Proposed Changes to Existing Measure for HEDIS : Osteoporosis Testing in Older Women (OTO)

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1 Draft Document for HEDIS 2015 Public Comment Obsolete After March 19, Proposed Changes to Existing Measure for HEDIS : Osteoporosis Testing in Older Women (OTO) NCQA seeks comments on proposed modifications to the Osteoporosis Testing in Older Women measure. This measure assesses the number of women 65 years of age and over who report ever having received a bone density test to check for osteoporosis. It is collected through the Health Outcomes Survey. We propose the following changes to the measure: Change the question wording to specify that testing for osteoporosis must have occurred since the responder turned 65 years of age and that the test can be done in the hip or back. Restrict this measure to women years of age. The U.S. Preventive Services Task Force (USPSTF) recommends screening for osteoporosis in women 65 years of age or older and in younger women whose fracture risk is equal to or greater than that of a 65-year-old White woman who has no additional risk factors. Dual-energy x-ray absorptiometry (DXA) of the hip and lumbar spine is the recommend method of screening for osteoporosis. The USPSTF did not identify risks to screening women under 65 with no risk factors; however, DXA screening for osteoporosis is one of the top five overused tests identified by the American Academy of Family Physicians. Revising the measure to ask about testing done since turning 65 will reduce the likelihood that this measure will capture potentially inappropriate screening done prior to age 65. The USPSTF does not define a specific upper age limit for testing in women, because the risk for fractures continues to increase with age and treatment harms remain no greater than small. However, very few clinical trials of osteoporosis treatment include women over 85 and the USPSTF concluded there is little data on the effectiveness of bisphosphonates (the most common treatment for osteoporosis) in women 85 and older. Clinicians should take a patient s remaining lifespan into account when deciding whether to screen for osteoporosis in this advanced age group. Supporting documents for the proposed measure include the draft measure specification, evidence work-up and performance data. NCQA acknowledges the contributions of the Geriatric Measurement Advisory Panel and the Osteoporosis Advisory Workgroup. 1 HEDIS is a registered trademark of the National Committee for Quality Assurance (NCQA).

2 Draft Document for HEDIS 2015 Public Comment Obsolete After March 19, Osteoporosis Testing in Older Women (OTO) SUMMARY OF CHANGES TO HEDIS 2015 Revised the Health Outcome Survey question. Restricted this measure to women years of age. Description This measure assesses the number of women years of age and older who report ever having received a bone density test to check for osteoporosis. Eligible Population Product line Age Medicare and older as of December 31 of the measurement year. Protocol and Survey Instrument Medicare Collected using the HOS. MAOs reporting the measure must contract with an NCQA Certified HOS Survey Vendor to administer the survey. Questions Included in the Measure Table E-4 presents the question included in the measure. Table E-4: Osteoporosis Testing in Older Women Q54 Question Since turning age 65, have you ever had a bone density test to check for osteoporosis, sometimes thought of as brittle bones? This test may have been done to your back or hip, wrist, heel or finger. Yes No Response Choices Calculating Results Results are calculated by NCQA using data collected in the combined Baseline and Follow-Up Survey samples from the same measurement year. The MAO must achieve a denominator of at least 100 to obtain a reportable result. If the denominator is less than 100, NCQA assigns a measure result of NA. Denominator Numerator The number of female members age and older as of December 31 of the measurement year who responded Yes or No to the question, Since turning age 65, have you ever had a bone density test to check for osteoporosis, sometimes thought of as brittle bones? This test may have been done to your back or hip, wrist, heel or finger. The number of members in the denominator who responded Yes to the question, Since turning age 65, have you ever had a bone density test to check for osteoporosis, sometimes thought of as brittle bones? This test may have been done to your back or hip, wrist, heel or finger.

