Predictors and outcomes of early adherence to the use of a home telehealth device by older veterans with heart failure.

OBJECTIVES: The present study examined home telehealth (HT) adherence, and its potential predictors and outcomes, in older Veterans with heart failure (HF) using the Health Buddy (Bosch Healthcare, Palo Alto, CA) device. SUBJECTS AND METHODS: This was a retrospective study using secondary data from the Department of Veterans Affairs (VA) databases, describing adherence rates and patterns in the first 90 days after enrollment in 248 older Veterans with HF enrolled in the VA HT Programs using the Health Buddy at five medical centers in Southern California and Nevada, between June 1, 2006 and June 1, 2008. Adherence to the use of Health Buddy was defined as the number of days the patient completed an HT session over different time frames during the study period. RESULTS: Significant differences occurred between average adherence across all three 30-day time frame increments, with adherence decreasing over time. Despite the use of standardized VA HT protocols and equipment, the department in which the HT program was embedded was a consistent significant predictor of patient adherence in all time frames, with odds ratios of 2.2-4.0 for the department with the consistent best adherence versus that with the worse adherence (confidence intervals varying with the time frame, p<0.03). Increased co-morbidity burden was associated with decreased adherence only in the first 30 days after enrollment. In this short-term study, no relationship was found between adherence to the use of the Health Buddy and outcomes. CONCLUSIONS: Program and patient characteristics warrant further study as potential predictors of HT device adherence. Additional research is also needed to further examine the relationships between HT device adherence and various outcomes.

Barriers in the management of glucocorticoid-induced osteoporosis.

OBJECTIVE: To determine present practice for the management of glucocorticoid-induced osteoporosis (GIOP) in veterans; to characterize provider knowledge, beliefs, and practice behaviors regarding management of GIOP; and to identify potential barriers and interventions in the management of GIOP. METHODS: To characterize current management of GIOP in an academic veterans administration medical center, we conducted a retrospective chart review of 100 patients who were prescribed a 90-day supply of prednisone. To assess clinicians' knowledge of GIOP clinical guidelines and perceptions of GIOP management, primary care clinicians and subspecialists completed a questionnaire and participated in focus groups. RESULTS: Chart review revealed that only 32 of 100 patients receiving long-term glucocorticoid treatment underwent bone mineral density testing, and only 32 patients were prescribed the recommended calcium supplements. Of the 23 providers who completed the questionnaire and participated in the focus groups, 4 correctly identified both the dose and duration of glucocorticoid use at which GIOP prevention measures should be instituted. Common GIOP management barriers cited by participants were lack of knowledge, having limited time during the clinic visit to address all problems, patient nonadherence, and system problems. The most commonly mentioned potential interventions were the use of computerized clinical reminders and patient education. CONCLUSION: Clinicians frequently do not follow recommended guidelines for the management of GIOP. Improving the management of GIOP will likely require a fundamental redesigning of care processes for this disorder in order to overcome provider, patient-related, and system barriers.