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Guideline Summary
Guideline Title
Management and prevention of osteoporosis.
Bibliographic Source(s)
Michigan Quality Improvement Consortium. Management and prevention of osteoporosis. Southfield (MI): Michigan Quality Improvement Consortium; 2012 Jan. 1 p.
Guideline Status

Note: This guideline has been updated. The National Guideline Clearinghouse (NGC) is working to update this summary.

Scope

Disease/Condition(s)
  • Osteopenia
  • Osteoporosis
Guideline Category
Diagnosis
Evaluation
Management
Prevention
Risk Assessment
Treatment
Clinical Specialty
Family Practice
Internal Medicine
Preventive Medicine
Intended Users
Advanced Practice Nurses
Health Plans
Physician Assistants
Physicians
Guideline Objective(s)
  • To achieve significant, measurable improvements in the management and prevention of osteoporosis through the development and implementation of common evidence-based clinical practice guidelines
  • To design concise guidelines that are focused on key management components of osteopenia and osteoporosis and prevention components of osteoporosis to improve outcomes
Target Population
  • Patients at potential risk for osteoporosis
  • Patients requiring therapy to reduce high risk of fracture
  • Patients with fracture
Interventions and Practices Considered

Evaluation

  1. Calculation of fracture risk using FRAX tool
  2. Assessment of risk factors
  3. Assessment for loss of height and back pain
  4. Bone mineral density (BMD) testing using dual energy x-ray absorptiometry (DEXA)

Note: Computed tomography (CT) scan for screening was considered but not recommended.

Management/Treatment/Prevention

  1. Dietary calcium and vitamin D
  2. Weight-bearing exercise
  3. Addressing modifiable risk factors
  4. Pharmacologic treatment (oral bisphosphonates)
  5. Specialist referral
  6. Fall prevention
Major Outcomes Considered

Not stated

Methodology

Methods Used to Collect/Select the Evidence
Searches of Electronic Databases
Description of Methods Used to Collect/Select the Evidence

The Michigan Quality Improvement Consortium (MQIC) health care analyst conducts a search of current literature in support of the guideline topic. Computer database searches are used to identify published studies, existing protocols, and/or national guidelines on the selected topic developed by organizations such as the American Diabetes Association, American Heart Association, American Academy of Pediatrics, etc. If available, clinical practice guidelines from participating MQIC health plans and Michigan health systems are also used to develop a framework for the new guideline.

For the current update of the guideline the following databases were searched from January 2010 through November 2011: U.S. Preventive Services Task Force (USPSTF), the Cochrane Library, Medline, Google. The specific search terms used were: postmenopausal osteoporosis, DXA, DEXA, FRAX, American Association of Clinical Endocrinologists.

Number of Source Documents

Not stated

Methods Used to Assess the Quality and Strength of the Evidence
Weighting According to a Rating Scheme (Scheme Given)
Rating Scheme for the Strength of the Evidence

Levels of Evidence for the Most Significant Recommendation

  1. Randomized controlled trials
  2. Controlled trials, no randomization
  3. Observational studies
  4. Opinion of expert panel
Methods Used to Analyze the Evidence
Review
Description of the Methods Used to Analyze the Evidence

Not stated

Methods Used to Formulate the Recommendations
Expert Consensus
Description of Methods Used to Formulate the Recommendations

Using information obtained from literature searches and available health plan guidelines on the designated topic, the Michigan Quality Improvement Consortium (MQIC) health care analyst prepares a draft guideline to be reviewed by the medical directors' committee at one of their scheduled meetings. Priority is given to recommendations with [A] and [B] levels of evidence (see the "Rating Scheme for the Strength of the Evidence" field).

The initial draft guideline is reviewed, evaluated, and revised by the committee, resulting in draft two of the guideline. Additionally, the Michigan Academy of Family Physicians participates in guideline development at the onset of the process and throughout the guideline development procedure. The MQIC guideline feedback form and draft two of the guideline are distributed to the medical directors, as well as the MQIC measurement and implementation group members, for review and comments. Feedback from members is collected by the MQIC health care analyst and prepared for review by the medical directors' committee at their next scheduled meeting. The review, evaluation, and revision process with several iterations of the guideline may be repeated over several meetings before consensus is reached on a final draft guideline.

Rating Scheme for the Strength of the Recommendations

Not applicable

Cost Analysis

A formal cost analysis was not performed and published cost analyses were not reviewed.

Method of Guideline Validation
External Peer Review
Internal Peer Review
Description of Method of Guideline Validation

When consensus is reached on the final draft guideline, the medical directors approve the guideline for external distribution to practitioners with review and comments requested via the Michigan Quality Improvement Consortium (MQIC) health plans (health care analyst distributes final draft to medical directors' committee, measurement and implementation groups to solicit feedback).