3 Draft Document for HEDIS 2015 Public Comment Obsolete After March 19, Osteoporosis Testing in Older Women (OTO) Measure Work-up Measure Description The Osteoporosis Testing in Older Women (OTO) measure assesses the percentage of women 65 years of age and older who report ever having received a bone density test to check for osteoporosis. Topic Overview Importance and Prevalence Osteoporosis is a bone disease characterized by low bone mass, which leads to bone fragility and an increased risk of fractures to the hip, spine or wrist (NIH NIAMS 2012). The U.S. Department of Health and Human Services indicates that as much as 50 percent of Americans older than 50 years of age will be at risk for an osteoporotic fracture in their lifetime. Currently, more than 40 million Americans live with either osteoporosis or osteopenia (lower- than -normal bone mineral density that increases risk of osteoporosis) (NIH NIAMS 2011). Osteoporosis can occur at any age or in either sex; however, risk increases with age and is more predominant in women (Table 1) (Looker et al 2012). Peak bone mass, which tends to be higher in men than in women, is attained around the age of 30. In women, minimal change in bone mass occurs between the age of 30 and menopause. Following menopause, most women experience rapid bone loss in the first few years, which then slows but continues throughout the postmenopausal years. Loss of bone mass can lead to osteoporosis. (NIH NIAMS, 2012). Table 1: Osteoporosis or Low Bone Mass at the Femur, Neck or Lumbar Spine, by Age and Sex Age Women 7% 10% 27% 35% Men 3% 3% 4% 10% People of all ethnic backgrounds are at risk of osteoporosis, however there are ethnic differences concerning prevalence of osteoporosis (Table 2) (Looker et al, 2012). Table 2: Percentage of Women 50 and Older With Osteoporosis, by Ethnicity Non-Hispanic Caucasian 15% Mexican-American 26% Non-Hispanic Black 9% Other Races 19% One in two women and up to one in five men will experience an osteoporosis-related fracture at some point in their lifetime (USDHHS 2004). This results in nearly 1.5 million osteoporosis-related fractures each year, including spinal fractures, wrist fractures and hip fractures (NIH NIAMS, 2012). Individuals who experience an osteoporosis-related fracture are at increased risk of experiencing additional fractures. In one study, women with a history of vertebral fracture were four times more likely to experience a new fracture within 15 years, relative to women without a history of vertebral fracture (Cauley et al 2007).

4 Draft Document for HEDIS 2015 Public Comment Obsolete After March 19, Fractures related to underlying osteoporosis often result in chronic pain, disability, loss of independence, decreased quality of life and increased mortality (USPSTF 2011). Hip and vertebral fractures are the most common osteoporosis-related fractures. Vertebral fractures can cause chronic back pain and have been linked to increased mortality in older people (NIH NIAMS 2011). Patients with a vertebral fracture have mortality rates twice that of matched controls without vertebral fractures (Lau et al 2008). Osteoporotic patients with vertebral fractures also report worse overall quality of life, including worse physical function, bodily pain, social function and general health perception (Romagnoli et al 2004; Salafi et al 2007). Hip fractures are associated with significant disability. Most require surgery; and after treatment, 50 percent of hip fracture patients cannot walk without assistance. Nearly 20 percent of hip-fracture patients over 50 die in the year following their fracture, as a result of associated medical complications (NIH NIAMS 2011). 40 percent of those who survive will never return to prefracture functional status, which often leads to the need for long-term nursing home care (USDHHS 2004). Financial importance and cost effectiveness In 2012, the estimated national direct expenditures for osteoporosis and related fractures in the U.S. totaled approximately $18 billion annually (NIH NIAMS 2012). Because these expenditures do not include indirect costs such as lost productivity or wages, the true financial impact of osteoporosis is likely much larger, and it is estimated that by 2040, the number of hip fractures and their associated costs could double or triple (Schneider 1990). Osteoporotic