Fall Prevention, Osteopenia & Osteoporosis Avoid the Pitfalls of A

Fall Prevention, Osteopenia & Osteoporosis Avoid the Pitfalls of a Break

David T Walsworth, MD, FAAFP Associate Chair for Clinical Affairs and Associate Chair Department of Family Medicine College of Human Medicine Michigan State University

Saturday, August 3, 2019 Disclosures

 No financial relationships with pharmaceutical, biological, or device manufacturers  Michigan Quality Improvement Consortium – Medical Directors Committee  American Academy of Family Physicians  Congress of Delegates, Delegate from Michigan Academy of Family Physicians  Course director, content developer, presenter – Care of Chronic Conditions National Live Course (Atrial Fibrillation, Chronic Opioid Therapy Update, Dizziness and Vertigo, Osteoporosis & Osteopenia, Performance Improvement, Preventive Care: Immunizations, Preventive Care: LGBTQ)  Content developer and presenter – FMX (Anticoagulation Management Update)  Michigan Academy of Family Physicians – Board of Directors; Practice Management Committee  Family Medicine Foundation of Michigan – Board of Trustees (Treasurer); Professional Development Cmte  American Medical Association – House of Delegates, Delegate from Michigan State Medical Society  Michigan State Medical Society  House of Delegates, Delegate from Ingham County Medical Society  Annual Scientific Meeting Planning Committee (Chair), CME Accreditation, Health Care Quality, Environment, and Efficiency Cmte Learning Objectives

 Summarize current guidelines for fall prevention  Evaluate elderly patients or patients at risk for low bone mass/osteoporosis using the FRAX® algorithm, and consider the impact of fracture risk scores on patient management  Advise patients on appropriate prophylactic strategies for patients with low bone mass/osteoporosis  Compare and contrast management with RANKL inhibitor vs bisphosphonates; and the pros and cons between various bisphosphonates  Determine the risks and benefits of maintaining bisphosphonate treatment for greater than 5 years Personal photograph taken by David T Walsworth on 5/6/16 Special Slide Icons

Look up here for one of the following:

Treatment or practice guideline(s) Choosing Wisely

Performance measure(s) Overcoming barriers to change

Practice tool(s) Monday morning “To Do List”

Key practice recommendation(s) Best Practice Recommendations Fall Prevention CDC Fall Statistics

 1/5 falls cause a broken bone or head injury  3 million emergency department visits annually  800,000 hospitalizations annually  300,000 hip fractures annually (95% from falls)  Falls are the most common cause of traumatic brain injuries  $50 billion spent in fall care in 2015  Fall death rates increased by 30% from 2007 – 2016 (46-61/100,000)  CDC estimates that there will be 7 deaths per hour by 2030

CDC, 2019. Important Facts about Falls. Accessed on 6/30/19 from https://www.cdc.gov/homeandrecreationalsafety/falls/adultfalls.html Who is at an Increased Risk of Falls?

According to CDC According to USPSTF  Lower body weakness  Age  Vitamin D deficiency  History of falls  Difficulties with walking and/or balance  Medications that affect balance  Impaired gait  Vision problems  Impaired mobility  Foot pain or poor footwear  Impaired balance  Broken or uneven steps or floors  Abnormal “Timed Get Up & Go Test” (TUG)  Throw rugs or clutter under foot  3 Key questions  Have you fallen in the past year?  Do you feel unsteady when standing or walking?  Do you worry about falling?

CDC, 2019. Important Facts about Falls. Accessed on 6/30/19 from https://www.cdc.gov/homeandrecreationalsafety/falls/adultfalls.html CDC, 2019. STEADI (Stopping Elderly Accidents, Injuries, and Deaths. Accessed on 6/30/19 from https://www.cdc.gov/steadi/ USPSTF, 2018. Fall Prevention in Community-Dwelling Older Adults: Interventions. Accessed on 6/30/19 from https://www.uspreventiveservicestaskforce.org/Page/Document/RecommendationStatementFinal/falls-prevention-in-older-adults-interventions1#consider Timed Get Up and Go Test (TUG) Tool available from CDC: https://www.cdc.gov/steadi/pdf /TUG_Test-print.pdf

