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Miller KL, Mccoy K, Richards C, Seaman A, Solimeo SL. Engagement in Primary Prevention Program among Rural Veterans With Osteoporosis Risk. JBMR Plus 2022; 6:e10682. [PMID: 36248271 PMCID: PMC9549732 DOI: 10.1002/jbm4.10682] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2022] [Revised: 08/24/2022] [Accepted: 09/05/2022] [Indexed: 02/05/2023] Open
Abstract
A primary osteoporosis prevention program using a virtual bone health team (BHT) was implemented to comanage the care of rural veterans in the Mountain West region of the United States. The BHT identified, screened, and treated rural veterans at risk for osteoporosis using telephone and United States Postal Service communications. Eligibility was determined by regular use of Veterans Health Administration primary care, age 50 or older, and evidence of fracture risk. This study was conducted to identify demographic and clinical factors associated with the acceptance of osteoporosis screening and the initiation of medication where indicated. A cross-sectional cohort design (N = 6985) was utilized with a generalized estimating equation and logit link function to account for facility-level clustering. Fully saturated and reduced models were fitted using backward selection. Less than a quarter of eligible veterans enrolled in BHT's program and completed screening. Factors associated with a lower likelihood of clinic enrollment included being of older age, unmarried, greater distance from VHA services, having a copayment, prior fracture, or history of rheumatoid arthritis. A majority of veterans with treatment indication started medication therapy (N = 453). In this subpopulation, Fisher's exact test showed a significant association between osteoporosis treatment uptake and a history of two or more falls in the prior year, self-reported parental history of fracture, current smoking, and weight-bearing exercise. The BHT was designed to reduce barriers to screening; however, for this population cost and travel continue to limit engagement. The remarkable rate of medication initiation notwithstanding, low enrollment reduces the impact of this primary prevention program, and findings pertaining to fracture, smoking, and exercise imply that health beliefs are an important contributing factor. Efforts to identify and address barriers to osteoporosis screening and treatment, such as clinical factors, social determinants of health, and health beliefs, may pave the way for effective implementation of population bone health care delivery systems. Published 2022. This article is a U.S. Government work and is in the public domain in the USA. JBMR Plus published by Wiley Periodicals LLC on behalf of American Society for Bone and Mineral Research.
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Affiliation(s)
- Karla L. Miller
- VHA Office of Rural Health, Veterans Rural Health Resource Center‐Salt Lake City, Department of Internal Medicine, Rheumatology SectionVeterans Affairs Salt Lake City Health Care SystemSalt Lake CityUtahUSA,Associate Professor (Clinical) of Medicine, Division of RheumatologyUniversity of Utah School of MedicineSalt Lake CityUtahUSA
| | - Kimberly Mccoy
- VHA Office of Rural Health, Veterans Rural Health Resource Center‐Iowa City (VRHRC‐IC), Center for Access & Delivery Research and Evaluation (CADRE)Veterans Affairs Iowa City VHA Health Care SystemIowa CityIowaUSA
| | - Chris Richards
- VHA Office of Rural Health, Veterans Rural Health Resource Center‐Iowa City (VRHRC‐IC), Center for Access & Delivery Research and Evaluation (CADRE)Department of Veterans Affairs Iowa City VHA Health Care SystemIowa CityIowaUSA
| | - Aaron Seaman
- VHA Office of Rural Health, Veterans Rural Health Resource Center‐Iowa City (VRHRC‐IC)Veterans Affairs Iowa City VHA Health Care SystemIowa CityIowaUSA,Division of General Internal Medicine, Department of Internal Medicine, Carver College of MedicineUniversity of IowaIowa CityIowaUSA
| | - Samantha L. Solimeo
- VHA Office of Rural Health, Veterans Rural Health Resource Center‐Iowa City (VRHRC‐IC), Center for Access & Delivery Research and Evaluation (CADRE), Primary Care Analytics Team Iowa City (PCAT‐IC)Veterans Affairs Iowa City VHA Health Care SystemIowa CityIowaUSA,Division of General Internal Medicine, Department of Internal Medicine, Carver College of MedicineUniversity of IowaIowa CityIowaUSA
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Seaman AT, Steffen MJA, Van Tiem JM, Wardyn S, Santana X, Miller KL, Solimeo SL. Cultivating across "pockets of excellence": challenges to sustaining efforts to improve osteoporosis care. Osteoporos Int 2022; 33:139-147. [PMID: 34414462 DOI: 10.1007/s00198-021-06098-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2021] [Accepted: 08/13/2021] [Indexed: 12/01/2022]
Abstract