fractures are responsible for more than 432,000 hospital admissions, almost 2.5 million medical office visits and about 180,000 nursing home admissions each year (USDHHS 2004). Supporting Evidence for Screening The US Preventive Services Task Force (USPSTF) recommends screening for osteoporosis in women 65 years or older and in younger women whose fracture risk is equal to or greater than that of a 65-year-old White woman with no additional risk factors (USPSTF 2011). This is a B recommendation, meaning that the USPSTF recommends the service and there is moderate certainty the net benefit of screening for osteoporosis by using dual-energy x-ray absorptiometry (DXA) is at least moderate. The USPSTF recommends using the fracture risk assessment tool (FRAX) to identify younger persons who may be at equal or greater risk of fracture than that of a 65-year-old White woman. The FRAX uses bone density information and other risk factors for breaking a bone (e.g. smoking, low BMI, alcohol use, and previous fracture) to estimate an individual s 10-year fracture risk. Based on the FRAX tool, a 65-year-old White woman with no other risk factors has a 9.3 percent 10-year risk for any osteoporotic fracture (USPSTF 2011). Screening tests Osteoporosis is characterized by low bone mineral density (BMD) and the resulting increased risk of fractures. The USPSTF found good evidence that BMD measurements accurately predict the risk for fractures in the short-term and that treatments for asymptomatic women with osteoporosis can reduce their risk for fracture. Although there are numerous advanced screening methods for low BMD, DXA of the hip and lumbar spine is the most common. DXA quantitatively calculates the photon absorption of the minerals in bone tissue. Quantitative ultrasonography of the calcaneus (heel) is an equally effective bone density test that is portable and less expensive than DXA, but current diagnostic and treatment criteria for osteoporosis rely on DXA measurements only (USPSTF 2011). There is no clear evidence to inform the optimal intervals for repeated screening and whether repeated screening is necessary in a woman with normal bone mineral density. A minimum two-year gap between tests is needed to reliably measure change in bone mineral density, but an even longer interval may be necessary to improve fracture risk prediction (Nelson 2010). A prospective study of women aged 65 years or older found that a bone density measurement from a test conducted up to eight years after an initial bone density test did not result in better prediction of subsequent fractures (Hiller 2007).

5 Draft Document for HEDIS 2015 Public Comment Obsolete After March 19, Age to screen Treatment Potential harm of screening and treatment The USPSTF does not define a specific upper age limit for screening in women because the risk for fractures continues to increase with age and treatment harms remain no greater than small. The current guideline recommends clinicians take a patient s remaining lifespan into account when deciding whether to screen patients with significant illness, and that benefits of treatment emerge months after treatment initiation (USPSTF 2011). Bisphosphonates, parathyroid hormone, raloxifene and estrogen have been shown to reduce vertebral fractures in postmenopausal women and are effective for primary prevention. Bisphosphonates and raloxifene have the strongest most consistent evidence of effectiveness in women (Nelson 2010). There is currently very little data on the effectiveness of bisphosphonates in women 85 and older (USPSTF 2011). There have been only a few randomized controlled trials (RCTs) that have included participants over 80 years of age to investigate the use of antiosteoporotic agents. During its 2011 evidence review, the USPSTF did not find evidence that addressed the potential harms of screening for osteoporosis, including false-positive test results causing unnecessary treatment, false-negative test results and patient anxiety about positive test results (USPSTF, 2011). Despite the lack of published summary data, recent research reveals that too many younger women may be screened unnecessarily for osteoporosis with a DXA scan (Schnatz 2011). According to a 2012 report released by the American Academy of Family Physicians (AAFP), DXA screening for osteoporosis is one of