STEADI (Stopping Elderly Accidents, Deaths, and Injuries) Toolkit available from CDC: https://www.cdc.gov/steadi/ Two Guidelines Somewhat Agree

CDC Fall Prevention Guideline USPSTF Fall Prevention Guideline  The USPSTF recommends exercise interventions to  Professional fall risk evaluation prevent falls in community-dwelling adults 65 years or older who are at increased risk for falls. (B  Professional medication review Recommendation)  Vitamin D supplementation  The USPSTF recommends that clinicians selectively offer multifactorial interventions to prevent falls to  Strength and balance exercises (e.g. tai chi) community-dwelling adults 65 years or older who are at increased risk for falls. Existing evidence indicates that  Professional vision assessment the overall net benefit of routinely offering multifactorial interventions to prevent falls is small.  Consider prescription lenses with distance only When determining whether this service is appropriate for correction for walking or other outdoor exercises an individual, patients and clinicians should consider the balance of benefits and harms based on the  Remove trip hazards circumstances of prior falls, presence of comorbid medical conditions, and the patient’s values and  Grab bars inside and outside of tub or shower, preferences. (C Recommendation) and for toilet  The USPSTF recommends against vitamin D supplementation to prevent falls in community-dwelling  Railings on both sides of a stair adults 65 years or older. (D Recommendation)  Increase light throughout home CDC, 2019. Important Facts about Falls. Accessed on 6/30/19 from https://www.cdc.gov/homeandrecreationalsafety/falls/adultfalls.html USPSTF, 2018. Fall Prevention in Community-Dwelling Older Adults: Interventions. Accessed on 6/30/19 from https://www.uspreventiveservicestaskforce.org/Page/Document/UpdateSummaryFinal/falls-prevention-in-older-adults-interventions1 Key Practice Recommendations (AFP SORT)

 A Evidence  A multifactorial intervention for falls in older persons should include exercise, particularly balance, strength, and gait training  B Evidence  Community-dwelling older persons at low to moderate risk of falls should participate in an exercise program or physical therapy and take vitamin D supplements

 Older persons at risk of falls who are hospitalized in an acute setting or for an extended time in a subacute setting should receive a multifactorial risk assessment and intervention tailored to their needs

 Nursing home residents at risk of falls should receive a multifactorial risk assessment and intervention tailored to their needs that are administered by a multidisciplinary team

 The following components should be included in multifactorial interventions for falls in older persons

 Vitamin D3 supplementation of at least 800 IU daily

 Withdrawal or minimization of psychoactive and other medications

 Adaptation or modification of the home environment for those who have fallen or have visual impairment

 Management of foot problems and footwear

 Management of postural hypotension

 Dual chamber cardiac pacing should be considered in patients with carotid sinus hypersensitivity who experience unexplained recurrent falls  C Evidence  Community-dwelling older persons at high risk of falls should receive a multifactorial risk assessment and intervention tailored to their needs

Van Voast Moncado & Mire, 2017. Preventing Falls in Older Persons. Am Fam Physician. 2017 Aug 15’ 96(4):240-247. Accessed on 6/30/19 from https://www.aafp.org/afp/2017/0815/p240.html Choosing Wisely

 AMDA – The Society for Post-Acute and Long-Term Care Medicine (Last updated August 10, 2017)

 Don’t initiate antihypertensive treatment in individuals ≥60 years of age for systolic blood pressure (SBP) <150 mm Hg or diastolic blood pressure (DBP) <90 mm Hg.

AMDA, 2017. Choosing Wisely. Accessed on 6/30/19 from http://www.choosingwisely.org/clinician-lists/amda-antihypertensive-treatment-in-individuals-sixty-and-over/ Performance Improvement Reporting

