Lee Richard H, Pearson Megan, Lyles Kenneth W, Jenkins Patricia W, Colon-Emeric Cathleen
Durham VAMC, Durham, North Carolina, USA.
Rural Remote Health. 2016 Jan-Mar;16(1):3440. Epub 2016 Jan 7.
Low-trauma, osteoporotic fractures among older men are associated with a significant increase in morbidity and mortality. Despite effective therapies for osteoporosis, several studies have demonstrated that management and treatment after a low trauma fracture remains inadequate, especially among men. Fracture liaison services have been shown to significantly improve osteoporosis evaluation and treatment. However, such programs may be less feasible and accessible in rural areas, with limited availability of specialty services. The study objective was to evaluate a centralized, electronic consult (e-consult) program serving multiple veterans administration medical centers, including the geographic scope, accessibility to rural patients, and impact on osteoporosis evaluation and treatment.
The e-consult program identified veterans with potential osteoporotic fractures from inpatient and outpatient encounter data, based on ICD9 diagnosis codes (800-829) from the central data warehouse. The medical record of an eligible patient was reviewed by a bone health specialist, and an e-consult note was sent to the patient's primary care provider that specified guideline-based recommendations for further evaluation and management. A bone health nurse liaison then coordinated the ordering and follow-up of laboratory and bone density assessment, osteoporosis education (eg medication administration and side effects, calcium and vitamin D supplementation, falls prevention, and exercise), and adherence follow-up via telephone. Patients were identified as living in a rural area if their ZIP code was not in a US Census Bureau-defined urban area (ie population density greater than approximately 386 persons per square kilometer/1000 persons per square mile).
From October 2013 to September 2014, 2775 fractures were identified by a fracture-related ICD9 code. After exclusion of those aged less than 50 years and high-trauma fractures, 321 e-consults were completed. Of those, 171 (53.3%) were for patients residing in a rural or highly rural area. The e-consult program saved a total of 19 187 km (11 917 miles) of travel. For rural patients, bisphosphonates were recommended 51 times, with 33 (64.7%) ordered, and bone density assessments were recommended 109 times with 79 (72.5%) ordered. A nurse liaison significantly improved bisphosphonate ordering (from 39.7% to 75.8%) and bone mineral density testing completion rates (from 37.1% to 63.0%), for both rural and urban patients (p<0.01).
A centralized e-consult program can effectively and efficiently provide specialty bone health services to patients residing in rural areas. The program was able to save substantial travel time and increase the rates of evaluation and treatment for osteoporosis.
老年男性低创伤性骨质疏松性骨折与发病率和死亡率的显著增加相关。尽管有有效的骨质疏松症治疗方法，但多项研究表明，低创伤骨折后的管理和治疗仍然不足，尤其是在男性中。骨折联络服务已被证明能显著改善骨质疏松症的评估和治疗。然而，在农村地区，这类项目可能不太可行且难以获得，专科服务有限。本研究的目的是评估一个为多个退伍军人管理医疗中心服务的集中式电子咨询（e-consult）项目，包括地理范围、农村患者的可及性以及对骨质疏松症评估和治疗的影响。
e-consult项目根据中央数据仓库中的ICD9诊断代码（800 - 829），从住院和门诊就诊数据中识别出可能患有骨质疏松性骨折的退伍军人。一名骨健康专家会审查符合条件患者的病历，并向患者的初级保健提供者发送一份电子咨询记录，其中指定了基于指南的进一步评估和管理建议。然后，一名骨健康护士联络人会协调实验室检查和骨密度评估的安排及随访、骨质疏松症教育（如药物服用和副作用、钙和维生素D补充、预防跌倒和锻炼），并通过电话进行依从性随访。如果患者的邮政编码不在美国人口普查局定义的城市区域（即人口密度大于约每平方公里386人/每平方英里1000人），则被确定为居住在农村地区。
2013年10月至2014年9月，通过与骨折相关的ICD9代码识别出2775例骨折。排除年龄小于50岁的患者和高创伤骨折后，完成了321次电子咨询。其中，171例（53.3%）是针对居住在农村或高度农村地区的患者。e-consult项目总共节省了19187公里（11917英里）的行程。对于农村患者，推荐双膦酸盐51次，其中33次（64.7%）被开出医嘱；推荐骨密度评估109次，其中79次（72.5%）被开出医嘱。一名护士联络人显著提高了农村和城市患者双膦酸盐的开出医嘱率（从39.7%提高到75.8%）和骨密度检测完成率（从37.1%提高到63.0%）（p<0.01）。
一个集中式的电子咨询项目可以有效且高效地为居住在农村地区的患者提供专科骨健康服务。该项目能够节省大量出行时间，并提高骨质疏松症的评估和治疗率。