the top five overused tests and AAFP recommended DXA scanning in women under the age of 65 with no risk factors be added to the Choosing Wisely campaign as an area of overuse (Choosing Wisely 2013). The Choosing Wisely campaign, spearheaded by the American Board of Internal Medicine (ABIM) Foundation in collaboration with multiple specialty societies, developed a list that recommends against commonly overused tests and procedures, to push physicians to be better stewards of finite healthcare resources. One study of data from the National Ambulatory Medical Care Survey suggests that overuse of DXA in primary care may have accounted for $527 million in national health care expenditure in 2009 (Kale 2011). Other research suggests that 41.3 percent of women under the age of 65 who were referred for DXA scanning did not meet the risk factor profile (Schnatz 2011). There is also evidence of potential harms of drug therapy for osteoporosis. Raloxifene and estrogen increase thromboembolic events; estrogen increases stroke; and estrogen with progestin increases coronary heart disease and breast cancer. Longterm use of bisphosphonates increases the risk for serious gastrointestinal adverse events, but based on its 2011 evidence review, the USPSTF concluded that the harms of bisphosphonates are small (USPSTF 2011). Screening and treatment in men Health care disparities Gaps in care Although the majority of individuals affected by osteoporosis are women, studies have begun to explore the benefits of osteoporosis screening in males. The USPSTF concluded in 2011 that the evidence was insufficient to assess the balance of benefits and harms of screening for osteoporosis in men (USPSTF 2011). There is a misconception that osteoporosis is only a concern for non-hispanic White women, which may result in delaying prevention and treatment in non-white and Hispanic populations. African-American and Hispanic women are less likely to believe they are at risk for osteoporosis (NIH NIAMS 2010). A study based on a large managed care organization found ethnic and racial minority patients two three times less likely to be offered osteoporosis screening or treatment than White women (Thomas 2007). Prevention efforts should target all women, irrespective of their race/ethnicity (Cauley 2011). Since this measure was introduced to HEDIS in 2006, national performance has increased 7.7 percent points for HMOs and 4.1 percent points for PPOs. Current HEDIS rates indicate that just under three quarters of women over 65 in Medicare

6 Draft Document for HEDIS 2015 Public Comment Obsolete After March 19, Advantage plans report having received at least one bone mineral density test in their lifetime (69.1 percent in 2010; 71.0 percent in 2011; 72.2 percent in 2012). In 2012, the spread in national health plan performance was percent (10th-90th percentiles). Analysis of Medicare FFS claims also suggests a trend towards increased use of BMD among women; 8.4 percent of women received a BMD test in 1999, compared with 12.9 percent of women in Over this seven-year observation period, 31.3 percent of White women and 15.3 percent of black women received a BMD test (Curtis 2008). Overall, these study rates are much lower than what is self-reported in the Health Outcomes Survey (HOS). One possibility for the difference is the observation period over which BMD is being assessed (seven years in Medicare FFS study and lifetime in HOS survey). Another explanation is that Medicare Advantage plans have historically placed more emphasis on preventive care than traditional, feefor-service Medicare, and higher rates observed in the HOS may reflect true differences in the quality of preventive care in these plans. References American Academy of Family Physicians releases top 5 list of possibly overused tests and procedures. April 4, American College of Obstetricians and Gynecologists (ACOG). Osteoporosis. Washington (DC): ACOG; 2012 Sep. 17 p. (ACOG practice bulletin; no. 129). Cauley, J Defining Ethnic and Racial Differences in Osteoporosic and Fragility Fractures. Clinical Orthopaedics & Related Research. 469(7): Cauley, J.A., M.C. Hochberg, L-Y Lui, et al Long-term risk of incident vertebral fractures. JAMA. 298: Choosing Wisely American Academy of Family Physicians: Fifteen Things Physicians and Patients Should Question. 