Falls Risk Assessment - National Quality Strategy Domain: Patient Safety - Measure 154 (NQF: 0101)  Definitions  Fall – A sudden, unintentional change in position causing an individual to land at a lower level, on an object, the floor, or the ground, other than as a consequence of sudden onset of paralysis, epileptic seizure, or overwhelming external force.  Risk Assessment – Comprised of balance/gait AND one or more of the following: postural blood pressure, vision, home fall hazards, and documentation on whether medications are a contributing factor or not to falls within the past 12 months. Balance/gait Assessment - Medical record must include documentation of observed transfer and walking or use of a standardized scale (e.g., Get Up & Go, Berg, Tinetti) or documentation of referral for assessment of balance/gait  Postural blood pressure - Documentation of blood pressure values in supine and then standing positions  Vision Assessment - Medical record must include documentation that patient is functioning well with vision or not functioning well with vision based on discussion with the patient or use of a standardized scale or assessment tool (e.g., Snellen) or documentation of referral for assessment of vision  Home fall hazards Assessment - Medical record must include documentation of counseling on home falls hazards or documentation of inquiry of home fall hazards or referral for evaluation of home fall hazards Medications Assessment- Medical record must include documentation of whether the patient’s current medications may or may not contribute to falls  Denominator - All patients aged 65 years and older who have a history of falls (history of falls is defined as 2 or more falls in the past year or any fall with injury in the past year). Documentation of patient reported history of falls is sufficient.  Numerator - Patients who had a risk assessment for falls completed within 12 months  3288F - Falls risk assessment documented (1P for documented medical exclusion or delete if no falls) AND 1100F - Patient screened for future fall risk; documentation of two or more falls in the past year or any fall with injury in the past year APTA, 2019. Measure 154. Accessed on 6/30/19 from https://www.apta.org/uploadedFiles/APTAorg/Payment/Medicare/Pay_for_Performance/PQRS/2016/2016_PQRS_Measure_154.pdf Performance Improvement Benchmarking

MIPS PY2017 Data with PY2019 Eligibility MIPS PY2017 Data with PY2019 Eligibility  Falls: Plan of Care (MIPS 155)  Falls: Risk Assessment (MIPS 154)  Claims (Topped out, 7 point cap)  Claims (Topped out, 7 point cap)  Average: 81.4% (SD 30.8%)  Average: 94% (SD 18.3%)  Decile 3: 55.81-84.61%  Decile 3: 96.95-99.99%  Decile 4: 84.62-99.20%  Decile 10: 100%  Decile 5: 99.21-99.99%  Registry/QCDR (Topped out, 7 point cap)  Decile 10: 100%  Average 73.2% (SD 35.4%)  Registry/QCDR (Topped out, 7 point cap)

 Decile 3: 28.63-60.81%  Average 82.7% (SD 28.8%)

 Decile 4: 60.82-84.99%  Decile 3: 67.86-86.78%

 Decile 5: 85.00–95.96%  Decile 4: 86.79-94.99%  Decile 5: 95.00-98.21%  Decile 6: 95.97-99.73%  Decile 6: 98.22-99.99%  Decile 7: 99.74-99.99%  Decile 10: 100%  Decile 10: 100% MDInteractive, 2019. 2019 MIPS Quality Benchmarks. Accessed on 6/30/19 from https://mdinteractive.com/2019-mips-quality-benchmarks USPSTF Osteopenia to Prevent Fractures (Screening)

 Women 65 years and older

 The USPSTF recommends screening for osteoporosis with bone measurement testing to prevent osteoporotic fractures in women 65 years and older. (B Recommendation)  Postmenopausal women younger than 65 at increased risk of osteoporosis

 The USPSTF recommends screening for osteoporosis with bone measurement testing to prevent osteoporotic fractures in postmenopausal women younger than 65 years who are at increased risk of osteoporosis, as determined by a formal clinical risk assessment tool. (B Recommendation)  Men

 The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of screening for osteoporosis to prevent osteoporotic fractures in men. (I Recommendation)

 Prevalence in white men aged 80 years is similar to white women aged 65 years

 Risk factors: low body mass index, excessive alcohol consumption, current smoking, long-term corticosteroid use, previous fractures, history of falls within the past year, hypogonadism, history of cerebrovascular accident, and history of diabetes

USPSTF, 2018. Osteoporosis to Prevent Fractures: Screening. Accessed on 7/4/19 from https://www.uspreventiveservicestaskforce.org/Page/Document/RecommendationStatementFinal/osteoporosis-screening1 Osteopenia & Osteoporosis Vitamin D, Calcium, or Combined Supplementation for Primary Prevention of Fractures in Community-Dwelling Adults: Preventive Medication

