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

Archives of Osteoporosis volume 16, Article number: 27 (2021) Cite this article

A Correction to this article was published on 07 April 2021

This article has been updated

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.

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Fig. 1

Change history

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Acknowledgments

We thank the VA personnel who participated in the qualitative aspects of this study and Anna Lynch, who assisted with research coordination and IRB documentation. This work was supported by the grants from the Department of Veterans Affairs Office of Rural Health Veterans Rural Health Resource Center-Iowa City (10707 to SLS) and Salt Lake City (7359 to KM), and by the VA Specialty Care Services Center of Innovation. SL Solimeo and M Steffen receive support from the Center for Comprehensive Access & Delivery Research and Evaluation (CADRE), Department of Veterans Affairs, Iowa City VA Health Care System, Iowa City, IA (Award # CIN 13-412). SL Solimeo also received support from VA HSR&D (Award # CDA 13-272) [add other funding if need be]. The US Department of Veterans Affairs had no role in the analysis or interpretation of data or the decision to report these data in a peer-reviewed journal. The views expressed in this article are those of the authors and do not necessarily reflect the position or policy of the Department of Veterans Affairs or the US government.

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.

Funding

This work was supported by the grants from the Department of Veterans Affairs Office of Rural Health Veterans Rural Health Resource Center-Iowa City (10707 to SLS) and Salt Lake City (7359 to KM). SL Solimeo and M Steffen receive support from the Center for Comprehensive Access & Delivery Research and Evaluation (CADRE), Department of Veterans Affairs, Iowa City VA Health Care System, Iowa City, IA (Award # CIN 13-412). SL Solimeo also receives support from VA HSR&D (Award # CDA 13-272). The US Department of Veterans Affairs had no role in the analysis or interpretation of data or the decision to report these data in a peer-reviewed journal. The views expressed in this article are those of the authors and do not necessarily reflect the position or policy of the Department of Veterans Affairs or the US government.

Author information

Affiliations

  1. VA Office of Rural Health, Veterans Rural Health Resource Center-Salt Lake City (VRHRC-SLC), Salt Lake City, UT, USA

    Karla L. Miller, Melissa J. Steffen, Zachary L. Anderson, Shardool Patel & Janiel Green

  2. Department of Internal Medicine, Rheumatology Section, Veterans Affairs Salt Lake City Health Care System, Salt Lake City, UT, USA

    Karla L. Miller & Grant Cannon

  3. Division of Rheumatology, University of Utah School of Medicine, Salt Lake City, UT, USA

    Karla L. Miller

  4. VA Office of Rural Health, Veterans Rural Health Resource Center-Iowa City (VRHRC-IC), Salt Lake City, UT, USA

    Melissa J. Steffen, Kimberly D. McCoy, Aaron T. Seaman, Shylo Wardyn & Samantha L. Solimeo

  5. Comprehensive Access & Delivery Research and Evaluation (CADRE), Primary Care Analytics Team Iowa City (PCAT-IC), Department of Veterans Affairs, CADRE, Iowa City VA HCS, Research 152, 601 Highway 6 West, Iowa City, IA, 52246, USA

    Melissa J. Steffen, Kimberly D. McCoy & Samantha L. Solimeo

  6. Division of Genera l Internal Medicine, Department of Internal Medicine, University of Iowa Carver College of Medicine, 200 Hawkins Drive, 52242, Iowa City, IA, USA

    Aaron T. Seaman & Samantha L. Solimeo

  7. Department of Anesthesiology, Veterans Affairs Salt Lake City Health Care System, Salt Lake City, UT, USA

    Zachary L. Anderson & Shardool Patel

  8. Division of Epidemiology, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, UT, USA

    Shardool Patel

  9. Veterans Affairs Salt Lake City Health Care System, Salt Lake City, UT, USA

    Janiel Green

Authors
  1. Karla L. Miller
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  2. Melissa J. Steffen
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  4. Grant Cannon
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  5. Aaron T. Seaman
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  7. Shardool Patel
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  8. Janiel Green
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  9. Shylo Wardyn
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  10. Samantha L. Solimeo
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Contributions

KM drafted the manuscript. SLS designed the study and contributed to qualitative data analysis. SW contributed to qualitative data collection and literature review. ATS and MJS contributed to the qualitative data collection, analysis, and writing. ZLA, KDM, and SP contributed to the clinical informatics operations of BHT and quantitative data collection. KM, JG, and GC contributed to the quantitative analysis and reporting on the BHT clinical model. All named authors have made substantive contributions to manuscript preparation.

Corresponding author

Correspondence to Karla L. Miller.

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Miller, K.L., Steffen, M.J., McCoy, K.D. et al. Delivering fracture prevention services to rural US veterans through telemedicine: a process evaluation. Arch Osteoporos 16, 27 (2021). https://doi.org/10.1007/s11657-021-00882-0

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Keywords

  • Primary prevention
  • Fracture
  • Telehealth
  • Rural