23, _sept2013.pdf (November 23, 2013) Curtis, J.R., L. Carbone, H. Cheng, et al Longitudinal trends in use of bone mass measurement among older Americans, J Bone Miner Res. 23: Grover, M., M. Anderson, R. Gupta, M. Haden, J. Hartmark-Hill, L.M. Morski, P. Sarmiento, A. Dueck Increased Osteoporosis Screening Rates Associated with the Provision of a Preventive Health Examination. The Journal of the American Board of Family Medicine. 22 (6): Hillier, T.A., K.L. Stone, D.C. Bauer, J.H. Rizzo, K.L. Pedula, J.A. Cauley, et al Evaluating the value of repeat bone mineral density measurement and prediction of fractures in older women: the study of osteoporotic fractures. Arch Intern Med. 167: Kale, M.S., T.F. Bishop, A.D. Federman, et al Top 5 lists top 5 billion. Arch Intern Med. 171: Looker, A.C., L.G. Borrud, B. Dawson-Hughs, J.A. Shepherd, N.C. Wright Osteoporosis or low bone mass at the femur neck or lumbar spine in older adults: United States, NCHS data brief no 93. Hyattsville, MD: National Center for Health Statistics. National Institutes of Health. National Institute of Arthritis and Musculoskeletal and Skin Disorders (NIH NIAMS). Osteoporosis Handout on Health. October 2011 (online). National Institutes of Health. National Institute of Arthritis and Musculoskeletal and Skin Disorders (NIH NIAMS). Osteoporosis: Overview. January National Institutes of Health. National Institute of Arthritis and Musculoskeletal and Skin Disorders (NIH NIAMS0. Osteoporosis and Related Bone Diseases National Resource Center. Osteoporosis: Peak Bone Mass in Women. January 2012 (online). (December 20, 2013) National Institutes of Health. Osteoporosis and Related Bone Diseases National Resource Center. The Surgeon General s Report on Bone Health and Osteoporosis: What It Means to You. March 2012 (online). National Osteoporosis Foundation. NOF Releases Updated Data and National Breakdown of Adults Age 50 and Older Affected by Osteoporosis and Low Bone Mass. (November 20, 2013)

7 Draft Document for HEDIS 2015 Public Comment Obsolete After March 19, Nelson, H.D., E.M. Haney, T. Dana, C. Bougatsos, R. Chou Screening for osteoporosis: an update for the U.S. Preventive Services Task Force. Ann Intern Med. 153: Romagnoli, E., V. Carnevale, I. Nofroni, et al Quality of life in ambulatory postmenopausal women: the impact of reduced bone mineral density and subclinical vertebral fractures. Osteporos Int. 15: Salaffi F., M.A. Cimmino, N. Malavoita, et al The burden of prevalent fractures on health-related quality of life in postmenopausal women with osteoporosis: the IMOF study. J Rheumatol. 34: Sego, S. Osteoporosis Screening in Postmenopausal Women. The Clinical Advisor. October 1, 2010 (online). Schneider, E.L., J.M. Guralnik. May 2, The aging of America: Impact on health care costs. JAMA. 263(17): Schousboe, J.T., B.C. Taylor, H.A. Fink, D.C. Bauer, J.A. Nyman, R.L. Kane, et al Cost Effectiveness of universal bone densitometry followed by treatment of those with femoral neck T-score <-2.5 compared to no densitometry or treatment in elderly Caucasian men with or without prior fracture. American Society of Bone and Mineral Research 28th Annual Meeting; Abstract. Schnatz, P.F., K.A. Marakovits, M. Dubois, et al. October Osteoporosis screening and treatment guidelines: are they being followed? Menopause. 18(10): Thomas, P. September Racial and Ethnic Differences in Osteoporosis. J Am Acad Orthop Surg, Vol 15, No suppl_1. S U.S. Department of Health and Human Services Bone Health and Osteoporosis: A Report of the Surgeon General. Rockville, MD: US Department of Health and Human Services, Office of the Surgeon General. U.S. Preventive Services Task Force. Recommendations and Rationale: Screening for Osteoporosis in Postmenopausal Women. Released January Watts, N.B., R.A. Adler, J.P. Bilezikian, M.T. Drake, Estell, R., Orwoll, E.S., and Finkelstein, J.S. June Osteoporosis in Men: An Endocrine Society Clinical Practice Guideline. J. Clin Endocrinol Metab, 97(6): Watts, N.B., J.P. Bilezikian, P.M. Camacho, S.L. Greenspan, S.T. Harris, S.F. Hodgson, M. Kleerekoper, M.M. Luckey, M.R. McClung, R.P. Pollack, S.M. Petak, AACE Osteoporosis Task Force. November- December American Association of Clinical Endocrinologists medical guidelines for clinical practice for the diagnosis and treatment of postmenopausal osteoporosis. Endocr Pract. (Suppl 3):1 37.