 Men and premenopausal women

 The USPSTF concludes that the current evidence is insufficient to assess the balance of the benefits and harms of vitamin D and calcium supplementation, alone or combined, for the primary prevention of fractures in men and premenopausal women. (I Recommendation)  Postmenopausal women

 The USPSTF concludes that the current evidence is insufficient to assess the balance of the benefits and harms of daily supplementation with doses greater than 400 IU of vitamin D and greater than 1000 mg of calcium for the primary prevention of fractures in community-dwelling, postmenopausal women. (I Recommendation)

 The USPSTF recommends against daily supplementation with 400 IU or less of vitamin D and 1000 mg or less of calcium for the primary prevention of fractures in community-dwelling, postmenopausal women. (D Recommendation)

USPSTF, 2018. Vitamin D, Calcium, or Combined Supplementation for Primary Prevention of Fractures in Community-Dwelling Adults: Preventive Medication. Accessed on 7/4/19 from https://www.uspreventiveservicestaskforce.org/Page/Document/UpdateSummaryFinal/vitamin-d-calcium-or-combined-supplementation-for-the-primary- prevention-of-fractures-in-adults-preventive-medication#consider Calcium and Vitamin D

 RDA recommendations are different than supplementation  You can have too much of a “good thing” Calcium

 Recommended Daily Allowances for Calcium  Tolerable Upper Limit Intake for Calcium

Age Male Female Pregnant Lactating Age Male Female Pregnant Lactating 0-6 mo 200 mg 200 mg 0-6 mo 1000 mg 1000 mg 7-12 mo 260 mg 260 mg 7-12 mo 1500 mg 1500 mg 1-3 yr 700 mg 700 mg 1-8 yr 2500 mg 2500 mg 4-8 yr 1000 mg 1000 mg 9-18 yr 2500 mg 2500 mg 3000 mg 3000 mg 9-13 yr 1300 mg 1300 mg 19-50 yr 2500 mg 2500 mg 2500 mg 2500 mg 14-18 yr 1300 mg 1300 mg 1300 mg 1300 mg 51+ yr 2500 mg 2500 mg 19-50 yr 1000 mg 1000 mg 1000 mg 1000 mg 51-70 yr 1000 mg 1200 mg 1200 mg 1200 mg 71+ yr 1200 mg 1200 mg

NIH, 2019. Calcium Fact Sheet for Health Professionals. Accessed on 7/7/19 from https://ods.od.nih.gov/factsheets/Calcium-HealthProfessional/ Calcium – Selected Food Sources

Food mg/Serv %DV Food mg/Serv %DV Yogurt, plain, low fat, 8 oz 415 42 Ready-to-eat cereal, calcium-fortified, 1 cup 100–1,000 10–100 Mozzarella, part skim, 1.5 oz 333 33 Frozen yogurt, vanilla, soft serve, ½ cup 103 10 Sardines, canned in oil, with bones, 3 oz 325 33 Turnip greens, fresh, boiled, ½ cup 99 10 Yogurt, fruit, low fat, 8 oz 313–384 31–38 Kale, fresh, cooked, 1 cup 94 9 Cheddar cheese, 1.5 oz 307 31 Ice cream, vanilla, ½ cup 84 8 Milk, nonfat, 8 oz 299 30 Chinese cabbage, bok choi, raw, shredded, 1 cup 74 7 Soymilk, calcium-fortified, 8 oz 299 30 Bread, white, 1 slice 73 7 Milk, reduced-fat (2% milk fat), 8 oz 293 29 Pudding, chocolate, 4 ounces 55 6 Milk, buttermilk, lowfat, 8 ounces 284 28 Tortilla, corn, one 6” diameter 46 5 Milk, whole (3.25% milk fat), 8 oz 276 28 Tortilla, flour, one 6” diameter 32 3 Orange juice, calcium-fortified, 6 oz 261 26 Sour cream, reduced fat, cultured, 2 Tbsp 31 3 Tofu, firm, with calcium sulfate, ½ cup 253 25 Bread, whole-wheat, 1 slice 30 3 Salmon, pink, canned, 3 oz 181 18 Kale, raw, chopped, 1 cup 24 2 Cottage cheese, 1% milk fat, 1 cup 138 14 Broccoli, raw, ½ cup 21 2 Tofu, soft, with calcium sulfate, ½ cup 138 14 Cheese, cream, regular, 1 Tbsp 14 1

