Impact of 3 Months of Supervised Exercise on Function by Arthritis Status

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Impact of 3 Months of Supervised Exercise on Function by Arthritis Status

Author(s)
Lauren M. Abbate, MD, PhD
Kelli D. Allen, PhD
P. Michael Ho, MD, PhD
Steven C. Castle, MD
Cathy C. Lee, MD
Leslie I. Katzel, MD, PhD
Jamie Giffuni, MA
Teresa Kopp, MBA, PT
Michelle McDonald, BS, OTR/L
Megan Pearson, MA
Richard Sloane, MPH
Vanessa Richardson, MS
Katherine S. Hall, PhD, MS
Miriam C. Morey, PhD

About half of US adults aged ≥ 65 years report arthritis, and of those, 44% have an arthritis-attributable activity limitation.1,2 Arthritis is a significant health issue for veterans, with veterans reporting higher rates of disability compared with the civilian population.3

Osteoarthritis (OA) is the most common type of arthritis.4 Among individuals aged ≥ 40 years, the incidence of OA is nearly twice as high among veterans compared with civilians and is a leading cause of separation from military service and disability.5,6 OA pain and disability have been shown to be associated with increases in health care and medication use, including opioids, nonsteroidal anti-inflammatory medications, and muscle relaxants.7,8 Because OA is chronic and has no cure, safe and effective management strategies—such as exercise— are critical to minimize pain and maintain physical function.9

Exercise can reduce pain and disability associated with OA and is a first-line recommendation in guidelines for the treatment of knee and hip OA.9 Given the limited exercise and high levels of physical inactivity among veterans with OA, there is a need to identify opportunities that support veterans with OA engaging in regular exercise.

Gerofit, an outpatient clinical exercise program available at 30 Veterans Health Administration (VHA) sites, may provide an opportunity for older veterans with arthritis to engage in exercise.10 Gerofit is specifically designed for veterans aged ≥ 65 years. It is not disease-specific and supports older veterans with multiple chronic conditions, including OA. Veterans aged ≥ 65 years with a referral from a VA clinician are eligible for Gerofit. Those who are unable to perform activities of daily living; unable to independently function without assistance; have a history of unstable angina, proliferative diabetic retinopathy, oxygen dependence, volatile behavioral issues, or are unable to work successfully in a group environment/setting; experience active substance abuse, homelessness, or uncontrolled incontinence; and have open wounds that cannot be appropriately dressed are excluded from Gerofit. Exercise sessions are held 3 times per week and last from 60 to 90 minutes. Sessions are supervised by Gerofit staff and include personalized exercise prescriptions based on functional assessments. Exercise prescriptions include aerobic, resistance, and balance/flexibility components and are modified by the Gerofit program staff as needed. Gerofit adopts a functional fitness approach and includes individual progression as appropriate according to evidence-based guidelines, using the Borg ratings of perceived exertion. 11 Assessments are performed at baseline, 3 months, 6 months, and annually thereafter. Clinical staff conduct all assessments, including physical function testing, and record them in a database. Assessments are reviewed with the veteran to chart progress and identify future goals or needs. Veterans perform personalized self-paced exercises in the Gerofit group setting. Exercise prescriptions are continuously modified to meet individualized needs and goals. Veterans may participate continuously with no end date.

Participation in supervised exercise is associated with improved physical function and individuals with arthritis can improve function even though their baseline functional status is lower than individuals without arthritis. 12 In this analysis, we examine the impact of exercise on the status and location of arthritis (upper body, lower body, or both). Lower body arthritis is more common than upper body arthritis and lower extremity function is associated with increased ability to perform activities of daily living, resulting in independence among older adults.13,14 We also include upper body strength measures to capture important functional movements such as reaching and pulling.15 Among those who participate in Gerofit, the greatest gains in physical function occur during the initial 3 months, which tend to be sustained over 12 months.16 For this reason, this study focused on the initial 3 months of the program.