8 Draft Document for HEDIS 2015 Public Comment Obsolete After March 19, Specific Guideline Recommendations US Preventive Services Task Force (USPSTF): The U.S. Preventive Services Task Force recommends screening for osteoporosis in women aged 65 years or older and in younger women whose fracture risk is equal to or greater than that of a 65-year old White woman who has no additional risk factors. Evidence is lacking about the optimal intervals for the timing of screening. American Association of Clinical Endocrinologists (AACE): Recommends women 65 years and older (Grade B, Best Evidence Level 2) and all younger postmenopausal women at increased risk of fracture be screened for osteoporosis (Grade C, Best Evidence Level 2). National Osteoporosis Foundation (NOF): In women 65 and older and men 70 and older, recommend bone mineral density (BMD) testing. In postmenopausal women and men 50 69, recommend BMD testing when there is a fracture or when you have concern based on their risk factor profile. American College of Obstetricians and Gynecologists (ACOG): Recommend bone density screening for women 65 and older. Dual-energy s-ray absorptiometry screening can be used selectively for women younger than 65 if they are post-menopausal and have other significant risk factors for osteoporosis or fracture. Clinical Practice Guidelines: Osteoporosis Management in Women Who Had a Fracture Organization (Year) Target Population Frequency Recommendation Grade U.S. Preventive Services Task Force (2011) American Association of Clinical Endocrinologists (2010) National Osteoporosis Foundation (2010) American College of Obstetricians and Gynecologists (2012) Women aged 65 or older without previous known fractures or secondary causes of osteoporosis and women under age 65 whose 10-year fracture risk is equal to or greater than that of a 65-year-old White woman without additional risk factors. Women 65 and older, as well as younger, post-menopausal women at increased risk of fracture. Women 65 and older and in post-menopausal women and men age 50 and older. Women age 65 and older and post-menopausal women with a risk of developing osteoporosis. Evidence is lacking about optimal intervals for repeated screening. Screening for osteoporosis in women 65 years and in young women whose fracture risk is equal to or greater than that of a 65-year old White woman who has no additional risk factors. N/A 1. Women 65 years should be screened for osteoporosis. 2. Younger post-menopausal women at increased risk of fracture, based on a list or risk factors should be screened for osteoporosis. N/A 1. In women age 65 and older and men 70, recommend bone mineral density (BMD) testing. 2. In post-menopausal women and men 50 69, recommend BMD testing when you have concern based on their risk factor profile. Dual-energy x-ray absorptiometry screening should not be performed more frequently than every 2 years. (Level B) 1. Bone density screening should be done in women Post- menopausal women<65 who have significant risk factors for osteoporosis or fracture. B Recommendation; moderate certainty level 1. Grade B, Best Evidence Level: 2 2. Grade C, Best Evidence Level: 2 N/A Level A

9 Draft Document for HEDIS 2015 Public Comment Obsolete After March 19, Grading System Key U.S. Preventive Services Task Force: What the Grade Means and Suggestions for Practice A B C D I Statement Grade Definition Suggestion for Practice The USPSTF recommends the service. There is high certainty that the net Offer or provide this service. benefit is substantial. The USPSTF recommends the service. There is high certainty that the net benefit is moderate or there is moderate certainty that the net benefit is Offer or provide this service. moderate to substantial. Clinicians may provide this service to selected patients depending on individual circumstances. However, for most individuals without signs or symptoms there is likely to be only a small benefit from this service The USPSTF recommends against the service. There is moderate or high certainty that the service has no net benefit or that the harms outweigh the benefits. The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of the service. Evidence is lacking, of poor quality, or conflicting, and the balance of benefits and harms cannot be determined. Offer or provide this service only if other considerations support offering or providing the service in an individual patient. Discourage the use of this service. Read the clinical considerations section of the USPSTF Recommendation Statement. If the service is offered, patients should understand the uncertainty about the balance of benefits and harms.