NIH, 2019. Calcium Fact Sheet for Health Professionals. Accessed on 7/7/19 from https://ods.od.nih.gov/factsheets/Calcium-HealthProfessional/ Vitamin D

 Recommended Daily Allowances for Vitamin D  Tolerable Upper Limit Intake for Vitamin D

Age Male Female Pregnant Lactating Age Male Female Pregnant Lactating 0-12 mo 400 IU 400 IU 0-6 mo 1000 IU 1000 IU 1-13 yr 600 IU 600 IU 7-12 mo 1500 IU 1500 IU 14-18 yr 600 IU 600 IU 600 IU 600 IU 1-3 yr 2500 IU 2500 IU 19-50 yr 600 IU 600 IU 600 IU 600 IU 4-8 yr 3000 IU 3000 IU 51-70 yr 600 IU 600 IU 9-18 yr 4000 IU 4000 IU 4000 IU 4000 IU 71+ yr 800 IU 800 IU 19+ yr 4000 IU 4000 IU 4000 IU 4000 IU

NIH, 2019. Vitamin D Fact Sheet for Health Professionals. Accessed on 7/7/19 from https://ods.od.nih.gov/factsheets/VitaminD-HealthProfessional/ Vitamin D – Selected Food Sources

Food IU/Serv %DV Cod liver oil (1 tsp) 1360 340 Swordfish, cooked, 3 oz 566 142 Mushrooms, grown in UV light, vary by type, 100 g 28-1123 Salmon (sockeye), cooked, 3 oz 447 112 Tuna, canned in water, drained, 3 oz 154 39 Orange Juice, fortified, 1 cup 137 34 Milk, nonfat, fortified, 1 cup 115-124 29-31 Yogurt, fortified, 6 oz 80 20 Margarine, fortified, 1 Tbsp 60 15 Sardines, canned in oil, drained, 2 46 12 Liver, beef, cooked, 3 oz 42 11 Egg yolk, large 41 10 Ready to eat cereal, fortified 40 10 Cheese, Swiss, 1 oz 6 2 NIH, 2019. Vitamin D Fact Sheet for Health Professionals. Accessed on 7/7/19 from https://ods.od.nih.gov/factsheets/VitaminD-HealthProfessional/ Osteoporosis Risk Factors - Lifestyle

 Alcohol abuse  Frequent falls  Inadequate physical activity  Vitamin D insufficiency  Excess thinness  High salt intake  Low calcium intake  Excess Vitamin A  Immobilization  Smoking (active or passive)

 Cystic fibrosis  Glycogen storage diseases  Hypophosphatemia  Osteogenesis imperfecta  Riley-Day syndrome  Ehlers-Danlos  Hemochromatosis  Marfan syndrome  Parental history of hip fracture  Gaucher’s disease  Homocystinuria  Menke’s Steely Hair syndrome  Porphyria

 Androgen insensitivity  Hyperprolactinemia  Turner’s syndrome  Klinefelter’s syndrome  Anorexia nervosa  Panhypopituitarism  Athletic amenorrhea  Premature menopause (< 40 years)

 Central obesity  Hyperparathyroidism  Cushing’s syndrome  Thyrotoxicosis  Diabetes mellitus (types 1 and 2)

 Celiac disease  Inflammatory bowel disease  Primary biliary cirrhosis  Gastric bypass  Malabsorption  Gastrointestinal surgery  Pancreatic disease

 Hemophilia  Multiple myeloma  Thalassemia  Leukemia  Lymphoma  Sickle cell disease  Monoclonal gammopathies  Systemic mastocytosis

