map the information to the WCHQ performance measurement specifications. The medical group must assure that the internally generated code matches the clinical specificity of the standard (ICD-9 or 10, CPT) codes included in the WCHQ performance measurement specifications.

In order to use internally developed codes for WCHQ performance measure reporting, the medical group needs to document the translation/mapping to the codes in the specifications. This documentation should include the internally generated code, a description of the internally developed code, any additional clinical information for the internally developed code, and the equivalent standard code with description from the WCHQ performance measurement specifications. Once the translation/ mapping documentation is established, the medical group’s WCHQ performance measurement team must review the mapping on a yearly basis and document that internally developed codes have not changed and are being used in the manner described in the translation/ mapping document.

The medical group must have documented processes in place for adding codes to the medical group’s administrative data system and procedures to implement the internally developed codes.

Medical Record Review for Numerator Inclusion/Denominator Exclusion

If appropriate, and/or when necessary, every organization may complement their electronic capture of patient medical history with electronic or manual record review. The following criteria apply only to data captured/reviewed during medical record review.

Numerator Inclusion

For WCHQ Preventive Screening Measures, which can include, internal, external, and/or patient reported information, proof of numerator compliance requires one of the following:

• Documentation indicating bone densitometry testing was done requiring year or date range that test was performed.The date range must have occurred after the age of 60 and before the end of the measurement period.
• An osteoporosis or osteopenia diagnosis requiring date of documentation with an unlimited look back. The diagnosis must have occurred prior to the end of the measurement period.

Denominator Exclusion

For all WCHQ Measures proof of Denominator exclusion requires:

Existence of exclusion criteria:

• NOTE: No exclusions apply to this measure

These data may be retrieved, in whole or in part, from any of the following:

• Notation in Progress Note
• Notation in Medical History or Surgical History
• Flag/Field in Electronic Medical Record
• Documentation in patient chart

Fields required for data submission for this measure depend upon the methodology used. The fields are as follows:

TOTAL POPULATION METHODOLOGY:

• Population Denominator (N) (Patients Eligible for a Bone Densitometry Test)
• Numerator (Patients who had a minimum of one Bone Densitometry Test or one diagnosis of Osteoporosis or Osteopenia)

Upon entry of these numbers, the rate is automatically calculated

RANDOM SAMPLE METHODOLOGY:

• Population Denominator (N) (Patients Eligible for a Bone Densitometry Test)
• Population Sample (n) (r) (Patients in Denominator Population whose records will be reviewed)

o (n)=Population Sample and (r)=Patients Reviewed equal the same number

o The Population Sample size must be determined using the WCHQ Sample

Calculator

• Numerator (Patients who had a minimum of one Bone Densitometry Test or one diagnosis of Osteoporosis or Osteopenia from Population Sample)

Upon entry of these numbers, the rate is automatically calculated

HYBRID METHODOLOGY:

• Population Denominator (N) (Patients Eligible for a Bone Densitometry Test)
• Administrative Review Denominator (Patients in Total Denominator Population whose

numerator information is obtained through administrative data)

• Administrative Review Denominator (Patients in Total Denominator Population whose

numerator information is obtained through administrative data)

• Administrative Review Numerator (Patients who had a minimum of one Bone Densitometry

Test or one diagnosis of Osteoporosis or Osteopenia found through administrative data)

• Manual Review Denominator (Patients in Total Denominator Population whose numerator

information cannot be obtained through administrative data)

• Manual Review Sample Size (Patients in Manual Review Denominator Population whose

records will be reviewed)

• The Manual Review Sample size must be determined using the WCHQ Sample

Calculator plus a 10% over sample

• Manual Review Numerator (Patients who had a minimum of one Bone Densitometry Test or one diagnosis of Osteoporosis or Osteopenia foundthrough Manual Review Sampling)

Upon entry of these numbers, the Rates, Weight Factors and Total Reviewed are automatically

calculated. Total Reviewed equals Administrative Review Denominator + Manual Review SampleSize.

Site Level Reporting:

Non-RBS Organizations:

1. Refer to the “Non-RBS Site Level Reporting Upload Template.xls” for specific instructions.

RBS Organizations:

1. Refer to the “RBS Site Level Reporting Upload Template.xls” for specific instructions.

PAYER STRATIFICATION:

1. Denominator data submission is requested by Payer Stratification for Medicare, Medicaid, Commercial and Uninsured.
2. Numerator data submission can be entered by primary payer category only for total population methodology

Refer to Appendix A for definitions of the payer stratification categories.

Validation of this measure will require patient level data files for Administrative Data and/or for Manual Review. The following indicates fields needed for validation, which may be helpful to consider when querying the measure:

Denominator Data File fields:

1.Patient Identifier (can be medical record number or other ID)

2.Office Visit Dates

3.Provider Specialty

4.Patient Date of Birth

5.Patient Gender

Numerator Data File fields:

1. Patient Identifier (can be medical record number or other ID)
2. Bone Densitometry Code from Table O-2, or
3. Other Bone Densitometry Documentation,or
4. Osteoporosis or Osteopenia Code from Table O-3, or
5. Documentation of Osteoporosis or Osteopenia diagnosis
6. Date of Service of Bone Densitometry Test code, or
7. Year or DateRange of documented Bone Densitometry Test, or
8. Date of Service of Osteoporosis or Osteopenia code, or
9. Date of documentation of Osteoporosis or Osteopenia diagnosis

Site Level Reporting fields:

• Clinic Name
• Period
• Metric ID
• Clinical Topic
• Measure
• Clinic ID
• Clinic Name
• Metric Level (for A1C and LDL Testing and Control measures)
• Payer (optional)
• Numerator
• Denominator
• Percentage
• Provider Count
• Provider Minimum Count Flag
• Patient Minimum Count Flag

Appendix A

Primary Payer

In keeping with the changing atmosphere of quality measurement and reporting, WCHQ would like for participating organizations to include the primary payer source with their data submissions for the ambulatory care measures.

The primary payer source should be identified in the denominator upon answering the question, “Is this patient current in our system?” Once it has been determined that a patient is current because of a visit to their physician within the specified time period (12 months for chronic care measures and 24 months for preventive care measures), the payer should be “pulled” into the query. The primary payer should be the payer at the most recent office visit within the measurement period.

There will be four categories of primary payer that will need to be submitted to WCHQ via the data submission tool: Medicare FFS, Medicaid (all types), Commercial (including Medicare HMO) and Uninsured/Self-Pay. The raw numbers for the denominator and numerator should be included for all three types of data submission, total population, hybrid, and sample.

Rationale

Opportunities exist for WCHQ to collect and report data on specific populations, like the Medicare population, through grant applications to begin to understand the disparities in quality of care. The purpose of this is to begin to understand the challenges of putting in additional data elements and complexities of data display for public reporting. At this time, the primary payer information will not be publicly reported.

Definitions:

Commercial: All plans not Medicaid or Medicare FFS (IncludesVA, DoD, etc.)

FFS Medicare: FFS plans, not Medicare HMO (Medicare Railroad is FFS Medicare)

Medicaid: All Medicaid plans including those managed by commercial plans