Older adults with arthritis may have pain and functional limitations that exceed those of the general older adult population. Exercise programs for older adults that do not specifically target arthritis but are able to improve physical function among those with arthritis could potentially increase access to exercise for older adults living with arthritis. Therefore, the purpose of this study was to determine whether change in physical function with participation in Gerofit for 3 months varies by arthritis status, including no arthritis, any arthritis, lower body arthritis, or both upper and lower body arthritis compared with no arthritis.

Methods

This is a secondary analysis of previously collected data from 10 VHA Gerofit sites (Ann Arbor, Baltimore, Greater Los Angeles, Canandaigua, Cincinnati, Miami, Honolulu, Denver, Durham, and Pittsburgh) from 2002 to 2019. Implementation data regarding the consistency of the program delivery at Gerofit expansion sites have been previously published.16 Although the delivery of Gerofit transitioned to telehealth due to COVID-19, data for this analysis were collected from in-person exercise sessions prior to the pandemic.17 Data were collected for clinical purposes. This project was part of the Gerofit quality improvement initiative and was reviewed and approved by the Durham Institutional Review Board as quality improvement.

Participants in Gerofit who completed baseline and 3-month assessments were included to analyze the effects of exercise on physical function. At each of the time points, physical functional assessments included: (1) usual gait speed (> 10 meters [m/s], or 10- meter walk test [10MWT]); (2) lower body strength (chair stands [number completed in 30 seconds]); (3) upper body strength (number of arm curls [5-lb for females/8-lb for males] completed in 30 seconds); and (4) 6-minute walk distance [6MWD] in meters to measure aerobic endurance). These measures have been validated in older adults.18-21 Arm curls were added to the physical function assessments after the 10MWT, chair stands, and 6MWD; therefore, fewer participants had data for this measure. Participants self-reported at baseline on 45 common medical conditions, including arthritis or rheumatism (both upper body and lower body were offered as choices). Self-reporting has been shown to be an acceptable method of identifying arthritis in adults.22

Descriptive statistics at baseline were calculated for all participants. One-way analysis of variance and X2 tests were used to determine differences in baseline characteristics across arthritis status. The primary outcomes were changes in physical function measures from baseline to 3 months by arthritis status. Arthritis status was defined as: any arthritis, which includes individuals who reported upper body arthritis, lower body arthritis, or both; and arthritis status individuals reporting either upper body arthritis, lower body arthritis, or both. Categories of arthritis for arthritis status were mutually exclusive. Two separate linear models were constructed for each of the 4 physical function measures, with change from baseline to 3 months as the outcome (dependent variable) and arthritis status, age, and body mass index (BMI) as predictors (independent variables). The first model compared any arthritis with no arthritis and the second model compared arthritis status (both upper and lower body arthritis vs lower body arthritis) with no arthritis. These models were used to obtain mean changes and 95% CIs in physical function and to test for differences in the change in physical function measures by arthritis status. Statistical analyses were performed using R software, version 4.0.3.

Results

Baseline and 3-month data were available for 737 Gerofit participants and included in the analysis. The mean (SD) age was 73.5 (7.1) years. A total of 707 participants were male (95.9%) and 322 (43.6%) reported some arthritis, with arthritis in both the upper and lower body being reported by 168 participants (52.2%) (Table 1). There were no differences in age, sex, or race for those with any arthritis compared with those with no arthritis, but BMI was significantly higher in those reporting any arthritis compared with no arthritis. For the baseline functional measures, statistically significant differences were observed between those with no arthritis and those reporting any arthritis for the 10MWT (P = .001), chair stands (P = .046), and 6MWD (P = .001), but not for arm curls (P = .77), with those with no arthritis performing better.

