Models of Primary Osteoporosis Screening in Male Veterans

男性退伍军人原发性骨质疏松症筛查模型

• 批准号: 10640049
• 负责人: CATHLEEN S COLON-EMERIC
• 金额: --
• 依托单位: DURHAM VA MEDICAL CENTER
• 依托单位国家: 美国
• 财政年份: 2019
• 资助国家: 美国
• 起止时间: 2019-08-01 至 2024-07-31
• 项目状态: 已结题
• 来源: https://reporter.nih.gov/project-details/10640049
• 关键词: Address; Adherence; Age; Behavioral; Caring; Chronic Disease; Clinic; Clinical; Collection; Data; Diagnosis; Electronic Health Record; Fracture; Guidelines; Health Policy; Health Services; Health system; Individual; Intervention; Learning; Masks; Measures; Metabolic Bone Diseases; Methods; Modeling; Morbidity - disease rate; Osteoporosis; Outcome; Patient Selection; Patients; Performance; Pharmaceutical Preparations; Policies; Policy Maker; Population Research; Practice Management; Prevention; Primary Health Care; Process; Provider; Publishing; Quality of life; Quality-Adjusted Life Years; Randomized; Regimen; Research Personnel; Research Priority; Resources; Risk; Risk Factors; Roentgen Rays; Safety; Selection for Treatments; Service delivery model; Source; Specific qualifier value; Structure; System; Techniques; Testing; Time; Veterans; Veterans Health Administration; Work; adherence rate; aged; base; bone; bone health; care costs; cohort; cost; cost effectiveness; design; disability; evidence base; fracture risk; group intervention; health care quality; health care service utilization; health information technology; high risk; improved; innovation; male; markov model; medication compliance; meetings; men; mortality; older men; osteoporosis with pathological fracture; pain reduction; premature; prevent; program costs; programs; randomized trial; relative cost; relative effectiveness; satisfaction; screening; screening guidelines; screening program; screening services; time use; tool; treatment adherence; treatment as usual; wasting

Current VA Undersecretary Guidelines recommend primary osteoporosis screening for at-risk men to reduce the morbidity, mortality, and cost associated with osteoporotic fractures. However, our recent work in a national Veterans Health Administration cohort of over 4,000,000 men demonstrated that primary osteoporosis screening as it is currently operationalized does not benefit most older Veterans due to inefficient targeting and low subsequent treatment and adherence rates. The overall objective of this application is to determine whether 2 new models of primary osteoporosis screening reduce fracture risk factors in older male Veterans compared to usual care. We propose a group randomized trial of PACTs to: 1) usual care; 2) a PACT practice management model with tools and processes to facilitate screening and adherence activities by PACT providers; 3) a Bone Health Service (BHS) screening model in which screening and adherence activities are managed by a centralized expert team. Both new models include a robust adherence component utilizing evidence-based methods appropriate for the model structure. The specific aims are to: 1) compare the impact of these 2 new screening models vs. usual care on patient-level outcomes strongly associated with fracture rates (eligible proportion screened, proportion meeting treatment criteria who receive osteoporosis medications, and medication adherence); 2) determine the impact of the 2 new screening models on provider and facility-level outcomes including change in DXA volume, change in metabolic bone disease clinic volume, and PACT provider time and satisfaction; and 3) determine the impact of the 2 new screening models on health system and policy outcomes (Markov models of screening program cost per quality adjusted life year based on VA national fracture data, results from aims 1 and 2, and published quality of life estimates). We propose a pragmatic group randomized trial of male Veterans aged 65-85 years meeting current VA Undersecretary primary osteoporosis screening guidelines. PACT teams will be randomized into 3 intervention groups: usual care (control); a PACT practice management model; or a centralized Bone Health Service (BHS) model. Outcomes for all eligible patients within randomized PACTs will be assessed by investigators masked to group assignment via EMR at baseline and 2 years. Analyses will account for 3-levels of clustering and relevant covariates. Expected results are the relative effectiveness and cost-effectiveness of 2 new models of osteoporosis screening and adherence promotion. Next steps include dissemination of the preferred model to a wider array of facilities via centralization of screening services (BHS) or Learning Collaborative with new performance metrics and toolkits (PACT practice management). To our knowledge this would be the first randomized trial of osteoporosis screening in older men. This application directly addresses HSR&D High Priority Research topics including improving medication and behavioral management for chronic disease; improving safety/value; system approaches to promoting high- value care; and innovative use of health information technology to improve diagnosis, reduce low-value care, and increase health care quality and value. The new models proposed in this application test fundamentally different screening paradigms (an individual practice management approach vs. a centralized health system approach) and are designed to be clinically feasible for rapid dissemination across VHA if found to be effective.

当前的VA副部长指南建议对高危男性进行主要骨质疏松症筛查至 降低与骨质疏松性骨折相关的发病率，死亡率和成本。但是，我们最近的工作 全国退伍军人卫生管理局队列超过4,000,000名，证明了原发性骨质疏松症 由于目前正在运营的筛查，因此由于目标效率低下而受益于大多数老年退伍军人 随后的治疗和依从率低。 该应用程序的总体目的是确定两种新的原发性骨质疏松症的新模型 与通常的护理相比，筛查减少了老年男性退伍军人的断裂危险因素。我们提出了一个小组 条约的随机试验至：1）常规护理； 2）具有工具和流程的契约实践管理模型 促进公约提供者的筛查和依从活动； 3）骨骼健康服务（BHS）筛查 筛查和依从性活动的模型由集中的专家团队管理。两者都是新的 模型包括使用适合模型的循证方法的强大辅助组件 结构。具体目的是：1）比较这两个新筛选模型与通常的护理对 患者水平的结果与断裂率密切相关（符合条件的比例筛选，比例 满足接受骨质疏松药物和药物依从性的治疗标准； 2）确定 两种新筛查模型对提供商和设施级别的结果的影响，包括DXA的变化 体积，代谢骨病诊所体积的变化以及PACT提供者的时间和满意度； 3） 确定两种新筛查模型对卫生系统和政策成果的影响（马尔可夫 根据VA国家断裂数据，结果，筛查计划的模型每年调整质量调整的生活年度成本，结果 来自目标1和2，并发布了生活质量估计）。 我们提出了一个65-85岁的男性退伍军人的务实团体随机试验 副秘书原发性骨质疏松筛查指南。协定团队将被随机分为3干预 小组：通常的护理（控制）；协议实践管理模型；或集中骨健康服务（BHS） 模型。随机协定中所有合格患者的结果将由掩盖的研究者评估 通过基线和2年通过EMR进行分组。分析将占聚类的3级和 相关的协变量。预期结果是2种新模型的相对有效性和成本效益 骨质疏松症筛查和依从性促进。下一步包括将优选模型传播到 通过集中筛查服务（BHS）或与新的合作进行合作，设施更广泛 绩效指标和工具包（PACT实践管理）。 据我们所知，这将是老年男性骨质疏松症筛查的首次随机试验。这 申请直接解决了HSR＆D高优先研究主题，包括改善药物和 慢性病的行为管理；提高安全/价值；促进高级的系统方法 价值护理；以及对健康信息技术的创新使用来改善诊断，减少低价值护理， 并提高医疗保健质量和价值。本申请测试中提出的新模型从根本上提出了 不同的筛选范例（个人实践管理方法与集中卫生系统 方法），如果发现有效，则设计在临床上可用于跨VHA的快速传播。