2014. Cosman, F; et al. Clinician’s Guide to Prevention and Treatment of Osteoporosis. Published online: 15 August 2014. Downloaded on 1/11/2015 from http://nof.org/files/nof/public/content/file/3593/upload/995.pdf Osteoporosis Risk Factors – Rheumatologic and Autoimmune Disorders  Hemophilia  Multiple myeloma  Thalassemia  Leukemia  Lymphoma  Sickle cell disease  Monoclonal gammopathies  Systemic mastocytosis

2014. Cosman, F; et al. Clinician’s Guide to Prevention and Treatment of Osteoporosis. Published online: 15 August 2014. Downloaded on 1/11/2015 from http://nof.org/files/nof/public/content/file/3593/upload/995.pdf Osteoporosis Risk Factors – Neurological and Musculoskeletal Disorders  Epilepsy  Parkinson’s disease  Multiple sclerosis  Spinal cord injury  Muscular dystrophy  Stoke

 HIV/AIDS  COPD  ESRD  Post-transplant bone disease  Amyloidosis  CHF  Hypercalciuria  Sarcoidosis  Chronic metabolic acidosis  Depression  Idiopathic scoliosis  Weight loss

 Aluminum  Glucocorticoids (> 5 mg/d prednisone or equivalent for > 3 months)  Aromatase inhibitors  Methotrexate  Depo-medoxyprogesterone  SSRIs  Lithium  Thiazolidinediones  Cyclosporine A  Anticonvulsants  Tacrolimus  Cancer chemotherapeutic drugs  Proton pump inhibitors  Gonadotropin-releasing hormone  Tamoxifen  Parenteral nutrition  Heparin  Thyroid hormones (in excess)  Barbiturates

 Diagnosed with rheumatoid arthritis three years ago

 Daily methotrexate

 Daily prednisone 5-10 mg depending on flares  Surgical menopause 2 years ago due to fibroids and endometriosis  Both parents with hip fractures  Previous fracture with minimal trauma  Ht 65”  Wt 125#

 Continent  Rheumatoid arthritis (confirmed only)  Country  Alcohol use (> 3 units per day)  Race  Previous BMD testing (result & device)  Age (DoB) (ages 40-90 years)  Secondary osteoporosis risk  Type I (insulin dependent) diabetes  Sex  Osteogenesis imperfecta in adults  Weight (kg)  Hyperthyroidism (untreated long-standing)  Height (cm)  Hypogonadism  Previous fracture (adult, unusual)  Premature menopause (<45 years)  Parental hip fracture  Chronic malnutrition, or malabsorption  Smoking status  Chronic liver disease  Glucocorticoid use (> 3 months and > 5 mg/day)  Average 65 year old has a 9.3% 10-year risk of major osteoporotic fracture

University of Sheffield, 2019. Frax – Fracture Risk Assessment. Accessed on 6/30/19 from https://www.sheffield.ac.uk/FRAX/ 42 Y/O W/F Wondering About Bone Health

 Per FRAX, 10 year probability of fracture is

 19% for major osteoporotic fracture

 3% for hip fracture

 Should she have bone mineral density testing?

 Her bone mineral density testing

 Developed by the American College of Physicians and endorsed by AAFP in April, 2017  Key Recommendations

 Pharmacologic treatment with alendronate, risedronate, zoledronic acid, or denosumab should be prescribed for women with osteoporosis to reduce the risk of hip and vertebral fractures. (Grade: strong recommendation; high-quality evidence)

 Pharmacologic treatment should continue for five years, during which time bone density monitoring should not be done. (Grade: weak recommendation; low-quality evidence)

 Menopausal estrogen therapy, menopausal estrogen plus progesterone, or raloxifene should not be used in women with osteoporosis. (Grade: strong recommendation; moderate-quality evidence)

 The decision to treat women 65 years of age or older who have osteopenia and are at a high risk for fracture should be based on a discussion of patient preferences, fracture risk profile, benefits and harms of treatment, and costs of medications. (Grade: weak recommendation; low-quality evidence)

 Treatment with bisphosphonates should be offered to men who have osteoporosis to reduce the risk of vertebral fractures. (Grade: weak recommendation; low-quality evidence)