FDP04202100_T1

All 4 arthritis status groups showed improvements in each of the physical function measures over 3 months. For the 10MWT the mean change (95% CI) in gait speed (m/s) was 0.06 (0.04-0.08) for patients with no arthritis, 0.07 (0.05- 0.08) for any arthritis, 0.07 (0.04-0.11) for lower body arthritis, and 0.07 (0.04- 0.09) for both lower and upper body arthritis. For the number of arm curls in 30 seconds the mean change (95% CI) was 2.3 (1.8-2.8) for patients with no arthritis, 2.1 (1.5-2.6) for any arthritis, 2.0 (1.1-3.0) for lower body arthritis, and 1.9 (1.1-2.7) for both lower and upper body arthritis. For the number of chair stands in 30 seconds the mean change (95% CI) was 2.1 (1.7-2.4) for patients with no arthritis, 2.2 (1.8-2.6) for any arthritis, 2.3 (1.6-2.9), for lower body arthritis, and 2.0 (1.5-2.5) for both lower and upper body arthritis. For the 6MWD distance in meters the mean change (95% CI) was 21.5 (15.5-27.4) for patients with no arthritis, 28.6 (21.9-35.3) for any arthritis, 30.4 (19.5-41.3) for lower body arthritis, and 28.6 (19.2-38.0) for both lower and upper body arthritis (Figure).

FDP04202100_F1

We used 2 models to measure the change from baseline to 3 months for each of the arthritis groups. Model 1 compared any arthritis vs no arthritis and model 2 compared lower body arthritis and both upper and lower body arthritis vs no arthritis for each physical function measure (Table 2). There were no statistically significant differences in 3-month change in physical function for any of the physical function measures between arthritis groups after adjusting for age and BMI.

FDP04202100_T2

Discussion

Participation in Gerofit was associated with functional gains among all participants over 3 months, regardless of arthritis status. Older veterans reporting any arthritis had significantly lower physical function scores upon enrollment into Gerofit compared with those veterans reporting no arthritis. However, compared with individuals who reported no arthritis, individuals who reported arthritis (any arthritis, lower body arthritis only, or both lower and upper body arthritis) experienced similar improvements (ie, no statistically significant differences in mean change from baseline to follow-up among those with and without arthritis). This study suggests that progressive, multicomponent exercise programs for older adults may be beneficial for those with arthritis.

Involvement of multiple sites of arthritis is associated with moderate to severe functional limitations as well as lower healthrelated quality of life.23 While it has been found that individuals with arthritis can improve function with supervised exercise, even though their baseline functional status is lower than individuals without arthritis, it was not clear whether individuals with multiple joint involvement also would benefit.12 The results of this study suggest that these individuals can improve across various domains of physical function despite variation in arthritis location and status. As incidence of arthritis increases with age, targeting older adults for exercise programs such as Gerofit may improve functional limitations and health-related quality of life associated with arthritis.2

We evaluated physical function using multiple measures to assess upper (arm curls) and lower (chair stands, 10MWT) extremity physical function and aerobic endurance (6MWD). Participants in this study reached clinically meaningful changes with 3 months of participation in Gerofit for most of the physical function measures. Gerofit participants had a mean gait speed improvement of 0.05 to 0.07 m/s compared with 0.10 to 0.30 m/s, which was reported previously. 24,25 In this study, nearly all groups achieved the clinically important improvements in the chair stand in 30 seconds (2.0 to 2.6) and the 6MWD (21.8 to 59.1 m) that have been reported in the literature.24-26

The Osteoarthritis Research Society International recommends the chair stand and 6MWD performance-based tests for individuals with hip and knee arthritis because they align with patient-reported outcomes and represent the types of activities relevant to this population.27 The findings of this study suggest that improvement in these physical function measures with participation in exercise align with data from arthritis-specific exercise programs designed for wide implementation. Hughes and colleagues reported improvements in the 6MWD after the 8-week Fit and Strong exercise intervention, which included walking and lower body resistance training.28 The Arthritis Foundation’s Walk With Ease program is a 6-week walking program that has shown improvements in chair stands and gait speed.29 Another Arthritis Foundation program, People with Arthritis Can Exercise, is an 8-week course consisting of a variety of resistance, aerobic, and balance activities. This program has been associated with increases in chair stands but not gait speed or 6MWD.30,31