UNLABELLED We conducted in-depth, semi-structured interviews with clinicians involved in bone health care to understand the challenges of implementing and sustaining bone health care interventions. Participants identified individual- and system-level challenges to care delivery, implementation, and sustainment. We discuss opportunities to address challenges through a commitment to relationship- and infrastructure-building support. PURPOSE Osteoporosis and fracture-related sequalae exact significant individual and societal costs; however, identification and treatment of at-risk patients are troublingly low, especially among men. The purpose of this study was to identify challenges to implementing and sustaining bone health care delivery interventions in the Veterans Health Administration. METHODS We conducted interviews with endocrinologists, pharmacists, primary care physicians, rheumatologists, and orthopedic surgeons involved in bone health care (n = 20). Interviews were audio-recorded and transcribed verbatim. To determine thematic domains, we engaged in an iterative, qualitative content analysis of the transcripts. RESULTS Participants reported multiple barriers to delivering bone health care and to sustaining the initiatives designed to address delivery challenges. Challenges of bone health care delivery existed at both the individual level-a lack of patient and clinician awareness and competing clinical demands-and the system level-multiple points of entry to bone health care, a dispersion of patient management, and guideline variability. To address the challenges, participants developed initiatives targeting the identification of at-risk patients, clinician education, increasing communication, and care coordination. Sustaining initiatives, however, was challenged by staff turnover and the inability to achieve and maintain priority status for bone health care. CONCLUSION The multiple, multi-level barriers to bone health care affect both care delivery processes and sustainment of initiatives to improve those processes. Barriers to care delivery, while tempered by intervention, are entangled and persist alongside sustainment challenges. These challenges require relationship- and infrastructure-building support.
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Affiliation(s)
- Aaron T Seaman
- VA Office of Rural Health Veterans Rural Health Resource Center- Iowa City (VRHRC-IC), Department of Veterans Affairs, Iowa City VA Health Care System, Iowa City, IA, USA.
- Center for Access and Delivery Research and Evaluation (CADRE), Department of Veterans Affairs, Iowa City VA Health Care System, Iowa City, IA, USA.
- Department of Internal Medicine, Carver College of Medicine, University of Iowa, 200 Hawkins Drive, Iowa City, IA, 280-B MRF, USA.
| | - Melissa J A Steffen
- VA Office of Rural Health Veterans Rural Health Resource Center- Iowa City (VRHRC-IC), Department of Veterans Affairs, Iowa City VA Health Care System, Iowa City, IA, USA
- Center for Access and Delivery Research and Evaluation (CADRE), Department of Veterans Affairs, Iowa City VA Health Care System, Iowa City, IA, USA
- Primary Care Analytics Team Iowa City (PCAT-IC), Department of Veterans Affairs, Iowa City VA Health Care System, Iowa City, IA, USA
| | - Jennifer M Van Tiem
- VA Office of Rural Health Veterans Rural Health Resource Center- Iowa City (VRHRC-IC), Department of Veterans Affairs, Iowa City VA Health Care System, Iowa City, IA, USA
- Center for Access and Delivery Research and Evaluation (CADRE), Department of Veterans Affairs, Iowa City VA Health Care System, Iowa City, IA, USA
| | - Shylo Wardyn
- VA Office of Rural Health Veterans Rural Health Resource Center- Iowa City (VRHRC-IC), Department of Veterans Affairs, Iowa City VA Health Care System, Iowa City, IA, USA
- Center for Access and Delivery Research and Evaluation (CADRE), Department of Veterans Affairs, Iowa City VA Health Care System, Iowa City, IA, USA
| | - Xiomara Santana
- VA Office of Rural Health Veterans Rural Health Resource Center- Iowa City (VRHRC-IC), Department of Veterans Affairs, Iowa City VA Health Care System, Iowa City, IA, USA
- Center for Access and Delivery Research and Evaluation (CADRE), Department of Veterans Affairs, Iowa City VA Health Care System, Iowa City, IA, USA
| | - Karla L Miller
- VA Office of Rural Health Veterans Rural Health Resource Center-Salt Lake City (VRHRC-SLC), Salt Lake City, UT, USA
- Department of Internal Medicine, Rheumatology Section, Veterans Affairs Salt Lake City Health Care System, Salt Lake City, UT, USA
- Division of Rheumatology, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Samantha L Solimeo
- VA Office of Rural Health Veterans Rural Health Resource Center- Iowa City (VRHRC-IC), Department of Veterans Affairs, Iowa City VA Health Care System, Iowa City, IA, USA
- Center for Access and Delivery Research and Evaluation (CADRE), Department of Veterans Affairs, Iowa City VA Health Care System, Iowa City, IA, USA
- Department of Internal Medicine, Carver College of Medicine, University of Iowa, 200 Hawkins Drive, Iowa City, IA, 280-B MRF, USA
- Primary Care Analytics Team Iowa City (PCAT-IC), Department of Veterans Affairs, Iowa City VA Health Care System, Iowa City, IA, USA
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