Category: Federal Forum Posters
Purpose: Osteoporosis is a silent, treatable, chronic condition that is underdiagnosed and undertreated both nationally and within the Veteran Affairs (VA) Healthcare system. Men account for 29 percent of fragility fractures, 25 percent of total costs, and have a significantly higher mortality rate than women, with one in three older men dying within one year after a hip fracture. The delivery of osteoporosis services is sub-optimal nationally and throughout the VA and particularly poor for rural Veterans. To meet this critical need, we developed a Rural Bone Health Team (BHT), to provide efficient, evidence-based primary prevention osteoporosis services to rural Veterans.
Methods: Adapted from the Patient-Aligned Care Team (PACT) model, the Rural BHT consists of a physician-led team and includes two program support assistants, two clinical nurse educators, and two APPs, including a Clinical Pharmacy Specialist. To identify Veterans with osteoporosis risk factors, we operationalized evidence-based screening guidelines into queries to the VHA Corporate Data Warehouse (CDW), a repository of medical and pharmacy records. Captured risk factors included Osteoporosis Self-assessment Tool (OST) score, sex, age, and/or chronic exposure to high risk medications. Veterans at risk were sent enrollment letters, invited to receive care by the BHT, and on acceptance evaluated by clinical nurse educators via standard protocols. As appropriate, enrolled Veterans received Dual-energy X-ray Absorptiometry (DXA) scans, education on bone healthy lifestyle, additional fracture risk assessment, and triage for treatment if identified as either osteoporosis or high-risk osteopenia. Advanced practice providers, then evaluated the Veteran’s need for osteoporosis pharmacotherapy, performed laboratory evaluations for secondary causes of bone loss, discussed risks/benefits of pharmacological therapies, and when indicated, initiated pharmacological therapy and monitored therapy at scheduled intervals. For this study, we included Veterans contacted by the Rural BHT between 12/1/2016 and 02/01/2018. A non-experimental cohort design was utilized to compare the proportion of osteoporosis screening and treatment in Veterans choosing to participate and those who did not participate, both before and after the establishment of the BHT.
Results: During the first 15 months of implementation, the Rural BHT contacted 3,582 Veterans, with 1,241 (34.6 percent; 95 percent CI, 33.10 to 36.22) Veterans accepting enrollment and 1,132 (91.2 percent; 95 percent CI, 89.51 to 92.67) enrollees completing a DXA scan. Of those participating Veterans, 318 (25.6 percent; 95 percent CI, 23.27 to 28.13) met criteria for and accepted pharmacological therapy. Veterans choosing to participate in the Rural BHT were significantly more likely to complete a DXA scan (91.2 versus 2.6 percent, P less than 0.0001) and to receive pharmacological therapy (25.6 versus 2.4 percent, P less than 0.0001) than those choosing not to participate.
Conclusion: Enrollment in the Rural BHT significantly increases the likelihood that rural Veterans will receive appropriate screening and treatment for osteoporosis. This model for the delivery of primary prevention services for osteoporosis provides unique processes and procedures without adding workload to the primary care team and could potentially be adapted to provide other preventative services, as well as instituted in other care settings outside the VA. Due to their proven benefit at improving patient outcomes in chronic disease management, Clinical Pharmacists are highly qualified and easily incorporated into this model of care.
Zachary Anderson– Clinical Pharmacy Specialist, Department of Veterans Affairs, Salt Lake City, UT