Delivering fracture prevention services to rural US veterans through telemedicine: a process evaluation

Abstract

Summary An informatics-driven population bone health clinic was implemented to identify, screen, and treat rural US Veterans at risk for osteoporosis. We report the results of our implementation process evaluation which demonstrated BHT to be a feasible telehealth model for delivering preventative osteoporosis services in this setting. Purpose An established and growing quality gap in osteoporosis evaluation and treatment of at-risk patients has yet to be met with corresponding clinical care models addressing osteoporosis primary prevention. The rural bone health tea m (BHT) was implemented to identify, screen, and treat rural Veterans lacking evidence of bone health care and we conducted a process evaluation to understand BHT implementation feasibility. Methods For this evaluation, we defined the primary outcome as the number of Veterans evaluated with DXA and a secondary outcome as the number of Veterans who initiated prescription therapy to reduce fracture risk. Outcomes were measured over a 15-month period and analyzed descriptively. Qualitative data to understand successful implementation were collected concurrently by conducting interviews with clinical personnel interacting with BHT and BHT staff and observations of BHT implementation processes at three site visits using the Promoting Action on Research Implementation in Health Services (PARIHS) framework. Results Of 4500 at-risk, rural Veterans offered osteoporosis screening, 1081 (24%) completed screening, and of these, 37% had normal bone density, 48% osteopenia, and 15% osteoporosis. Among Veterans with pharmacotherapy indications, 90% initiated therapy. Qualitative analyses identified barriers of rural geography, rural population characteristics, and the infrastructural resource requirement. Data infrastructure, evidence base for care delivery, stakeholder buy-in, formal and informal facilitator engagement, and focus on teamwork were identified as facilitators of implementation success. Conclusion The BHT is a feasible population telehealth model for delivering preventative osteoporosis care to rural Veterans.

Telemedicine trends in orthopaedics and trauma during the COVID-19 pandemic: A bibliometric analysis and review

“…Telemedicine was satisfactorily utilised in the care, decision making, and rehabilitation of general orthopaedic disorders, including fracture care, osteoporosis, spine disorders, sports injuries, arthroplasty patients, and post-operative care of patients. 48 , 49 , 50 , 51 , 52 , 53 , 54 The common trends observed by the investigators were a significant reduction in inpatient visits, high patient satisfaction rates, and most importantly, timely care and referral of the patients requiring in-person evaluation. 44 , 52 , 55 Hendrickson et al.…”

“…Fifty-nine articles met the inclusion criteria and were considered for the analysis. 9 , 10 , 11 , 12 , 13 , 14 , 15 , 16 , 17 , 18 , 19 , 20 , 21 , 22 , 23 , 24 , 25 , 26 , 27 , 28 , 29 , 30 , 31 , 32 , 33 , 34 , 35 , 36 , 37 , 38 , 39 , 40 , 41 , 42 , 43 , 44 , 45 , 46 , 47 , 48 , 49 , 50 , 51 , 52 , 53 , 54 , 55 , 56 , 57 , 58 , 59 , 60 , 61 , 62 , 63 , 64 , 65 , 66 , 67 The excluded thirty-four papers were editorials, letters, duplicate entries, and articles with no discussion on telemedicine even in the full text ( Figure 1 ). The monthly contributions trend of the orthopaedic telemedicine-related articles is shown in Figure 2 .…”

Attitudes toward bone health among rural‐dwelling veterans identified as at risk of fracture: a qualitative analysis

“…Eligibility criteria for receiving outreach from the RBHT included: rural residence, evidence of regular Veterans Health Administration (VHA) primary care, renal sufficiency for treatment, and age‐related risk. ( 10 ) We used electronic health record data to ascertain patient completion of DXA and initiation of osteoporosis medications when indicated, in order to recruit patients in each of our subgroups. Target sample size was set at 75 overall, 25 per group, consistent with typical qualitative approaches to achieving data saturation (20–30 participants in a heterogeneous sample, and five participants per subgroup).…”

“…Although implementation of the RBHT was determined to be feasible, less than half of eligible Veterans accept care from RBHT. ( 9,10 ) Given that this clinic design reduces cost and travel barriers, the objective of this study was to identify other factors limiting engagement in bone health care from the perspective of patients with known untreated risk. In this article we report our analysis of qualitative interviews with Veterans who declined care from the clinic, those who accepted a DXA but declined to initiate medications, and those who completed a DXA and started pharmacotherapy.…”

Engagement in Primary Prevention Program among Rural Veterans With Osteoporosis Risk

“…Our prior work demonstrated implementation feasibility from the perspective of VHA primary care providers (PCPs) and patients, with a quarter of identified rural veterans accepting DXA screening and 91% of those eligible choosing to initiate fracture risk–reducing therapies. ( 12 ) Qualitative interviews with veterans invited to enroll in BHT revealed the role of competing comorbidities and beliefs about perceived osteoporosis importance and susceptibility on patient decision making around DXA. ( 13 ) Patient medication decision making was found to stem from their desire to preserve of quality of life and maintain function and from concerns about side effects in the context of aging, physical limitations, or polypharmacy.…”