This study found that participation in a VHA outpatient clinical supervised exercise program results in improvements in physical function that can be realized by older adults regardless of arthritis burden. Gerofit programs typically require 1.5 to 2.0 dedicated full-time equivalent employees to run the program effectively and additional administrative support, depending on size of the program.32 The cost savings generated by the program include reductions in hospitalization rates, emergency department visits, days in hospital, and medication use and provide a compelling argument for the program’s financial viability to health care systems through long-term savings and improved health outcomes for older adults.33-36

While evidenced-based arthritis programs exist, this study illustrates that an exercise program without a focus on arthritis also improves physical function, potentially reducing the risk of disability related to arthritis. The clinical implication for these findings is that arthritis-specific exercise programs may not be needed to achieve functional improvements in individuals with arthritis. This is critical for under-resourced or exercise- limited health care systems or communities. Therefore, if exercise programming is limited, or arthritis-specific programs and interventions are not available, nonspecific exercise programs will also be beneficial to individuals with arthritis. Thus, individuals with arthritis should be encouraged to participate in any available exercise programming to achieve improvements in physical function. In addition, many older adults have multiple comorbidities, most of which improve with participation in exercise. 37 Disease-specific exercise programs can offer tailored exercises and coaching related to common barriers in participation, such as joint pain for arthritis.31 It is unclear whether these additional programmatic components are associated with greater improvements in outcomes, such as physical function. More research is needed to explore the benefits of disease-specific tailored exercise programs compared with general exercise programs.

Strengths and Limitations

This study demonstrated the effect of participation in a clinical, supervised exercise program in a real-world setting. It suggests that even exercise programs not specifically targeted for arthritis populations can improve physical function among those with arthritis.

As a VHA clinical supervised exercise program, Gerofit may not be generalizable to all older adults or other exercise programs. In addition, this analysis only included a veteran population that was > 95% male and may not be generalizable to other populations. Arthritis status was defined by self-report and not verified in the health record. However, this approach has been shown to be acceptable in this setting and the most common type of arthritis in this population (OA) is a painful musculoskeletal condition associated with functional limitations.4,22,38,39 Self-reported arthritis or rheumatism is associated with functional limitations.1 Therefore, it is unlikely that the results would differ for physician-diagnosed or radiographically defined OA. Additionally, the study did not have data on the total number of joints with arthritis or arthritis severity but rather used upper body, lower body, and both upper and lower body arthritis as a proxy for arthritis status. While our models were adjusted for age and BMI, 2 known confounding factors for the association between arthritis and physical function, there are other potential confounding factors that were not included in the models. 40,41 Finally, this study only included individuals with completed baseline and 3-month follow-up assessments, and the individuals who participated for longer or shorter periods may have had different physical function outcomes than individuals included in this study.

Conclusions

Participation in 3 months VHA Gerofit outpatient supervised exercise programs can improve physical function for all older adults, regardless of arthritis status. These programs may increase access to exercise programming that is beneficial for common conditions affecting older adults, such as arthritis.

