Aaron T Seaman1,2,3, Melissa J A Steffen4,5,6, Jennifer M Van Tiem4,5, Shylo Wardyn4,5, Xiomara Santana4,5, Karla L Miller7,8,9, Samantha L Solimeo4,5,10,6. 1. VA Office of Rural Health Veterans Rural Health Resource Center- Iowa City (VRHRC-IC), Department of Veterans Affairs, Iowa City VA Health Care System, Iowa City, IA, USA. aaron-seaman@uiowa.edu. 2. Center for Access and Delivery Research and Evaluation (CADRE), Department of Veterans Affairs, Iowa City VA Health Care System, Iowa City, IA, USA. aaron-seaman@uiowa.edu. 3. Department of Internal Medicine, Carver College of Medicine, University of Iowa, 200 Hawkins Drive, Iowa City, IA, 280-B MRF, USA. aaron-seaman@uiowa.edu. 4. VA Office of Rural Health Veterans Rural Health Resource Center- Iowa City (VRHRC-IC), Department of Veterans Affairs, Iowa City VA Health Care System, Iowa City, IA, USA. 5. Center for Access and Delivery Research and Evaluation (CADRE), Department of Veterans Affairs, Iowa City VA Health Care System, Iowa City, IA, USA. 6. Primary Care Analytics Team Iowa City (PCAT-IC), Department of Veterans Affairs, Iowa City VA Health Care System, Iowa City, IA, USA. 7. VA Office of Rural Health Veterans Rural Health Resource Center-Salt Lake City (VRHRC-SLC), Salt Lake City, UT, USA. 8. Department of Internal Medicine, Rheumatology Section, Veterans Affairs Salt Lake City Health Care System, Salt Lake City, UT, USA. 9. Division of Rheumatology, University of Utah School of Medicine, Salt Lake City, UT, USA. 10. Department of Internal Medicine, Carver College of Medicine, University of Iowa, 200 Hawkins Drive, Iowa City, IA, 280-B MRF, USA.
Abstract
We conducted in-depth, semi-structured interviews with clinicians involved in bone health care to understand the challenges of implementing and sustaining bone health care interventions. Participants identified individual- and system-level challenges to care delivery, implementation, and sustainment. We discuss opportunities to address challenges through a commitment to relationship- and infrastructure-building support. PURPOSE: Osteoporosis and fracture-related sequalae exact significant individual and societal costs; however, identification and treatment of at-risk patients are troublingly low, especially among men. The purpose of this study was to identify challenges to implementing and sustaining bone health care delivery interventions in the Veterans Health Administration. METHODS: We conducted interviews with endocrinologists, pharmacists, primary care physicians, rheumatologists, and orthopedic surgeons involved in bone health care (n = 20). Interviews were audio-recorded and transcribed verbatim. To determine thematic domains, we engaged in an iterative, qualitative content analysis of the transcripts. RESULTS: Participants reported multiple barriers to delivering bone health care and to sustaining the initiatives designed to address delivery challenges. Challenges of bone health care delivery existed at both the individual level-a lack of patient and clinician awareness and competing clinical demands-and the system level-multiple points of entry to bone health care, a dispersion of patient management, and guideline variability. To address the challenges, participants developed initiatives targeting the identification of at-risk patients, clinician education, increasing communication, and care coordination. Sustaining initiatives, however, was challenged by staff turnover and the inability to achieve and maintain priority status for bone health care. CONCLUSION: The multiple, multi-level barriers to bone health care affect both care delivery processes and sustainment of initiatives to improve those processes. Barriers to care delivery, while tempered by intervention, are entangled and persist alongside sustainment challenges. These challenges require relationship- and infrastructure-building support.
We conducted in-depth, semi-structured interviews with clinicians involved in bone health care to understand the challenges of implementing and sustaining bone health care interventions. Participants identified individual- and system-level challenges to care delivery, implementation, and sustainment. We discuss opportunities to address challenges through a commitment to relationship- and infrastructure-building support. PURPOSE: Osteoporosis and fracture-related sequalae exact significant individual and societal costs; however, identification and treatment of at-risk patients are troublingly low, especially among men. The purpose of this study was to identify challenges to implementing and sustaining bone health care delivery interventions in the Veterans Health Administration. METHODS: We conducted interviews with endocrinologists, pharmacists, primary care physicians, rheumatologists, and orthopedic surgeons involved in bone health care (n = 20). Interviews were audio-recorded and transcribed verbatim. To determine thematic domains, we engaged in an iterative, qualitative content analysis of the transcripts. RESULTS: Participants reported multiple barriers to delivering bone health care and to sustaining the initiatives designed to address delivery challenges. Challenges of bone health care delivery existed at both the individual level-a lack of patient and clinician awareness and competing clinical demands-and the system level-multiple points of entry to bone health care, a dispersion of patient management, and guideline variability. To address the challenges, participants developed initiatives targeting the identification of at-risk patients, clinician education, increasing communication, and care coordination. Sustaining initiatives, however, was challenged by staff turnover and the inability to achieve and maintain priority status for bone health care. CONCLUSION: The multiple, multi-level barriers to bone health care affect both care delivery processes and sustainment of initiatives to improve those processes. Barriers to care delivery, while tempered by intervention, are entangled and persist alongside sustainment challenges. These challenges require relationship- and infrastructure-building support.
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