title: Geographic scope and accessibility of a centralized, electronic consult program for patients with recent fracture.
abstract: BACKGROUND
  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.
  
  
  METHODS
  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).
  
  
  RESULTS
  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).
  
  
  CONCLUSIONS
  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.
authors.affiliation: Durham VAMC, Durham, North Carolina, USA. r.lee@duke.edu.
authors.forename: Richard H
authors.initials: RH
authors.lastname: Lee
authors.affiliation: Durham VAMC, Durham, North Carolina, USA. megan.pearson@va.gov.
authors.forename: Megan
authors.initials: M
authors.lastname: Pearson
authors.affiliation: Durham VAMC, Durham, North Carolina, USA. kenneth.lyles@dm.duke.edu.
authors.forename: Kenneth W
authors.initials: KW
authors.lastname: Lyles
authors.affiliation: Durham VAMC, Durham, North Carolina, USA. patricia.jenkins2@va.gov.
authors.forename: Patricia W
authors.initials: PW
authors.lastname: Jenkins
authors.affiliation: Durham VAMC, Durham, North Carolina, USA. cathleen.colonemeric@dm.duke.edu.
authors.forename: Cathleen
authors.initials: C
authors.lastname: Colon-Emeric
mesh_terms: D057286:Electronic Health Records / Q000706:statistics & numerical data; D005260:Female; D006801:Humans; D008297:Male; D008403:Mass Screening / Q000706:statistics & numerical data*; D058866:Osteoporotic Fractures / Q000453:epidemiology* / Q000534:rehabilitation; D017063:Outcome Assessment, Health Care; D010818:Practice Patterns, Physicians'; D012017:Referral and Consultation / Q000706:statistics & numerical data*; D019114:Remote Consultation / Q000706:statistics & numerical data*; D012424:Rural Population / Q000706:statistics & numerical data*
keywords: Administrator; Aged Care; Endocrinology; Geriatrics; Health Promotion; Health Service reform; Informatics; Medical; North America; Nursing; Primary Health Care; Rheumatology/Orthopaedics