The MQIC health care analyst also forwards the approved guideline draft to appropriate state medical specialty societies for their input. After all feedback is received from external reviews, it is presented for discussion at the next scheduled committee meeting. Based on feedback, subsequent guideline review, evaluation, and revision may be required prior to final guideline approval.

The MQIC Medical Directors approved this updated guideline in January 2012.

Recommendations

Major Recommendations

Note: This guideline has been updated. The National Guideline Clearinghouse (NGC) is working to update this summary. The recommendations that follow are based on the previous version of the guideline.

The level of evidence grades (A–D) are provided for the most significant recommendations and are defined at the end of the "Major Recommendations" field.

Assessment

  • Calculate FRAX (http://www.shef.ac.uk/FRAX/index.jsp External Web Site Policy) to assess fracture risk and to determine need for bone mineral density (BMD) testing. Record result.
  • Assess fracture risk and other risk factors:
    • Age
    • Sex
    • Weight (kg)
    • Height (cm)
    • Previous fracture
    • Parent fractured hip
    • Current smoking
    • Glucocorticoids
    • Rheumatoid arthritis
    • Secondary osteoporosis [type 1 diabetes, osteogenesis imperfecta in adults, untreated long-standing hyperthyroidism, hypogonadism or premature menopause (<45 years), chronic malnutrition, or malabsorption, and chronic liver disease)
    • Alcohol 3 or more units per day
    • Femoral neck BMD (g/cm2)
    • Calcium or vitamin D deficiency
    • Depo-Provera use
    • Family history of osteoporosis
    • Transplant or pending organ transplant
    • Drugs to treat malignancy
    • Inadequate physical activity
  • Assess for loss of height (>1.5 inches) and back pain
  • BMD testing using dual-energy X-ray absorptiometry (DXA) for white women >65 years or men/women with similar or higher fracture risk (>9.3%/10 years by FRAX). The United States Preventive Services Task Force (USPSTF) recommends this service for women.
  • Computed tomography (CT) scan for screening is not recommended.

Eligible Population

Patients at potential risk for osteoporosis

Frequency

  • Adult height assessments at periodic well exams

Core Principles of Treatment and Prevention

Regardless of risk factors:

  • Dietary calcium 1200 mg/d and 800 to 1000 international units (IU) vitamin D3 [B]
  • Weight-bearing exercise [A]
  • Address modifiable risk factors above

Eligible Population

Patients at potential risk for osteoporosis

Frequency

  • Repeating DXA within 8 years does not improve prediction of fractures

Patient Selection for Pharmacological Management Based on Risk

  • Treat patients on corticosteroid therapy with a T-score ≤ -1.0 [A].
  • Treat patients with a history of an osteoporotic fracture or fracture of the hip or spine. [A]
  • Patients without a history of fractures but with a T-score of -2.5 or lower. [A]
  • Patients with a T-score between -1.0 and -2.5 if FRAX major osteoporotic fracture probability is ≥20% or hip fracture probability is ≥3%. [A]

Eligible Population

Patients requiring therapy to reduce high risk of fracture

Pharmacological Management

  • Consider oral bisphosphonate, generic if available.1
  • If not tolerated or ineffective, consider other agents.
  • Consider referral to endocrine or bone and mineral metabolism specialist if patient does not tolerate treatment or shows progression or recurrent fracture after 2 years on treatment.

1Use caution in patients with active upper gastrointestinal (GI) disorders. Take medication on an empty stomach with water, remain upright, no food or beverage for 30 minutes (60 minutes for ibandronate).

Eligible Population

Patients requiring therapy to reduce high risk of fracture

Diagnosis and Treatment

  • Calculate FRAX and record result:
    • If >20% prediction, prescribe a drug to treat osteoporosis (e.g. bisphosphonate)
    • If <20% prediction, obtain a BMD if not done in the past year. Re-calculate FRAX with BMD result, and treat as above.
  • Fall prevention

Eligible Population

Patients with fracture

Definitions:

Levels of Evidence for the Most Significant Recommendations

  1. Randomized controlled trials
  2. Controlled trials, no randomization
  3. Observational studies
  4. Opinion of expert panel
Clinical Algorithm(s)

None provided

Evidence Supporting the Recommendations

Type of Evidence Supporting the Recommendations

The type of evidence is provided for the most significant recommendations (see the "Major Recommendations" field).

This guideline is based on several sources, including the Guide to Clinical Preventive Services 2010-2011, Recommendations of the U.S. Preventive Services Task Force (http://www.ahrq.gov/clinic/pocketgd.htm External Web Site Policy), and the Diagnosis and Treatment of Osteoporosis Guideline, Institute for Clinical Systems Improvement, 2011 (www.icsi.org External Web Site Policy).