References
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  27. Dobson F, Hinman R, Roos EM, et al. OARSI recommended performance-based tests to assess physical function in people diagnosed with hip or knee osteoarthritis. Osteoarthritis Cartilage. 2013;21:1042- 1052. doi:10.1016/j.joca.2013.05.002
  28. Hughes SL, Seymour RB, Campbell R, Pollak N, Huber G, Sharma L. Impact of the fit and strong intervention on older adults with osteoarthritis. Gerontologist. 2004;44:217-228. doi:10.1093/geront/44.2.217
  29. Callahan LF, Shreffler JH, Altpeter M, et al. Evaluation of group and self-directed formats of the Arthritis Foundation's Walk With Ease Program. Arthritis Care Res (Hoboken). 2011;63:1098-1107. doi:10.1002/acr.20490
  30. Boutaugh ML. Arthritis Foundation community-based physical activity programs: effectiveness and implementation issues. Arthritis Rheum. 2003;49:463-470. doi:10.1002/art.11050
  31. Callahan LF, Mielenz T, Freburger J, et al. A randomized controlled trial of the People with Arthritis Can Exercise Program: symptoms, function, physical activity, and psychosocial outcomes. Arthritis Rheum. 2008;59:92-101. doi:10.1002/art.23239
  32. Hall KS, Jennings SC, Pearson MP. Outpatient care models: the Gerofit model of care for exercise promotion in older adults. In: Malone ML, Boltz M, Macias Tejada J, White H, eds. Geriatrics Models of Care. Springer; 2024:205-213. doi:10.1007/978-3-031-56204-4_21
  33. Pepin MJ, Valencia WM, Bettger JP, et al. Impact of supervised exercise on one-year medication use in older veterans with multiple morbidities. Gerontol Geriatr Med. 2020;6:2333721420956751. doi:10.1177/ 2333721420956751
  34. Abbate L, Li J, Veazie P, et al. Does Gerofit exercise reduce veterans’ use of emergency department and inpatient care? Innov Aging. 2020;4(suppl 1):771. doi:10.1093/geroni/igaa057.2786
  35. Morey MC, Pieper CF, Crowley GM, Sullivan RJ Jr, Puglisi CM. Exercise adherence and 10-year mortality in chronically ill older adults. J Am Geriatr Soc. 2002;50:1929-1933. doi:10.1046/j.1532-5415.2002.50602.x
  36. Manning KM, Hall KS, Sloane R, et al. Longitudinal analysis of physical function in older adults: the effects of physical inactivity and exercise training. Aging Cell. 2024;23:e13987. doi:10.1111/acel.13987
  37. Bean JF, Vora A, Frontera WR. Benefits of exercise for community-dwelling older adults. Arch Phys Med Rehabil. 2004;85(7 suppl 3):S31-S42; quiz S3-S4. doi:10.1016/j.apmr.2004.03.010
  38. Covinsky KE, Lindquist K, Dunlop DD, Yelin E. Pain, functional limitations, and aging. J Am Geriatr Soc. 2009; 57:1556-1561. doi:10.1111/j.1532-5415.2009.02388.x
  39. Katz JN, Wright EA, Baron JA, Losina E. Development and validation of an index of musculoskeletal functional limitations. BMC Musculoskelet Disord. 2009;10:62. doi:10.1186/1471-2474-10-62
  40. Allen KD, Thoma LM, Golightly YM. Epidemiology of osteoarthritis. Osteoarthritis Cartilage. 2022;30:184-195. doi:10.1016/j.joca.2021.04.020
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Author and Disclosure Information

Lauren M. Abbate, MD, PhDa,b; Kelli D. Allen, PhDc,d; P. Michael Ho, MD, PhDe; Steven C. Castle, MDf,g; Cathy C. Lee, MSf,g; Leslie I. Katzel, MD, PhDh,i; Jamie Giffuni, MAh; Teresa Kopp, MBA, PTj; Michelle McDonald, BS, OTR/Lk; Megan Pearson, MAc; Richard Sloane, MPHl; Vanessa Richardson, MSa; Katherine S. Hall, PhD, MSc,l; Miriam C. Morey, PhDc,l

Author affiliations
aVeterans Affairs Eastern Colorado Geriatric Research Education and Clinical Center, Aurora
bUniversity of Colorado, Aurora
cVeterans Affairs Durham Health Care System, North Carolina
dUniversity of North Carolina, Chapel Hill
eVeterans Affairs Eastern Colorado Health Care System, Aurora
fVeterans Affairs Greater Los Angeles Health Care System, California
gDavid Geffen School of Medicine at UCLA, Los Angeles, California
hVeterans Affairs Maryland Health Care System, Baltimore
iUniversity of Maryland School of Medicine, Baltimore
jCanandaigua Veterans Affairs Medical Center, New York
kVeterans Affairs Pacific Islands Health Care System, Honolulu, Hawaii
lDuke University Medical Center, Durham, North Carolina

Author disclosures The authors report no actual or potential conflicts of interest with regard to this article.

