Many commonly used performance measures to assess how physicians screen for and treat osteoporosis lack evidence for their effectiveness, according to a new position paper by the American College of Physicians (ACP), published in the Annals of Internal Medicine.
An ACP committee evaluated six quality metrics for osteoporosis used by the Centers for Medicaid & Medicaid Services (CMS); if physicians meet benchmarks on these measures, they receive incentive payments. Of the six measures, the ACP believes that complying with only one of them — screening women aged 65-85 years for osteoporosis with a DXA bone density scan — is clinically meaningful, because knowing osteoporosis risk can guide strategies to prevent fractures.
The ACP committee said that screening of men who are aged 70 years or older, or younger women who do not have a risk for osteoporosis such as a prior fracture, may not be accurate, although other performance measures used by CMS encourage such screening.
"ACP strongly believes performance measures used at the physician level should be proven to be reliable before assessing quality at the physician level," said Omar T. Atiq, MD, FACP, current president of the ACP and a medical oncologist at the University of Arkansas for Medical Sciences in Little Rock. "ACP's findings will help improve the current osteoporosis performance measures used in accountability programs."
Best Practices for Bone Health
Clinicians who spoke to Medscape agreed with ACP's support of screening women over age 65 for osteoporosis, as well as the organization's claim that it is more of a patient-specific decision with other groups.
"Screening becomes a little bit trickier in younger women and also in men, because we don't really have good guidelines for them," said Maryam Sattari, MD, MS, an internal medicine physician at University of Florida Health in Gainesville. Sattari said she would consider DXA screening for younger women with breast cancer whose medication history may have weakened their bones; people who have taken steroids chronically; or men who have had a fracture after a fall from standing height or less. All of these histories could signal osteoporosis, she said.
"For people who have had a fracture, they are at really high risk of having another fracture," said Sarah Berry, MD, MS, a clinical researcher at the Hinda and Arthur Marcus Institute for Aging Research in Boston.
Berry noted that the most common medications used to reduce risk for fracture in people with osteoporosis are bisphosphonates such as alendronic acid, which is generally taken daily or weekly on an empty stomach. She said bisphosphonates can reduce fracture risk within a year of beginning the medication. Other options include intravenous infusions or shots taken in intervals ranging from daily to a few times a year.
Sometimes patients are averse to taking pills, Sattari said, or they have specific concerns about bisphosphonates.
"We have patients who decide, I'm just going to take calcium and vitamin D and exercise. The reason a lot of patients are reluctant to start bisphosphonates are the rare side effects that have been reported," Sattari said, such as necrosis of the jaw. Sattari explains the rarity of these events to her patients and the benefits of bisphosphonates while respecting that the decision of which therapy to use lies with the patient.
"It's very much a shared decision-making process with patients, because a lot of patients have fears about taking medications, and a lot of providers have questions because there are so many products on the market," added Sonja Rosen, MD, chief of geriatrics at Cedars-Sinai in Beverly Hills, California. Rosen encourages providers who are not familiar with different osteoporosis treatment options to consult with bone health experts or geriatricians in their area.
Rosen emphasized that although medications are important, so too is making arrangements to prevent future falls.
"This fracture occurred because the patient fell. How do we help the patient not fall again? How can we reduce the risk of falls and reduce the risk of injury?" Rosen asked. Steps could include deprescribing medications that increase fall risk, making sure people use assistive walkers, and even assessing their homes for loose rugs or other fall risks.
A simple walk can help, too.
"Weight-bearing exercises are really good for your bones, and it's never too late to start exercising," Berry said.
No relevant financial relationships were reported.
Ann Intern Med. Published online October 2, 2023. Full text
Marcus A. Banks, MA, is a journalist based in New York City who covers health news with a focus on new cancer research. His work appears in Medscape, Cancer Today, The Scientist, Gastroenterology & Endoscopy News, Slate, TCTMD, and Spectrum.
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