Benefits/Harms of Implementing the Guideline Recommendations

Potential Benefits

Through a collaborative approach to developing and implementing common clinical practice guidelines and performance measures for osteoporosis, Michigan health plans will achieve consistent delivery of evidence-based services and better health outcomes. This approach also will augment the practice environment for physicians by reducing the administrative burdens imposed by compliance with diverse health plan guidelines and associated requirements.

Potential Harms

Oral bisphosphonates should be used with caution in patients with active upper gastrointestinal disorders.

Qualifying Statements

Qualifying Statements

This guideline represents core management steps. Individual patient considerations and advances in medical science may supersede or modify these recommendations.

Implementation of the Guideline

Description of Implementation Strategy

Approved Michigan Quality Improvement Consortium (MQIC) guidelines are disseminated through email, U.S. mail, and websites.

The MQIC health care analyst prepares approved guidelines for distribution. Portable Document Format (PDF) versions of the guidelines are used for distribution.

The MQIC health care analyst distributes approved guidelines to the MQIC membership via email.

The MQIC health care analyst submits request to website vendor to post approved guidelines to the MQIC website (www.mqic.org External Web Site Policy).

The MQIC health care analyst completes an annual statewide postcard mailing to physicians in all areas of medicine including primary care and specialties. The postcard provides the complete list of MQIC guidelines and includes which have been recently revised, which are coming up for revision, and any new published guidelines.

The statewide mailing list is derived from the Blue Cross Blue Shield of Michigan (BCBSM) provider database. Approximately 95% of the state's MDs and 96% of the state's DOs are included in the database.

The MQIC health care analyst submits request to the National Guideline Clearinghouse (NGC) to post approved guidelines to the NGC website (www.guideline.gov External Web Site Policy).

Implementation Tools
Chart Documentation/Checklists/Forms
For information about availability, see the Availability of Companion Documents and Patient Resources fields below.

Institute of Medicine (IOM) National Healthcare Quality Report Categories

IOM Care Need
Living with Illness
Staying Healthy
IOM Domain
Effectiveness

Identifying Information and Availability

Bibliographic Source(s)
Michigan Quality Improvement Consortium. Management and prevention of osteoporosis. Southfield (MI): Michigan Quality Improvement Consortium; 2012 Jan. 1 p.
Adaptation

This guideline is based on several sources, including the Guide to Clinical Preventive Services 2010-2011, Recommendations of the U.S. Preventive Services Task Force (http://www.ahrq.gov/clinic/pocketgd.htm External Web Site Policy), and the Diagnosis and Treatment of Osteoporosis Guideline, Institute for Clinical Systems Improvement, 2011 (www.icsi.org External Web Site Policy).

Date Released
2003 Oct (revised 2012 Jan)
Guideline Developer(s)
Michigan Quality Improvement Consortium - Professional Association
Source(s) of Funding

Michigan Quality Improvement Consortium

Guideline Committee

Michigan Quality Improvement Consortium Medical Director's Committee

Composition of Group That Authored the Guideline

Physician representatives from the 13 participating Michigan Quality Improvement Consortium health plans, Michigan State Medical Society, Michigan Osteopathic Association, Michigan Association of Health Plans, Michigan Department of Community Health, Michigan Peer Review Organization, and the University of Michigan Health System

Financial Disclosures/Conflicts of Interest

Standard disclosure is requested from all individuals participating in the Michigan Quality Improvement Consortium (MQIC) guideline development process, including those parties who are solicited for guideline feedback (e.g., health plans, medical specialty societies). Additionally, members of the MQIC Medical Directors' Committee are asked to disclose all commercial relationships as well.

Guideline Status

Note: This guideline has been updated. The National Guideline Clearinghouse (NGC) is working to update this summary.

Guideline Availability

Electronic copies of the updated guideline: Available in Portable Document Format (PDF) from the Michigan Quality Improvement Consortium Web site External Web Site Policy.

Availability of Companion Documents

The following is available:

Patient Resources

None available

NGC Status

This NGC summary was completed by ECRI on April 14, 2004. The information was verified by the guideline developer on July 27, 2004. This NGC summary was updated by ECRI on October 13, 2006. The updated information was verified by the guideline developer on November 3, 2006. This summary was updated by ECRI Institute on April 14, 2008. The updated information was verified by the guideline developer on April 18, 2008. This summary was updated by ECRI Institute on June 3, 2010. The updated information was verified by the guideline developer on June 28, 2010. This summary was updated by ECRI Institute on December 10, 2010 following the U.S. Food and Drug Administration (FDA) advisory on Bisphosphonates. This NGC summary was updated by ECRI Institute on May 25, 2012. The updated information was verified by the guideline developer on June 25, 2012.

Copyright Statement

This NGC summary is based on the original guideline, which may be reproduced with the citation developed by the Michigan Quality Improvement Consortium.

Disclaimer

NGC Disclaimer

The National Guideline Clearinghouseâ„¢ (NGC) does not develop, produce, approve, or endorse the guidelines represented on this site.

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