Correspondence: Lauren Abbate ([email protected])

Fed Pract. 2025;42(2). Published online February 15. doi:10.12788/fp.0549

Issue
Federal Practitioner - 42(2)
Publications
Federal Practitioner
Topics
Rheumatoid Arthritis
Geriatrics
Obesity
Page Number
100-106
Sections
Original Research
Author(s)
Lauren M. Abbate, MD, PhD
Kelli D. Allen, PhD
P. Michael Ho, MD, PhD
Steven C. Castle, MD
Cathy C. Lee, MD
Leslie I. Katzel, MD, PhD
Jamie Giffuni, MA
Teresa Kopp, MBA, PT
Michelle McDonald, BS, OTR/L
Megan Pearson, MA
Richard Sloane, MPH
Vanessa Richardson, MS
Katherine S. Hall, PhD, MS
Miriam C. Morey, PhD
Author(s)
Lauren M. Abbate, MD, PhD
Kelli D. Allen, PhD
P. Michael Ho, MD, PhD
Steven C. Castle, MD
Cathy C. Lee, MD
Leslie I. Katzel, MD, PhD
Jamie Giffuni, MA
Teresa Kopp, MBA, PT
Michelle McDonald, BS, OTR/L
Megan Pearson, MA
Richard Sloane, MPH
Vanessa Richardson, MS
Katherine S. Hall, PhD, MS
Miriam C. Morey, PhD
Author and Disclosure Information

Lauren M. Abbate, MD, PhDa,b; Kelli D. Allen, PhDc,d; P. Michael Ho, MD, PhDe; Steven C. Castle, MDf,g; Cathy C. Lee, MSf,g; Leslie I. Katzel, MD, PhDh,i; Jamie Giffuni, MAh; Teresa Kopp, MBA, PTj; Michelle McDonald, BS, OTR/Lk; Megan Pearson, MAc; Richard Sloane, MPHl; Vanessa Richardson, MSa; Katherine S. Hall, PhD, MSc,l; Miriam C. Morey, PhDc,l

Author affiliations
aVeterans Affairs Eastern Colorado Geriatric Research Education and Clinical Center, Aurora
bUniversity of Colorado, Aurora
cVeterans Affairs Durham Health Care System, North Carolina
dUniversity of North Carolina, Chapel Hill
eVeterans Affairs Eastern Colorado Health Care System, Aurora
fVeterans Affairs Greater Los Angeles Health Care System, California
gDavid Geffen School of Medicine at UCLA, Los Angeles, California
hVeterans Affairs Maryland Health Care System, Baltimore
iUniversity of Maryland School of Medicine, Baltimore
jCanandaigua Veterans Affairs Medical Center, New York
kVeterans Affairs Pacific Islands Health Care System, Honolulu, Hawaii
lDuke University Medical Center, Durham, North Carolina

Author disclosures The authors report no actual or potential conflicts of interest with regard to this article.

Correspondence: Lauren Abbate ([email protected])

Fed Pract. 2025;42(2). Published online February 15. doi:10.12788/fp.0549

Author and Disclosure Information

Lauren M. Abbate, MD, PhDa,b; Kelli D. Allen, PhDc,d; P. Michael Ho, MD, PhDe; Steven C. Castle, MDf,g; Cathy C. Lee, MSf,g; Leslie I. Katzel, MD, PhDh,i; Jamie Giffuni, MAh; Teresa Kopp, MBA, PTj; Michelle McDonald, BS, OTR/Lk; Megan Pearson, MAc; Richard Sloane, MPHl; Vanessa Richardson, MSa; Katherine S. Hall, PhD, MSc,l; Miriam C. Morey, PhDc,l