AAFP, 2017. AAFP Clinical Practice Guideline: Treatment of Low Bone Density or Osteoporosis to Prevent Fractures in Men and Women. Accessed on 7/4/19 from https://www.aafp.org/patient-care/clinical-recommendations/all/osteoporosis-cpg.html endorsed from Qaseem, et al, 2017. Treatment of Low Bone Density or Osteoporosis to Prevent Fractures in Men and Women: A Clinical Practice Guideline Update From the American College of Physicians. Ann Int Med 166(11). Accessed on 7/4/19 from https://annals.org/aim/fullarticle/2625385/treatment-low-bone-density-osteoporosis-prevent-fractures-men-women-clinical Duration of Therapy

 Evidence of efficacy beyond 5 years is limited  Comprehensive reassessment after 3-5 years depending on agent  Risk of osteonecrosis of jaw roughly 1/60,000

Agent Benefits Harms Vertebral Non-Vertebral Hip Fractures Fractures Fractures Bisphosphonates Atypical subtrochanteric fractures Osteonecrosis of the jaw Mild upper GI symptoms ◦ Alendronate + + + ◦ Risendonate + + + ◦ Ibandronate + Myalgias, cramps, arthralgias, and arthritis Atrial fibrillation ◦ Zolendronic acid + + + Hypocalcemia Flu-like symptoms Uveitis and episcleritis Denosumab + + + Increased risk of infection Teriparatide + + Hypercalciuria Qaseem, et al, 2017. Treatment of Low Bone Density or Osteoporosis to Prevent Fractures in Men and Women: A Clinical Practice Guideline Update From the American College of Physicians. Ann Int Med 166(11). Accessed on 7/4/19 from https://annals.org/aim/fullarticle/2625385/treatment-low-bone-density-osteoporosis-prevent-fractures-men- women-clinical Mechanisms of action

 Bisphosphonates (alendronate, ibandronate, risedronate, zoledronic acid)

 Inhibits osteoclast activity resulting in reducing bone reabsorption and turnover  RANKL inhibitor (denosumab)

 Binds to receptor activator of nuclear factor kappa-B-ligand (RANKL), inhibiting osteoclast formation, maintenance, and survival resulting in reducing bone resorption and turnover  Sclerostin inhibitor (romosozumab)

 Inhibits sclerostin, increasing new bone formation and decreasing bone reabsorption  Selective estrogen receptor modulator (raloxifene)

 Estrogen agonist in bone – decreases bone reabsorption and turnover  Parathyroid hormone analogs (abaloperitide, teriparatide)

 Regulates bone metabolism, intestinal calcium absorption, and renal tubular calcium and phosphorus reabsorption (recombinant N-terminal human PTH) Performance Improvement Reporting

Screening for Osteoporosis for Women Aged 65-85 Years - Measure 39 (NQF: 0046)  Denominator – Female patients aged 65-85 years on the date of the encounter  Denominator Exclusion  G9698 Patient receiving hospice services at any time during the measurement period  Numerator – Number of women who have documentation in their medical record of having received a DXA test of the hip or spine  G8399 – Performance met  G8400 – Performance not met

2019, MDInteractive. Measure 39. Accessed on 6/30/19 from https://mdinteractive.com/2019-MIPS-Quality-Measures-039 Performance Improvement Benchmarking

MIPS PY2017 Data with PY2019 Eligibility MIPS PY2017 Data with PY2019 Eligibility  Screening for Osteoporosis for Women Aged 65-  Screening for Osteoporosis for Women Aged 65- 85 Years (MIPS 39) 85 Years (MIPS 39)

 Claims  Registry/QCDR

 Average: 56.2% (SD 26.5%)  Average 46.2% (SD 31%)

 Decile 3: 32.79-42.36%  Decile 3: 11.38-22.43%

 Decile 4: 42.37-49.00%  Decile 4: 22.44-34.71%

 Decile 5: 49.01-55.90%  Decile 5: 34.72-45.25%

 Decile 6: 55.91-62.54%  Decile 6: 45.26-58.10%

 Decile 7: 62.55-70.68%  Decile 7: 58.11-67.97%

 Decile 8: 70.69-82.88%  Decile 8: 67.98-78.45%

 Decile 9: 82.89-95.49%  Decile 9: 78.46-88.23%

 Decile 10: >95.50%  Decile 10: >88.24 %

MDInteractive, 2019. 2019 MIPS Quality Benchmarks. Accessed on 6/30/19 from https://mdinteractive.com/2019-mips-quality-benchmarks Performance Improvement Reporting

