Models of Primary Osteoporosis Screening in Male Veterans

目前退伍军人事务部副部长指南建议对高危男性进行初级骨质疏松症筛查 降低与骨质疏松性骨折相关的发病率、死亡率和成本。然而，我们最近在一项 国家退伍军人健康管理局对400多万名男性的队列研究表明，原发性骨质疏松症 目前正在实施的筛查并没有使大多数老年退伍军人受益，因为目标确定和 较低的后续治疗和依从率。 这项应用的总体目标是确定两种新的原发性骨质疏松症模型 与常规护理相比，筛查降低了老年男性退伍军人的骨折风险因素。我们建议成立一个小组 PACTS的随机试验：1)常规护理；2)具有工具和流程的PACT实践管理模式 促进PACT提供者的筛查和遵守活动；3)骨健康服务(BHS)筛查 筛选和遵守活动由一个集中的专家团队管理的模式。两者都是新的 模型包括使用适用于模型的基于证据的方法的健壮遵守组件 结构。具体目的是：1)比较这两种新的筛查模式与常规护理的影响 患者级别的结果与骨折发生率密切相关(筛查的合格比例、比例 符合接受骨质疏松症药物治疗的标准，以及药物依从性)；2)确定 两种新的筛查模式对提供者和设施级结果的影响，包括DXA的变化 数量、代谢性骨病诊疗量的变化、PACT提供者的时间和满意度；以及3) 确定两种新的筛查模式对卫生系统和政策结果的影响(马尔科夫 基于VA全国骨折数据的每质量调整寿命年筛查计划成本模型，结果 来自目标1和目标2，并出版了生活质量评估)。 我们建议对65-85岁的男性退伍军人进行务实组随机试验，以满足当前退伍军人的需求 初级骨质疏松症筛查指南。PACT团队将随机分为3组干预 小组：常规护理(对照)；契约实践管理模式；或集中式骨健康服务(BHS) 模特。所有符合条件的患者在随机试验中的结果将由蒙面调查人员评估 在基线和2年时通过电子病历进行分组分配。分析将考虑3个级别的集群和 相关协变量。预期结果是两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。下一步包括将首选模型传播到 通过集中筛选服务(BHS)或与新的 绩效指标和工具包(PACT实践管理)。 据我们所知，这将是第一次对老年男性进行骨质疏松症筛查的随机试验。这 应用程序直接解决HSR&D高优先级研究主题，包括改进药物和 慢性病的行为管理；提高安全性/价值；促进高安全性的系统方法 价值护理；以及创新地使用卫生信息技术，以改进诊断，减少低价值护理， 并提高医疗质量和价值。此应用程序中提出的新模型从根本上进行了测试 不同的筛查范例(个人执业管理方法与集中的卫生系统 方法)，并被设计为临床上可行的快速传播在VHA，如果被发现是有效的。

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.