10 Draft Document for HEDIS 2015 Public Comment Obsolete After March 19, U.S. Preventive Services Task Force: Levels of Certainty Regarding Net Benefit High: The available evidence usually includes consistent results from well-designed, well-conducted studies in representative primary care populations. These studies assess the effects of the preventive service on health outcomes. This conclusion is therefore unlikely to be strongly affected by the results of future studies. Moderate: The available evidence is insufficient to determine the effects of the preventive services on health outcomes, but confidence in the estimate is constrained by factors such as: (1) the number, size or quality of individual studies, (2) Inconsistency of findings across individual studies, (3) Limited generalizability of findings to routine primary care practice, (4) Lack of coherence in the chain of evidence. As more information becomes available, the magnitude or direction of the observed effect could change, and this change may be large enough to alter the conclusion. Low: The available evidence is insufficient to assess effects on health outcomes. Evidence is insufficient because of: (1) the limited number of size of studies, (2) important flaws in study design and methods, (3) inconsistency of findings across individual studies, (4) gaps in the chain of evidence, (5) findings not generalizable to routine primary care practice, (6) and a lack of information on important health outcomes. More information may allow an estimation of effects on health outcomes. American Association of Clinical Endocrinologists: Criteria for Grading Recommendation Grade Definition A Homogenous evidence from multiple well-designed randomized or cohort controlled trials with sufficient statistical power. 1 conclusive level 1 publications demonstrating benefit= risk B Evidence from at least 1 large well-designed clinical trial, cohort or case-controlled analytic study, or meta-analysis. No conclusive level 1 publication; 1 conclusive level 2 publications demonstrating benefit= risk C Evidence based on clinical experience, descriptive studies, or expert consensus opinion. No conclusive level 1 or 2 publications; 1 conclusive level 3 publications demonstrating benefit= risk. No conclusive risk at all and no conclusive benefit demonstrated by evidence. D Not rated. No conclusive level 1, 2, or 3 publication demonstrating benefit= risk. Conclusive level 1, 2, or 3 publication demonstrating risk= benefit American Association of Clinical Endocrinologists Criteria for Rating of Published Evidence* Numerical Descriptor Semantic Descriptor (reference methods) (evidence level) 1 Meta- analysis of randomized controlled trials 1 Randomized controlled trial 2 Meta-analysis of nonrandomized prospective or case-controlled trials 2 Nonrandomized controlled trial 2 Prospective cohort study 2 Retrospective case-control study 3 Cross-sectional study 3 Surveillance study (registries, surveys, epidemiologic study) 3 Consecutive case series 3 Single case reports 4 No evidence (theory, opinion, consensus, or review) *1 = Strong Evidence; 2 = Intermediate Evidence; 3 = Weak Evidence; 4 = No Evidence.

11 Draft Document for HEDIS 2015 Public Comment Obsolete After March 19, American College of Obstetricians and Gynecologists: Levels of Recommendations Grade Definition A Recommendations are based on good and consistent evidence. B Recommendations are based on limited of inconsistent scientific evidence. C Recommendations are based primarily on consensus and expert opinion.

12 Draft Document for HEDIS 2015 Public Comment Obsolete After March 19, HEDIS Health Outcome Survey (HOS) Performance Rates: Osteoporosis Testing in Older Women (OTO) Table 1. HOS OTO Measure Performance (All Women 65) Medicare HMO/PPO Plans Year Total Number of Plans Average Standard Deviation 10th 25th 50th 75th 90th Table 2. HOS OTO Measure Performance (Women 65 74) Medicare HMO/PPO Plans Year Total Number of Plans Average Standard Deviation 10th 25th 50th 75th 90th Table 3. HOS OTO Measure Performance (Women 75 84) Medicare HMO/PPO Plans Year Total Number of Plans Average Standard Deviation 10th 25th 50th 75th 90th Table 4. HOS OTO Measure Performance (Women 85 and Older) Medicare HMO/PPO Plans Year Total Number of Plans Average Standard Deviation 10th 25th 50th 75th 90th