Osteoporosis Management in Women Who Had a Fracture- Measure 418 (NQF: 0046)  Denominator – Women who experienced a fracture, except fractures of the finger, toe, face or skull, during the six months prior to the performance period through June 30 of the performance period  Denominator Exclusion  G9698 Patient receiving hospice services at any time during the measurement period  G9769 Patient had a bone mineral density test in the past 2 years OR received osteoporosis medication or therapy in the past 12 mo  G9938 Patients age 65 or older in Institutional Special Needs Plans (SNP) or residing in long-term care with POS code, 32, 33, 34, 54, or 56 any time during the measurement period  Numerator – Patients who received either a bone mineral density test or a prescription for a drug to treat osteoporosis in the six months after the fracture  3095F – Performance met - Central Dual-energy X-Ray Absorptiometry (DXA) results documented  G8633 – Performance met - Pharmacologic therapy (other than minerals/vitamins) for osteoporosis prescribed  3095F-8P – Performance not met - Central Dual-energy X-Ray Absorptiometry (DXA) was not performed  G8635 – Performance not met - Pharmacologic therapy (other than minerals/vitamins) for osteoporosis was not prescribed  No current benchmarking data found

2019, MDInteractive. Measure 418. Accessed on 6/30/19 from https://mdinteractive.com/2019-MIPS-Quality-Measures-418 Performance Improvement Reporting

Appropriate Use of DXA Scans in Women Under 65 Years Who Do Not Meet the Risk Factor Profile for Osteoporotic Fracture - Measure 472

 Description – Percentage of female patients 50 to 64 years of age without select risk factors for osteoporotic fracture who received an order for a dual-energy x-ray absorptiometry (DXA) scan during the measurement period  No current benchmarking data found

2019, MDInteractive. Measure 472. Accessed on 6/30/19 from https://mdinteractive.com/2019-MIPS-Quality-Measures-472 Performance Improvement Reporting

Additional Measures  Osteoporosis: Management following fracture of hip, spine, or distal radius for men and women aged 50 years and older (NOF13)  Osteoporosis: Percentage of patients, any age, with a diagnosis of osteoporosis who are either receiving both calcium and vitamin D intake and exercise at least once within 12 months (NOF7)  No current benchmarking data found

2019, Choosing Wisely. Accessed on 6/30/19 from http://www.choosingwisely.org/page/3/?s=osteo Choosing Wisely

 American Academy of Family Physicians

 Don’t use dual-energy x-ray absorptiometry (DEXA) screening for osteoporosis in women younger than 65 or men younger than 70 with no risk factors.  American College of Rheumatology

 Don’t routinely repeat DXA scans more often than once every two years.  American Society for Clinical Pathology

 Don’t perform population based screening for 25-OH-Vitamin D deficiency. Best Practice Recommendations

 Use FRAX Scores and risk factors to determine who may benefit from bone mineral density determinations  Include diet and lifestyle changes as anticipatory guidance

 Healthy diet with RDA of calcium and vitamin D

 Daily weight-bearing exercise  Determine treatment strategies based on patient risk factors and patient preferences

 Anti-reabsorption then increased bone formation? Overcoming Barriers

 Time

 Calculating FRAX Scores – include desktop shortcut if not in EMR

 Diet and lifestyle change anticipatory guidance – elevator speech, quick text, handout

 Shared decision making – bill for time during a dedicated visit if lengthy?  Cost

 DXA cost – consult payors to determine coverage (patient responsibility)

 Medications – Consult payor formularies, GoodRx, NeedyMeds  Registry

 EMR vs report based Monday Morning “To Do List”

 Desktop icon for FRAX  Diet and lifestyle advice  Desktop icon for GoodRx and NeedyMeds  Guidelines

 AAFP

 USPSTF  Choosing Wisely Personal photograph taken by David T Walsworth on 7/28/19 Personal photograph taken by David T Walsworth on 5/6/16