Author affiliations
aVeterans Affairs Eastern Colorado Geriatric Research Education and Clinical Center, Aurora
bUniversity of Colorado, Aurora
cVeterans Affairs Durham Health Care System, North Carolina
dUniversity of North Carolina, Chapel Hill
eVeterans Affairs Eastern Colorado Health Care System, Aurora
fVeterans Affairs Greater Los Angeles Health Care System, California
gDavid Geffen School of Medicine at UCLA, Los Angeles, California
hVeterans Affairs Maryland Health Care System, Baltimore
iUniversity of Maryland School of Medicine, Baltimore
jCanandaigua Veterans Affairs Medical Center, New York
kVeterans Affairs Pacific Islands Health Care System, Honolulu, Hawaii
lDuke University Medical Center, Durham, North Carolina

Author disclosures The authors report no actual or potential conflicts of interest with regard to this article.

Correspondence: Lauren Abbate ([email protected])

Fed Pract. 2025;42(2). Published online February 15. doi:10.12788/fp.0549

Article PDF
FDP04202100.pdf
Article PDF
FDP04202100.pdf

About half of US adults aged ≥ 65 years report arthritis, and of those, 44% have an arthritis-attributable activity limitation.1,2 Arthritis is a significant health issue for veterans, with veterans reporting higher rates of disability compared with the civilian population.3

Osteoarthritis (OA) is the most common type of arthritis.4 Among individuals aged ≥ 40 years, the incidence of OA is nearly twice as high among veterans compared with civilians and is a leading cause of separation from military service and disability.5,6 OA pain and disability have been shown to be associated with increases in health care and medication use, including opioids, nonsteroidal anti-inflammatory medications, and muscle relaxants.7,8 Because OA is chronic and has no cure, safe and effective management strategies—such as exercise— are critical to minimize pain and maintain physical function.9

Exercise can reduce pain and disability associated with OA and is a first-line recommendation in guidelines for the treatment of knee and hip OA.9 Given the limited exercise and high levels of physical inactivity among veterans with OA, there is a need to identify opportunities that support veterans with OA engaging in regular exercise.

Gerofit, an outpatient clinical exercise program available at 30 Veterans Health Administration (VHA) sites, may provide an opportunity for older veterans with arthritis to engage in exercise.10 Gerofit is specifically designed for veterans aged ≥ 65 years. It is not disease-specific and supports older veterans with multiple chronic conditions, including OA. Veterans aged ≥ 65 years with a referral from a VA clinician are eligible for Gerofit. Those who are unable to perform activities of daily living; unable to independently function without assistance; have a history of unstable angina, proliferative diabetic retinopathy, oxygen dependence, volatile behavioral issues, or are unable to work successfully in a group environment/setting; experience active substance abuse, homelessness, or uncontrolled incontinence; and have open wounds that cannot be appropriately dressed are excluded from Gerofit. Exercise sessions are held 3 times per week and last from 60 to 90 minutes. Sessions are supervised by Gerofit staff and include personalized exercise prescriptions based on functional assessments. Exercise prescriptions include aerobic, resistance, and balance/flexibility components and are modified by the Gerofit program staff as needed. Gerofit adopts a functional fitness approach and includes individual progression as appropriate according to evidence-based guidelines, using the Borg ratings of perceived exertion. 11 Assessments are performed at baseline, 3 months, 6 months, and annually thereafter. Clinical staff conduct all assessments, including physical function testing, and record them in a database. Assessments are reviewed with the veteran to chart progress and identify future goals or needs. Veterans perform personalized self-paced exercises in the Gerofit group setting. Exercise prescriptions are continuously modified to meet individualized needs and goals. Veterans may participate continuously with no end date.

Participation in supervised exercise is associated with improved physical function and individuals with arthritis can improve function even though their baseline functional status is lower than individuals without arthritis. 12 In this analysis, we examine the impact of exercise on the status and location of arthritis (upper body, lower body, or both). Lower body arthritis is more common than upper body arthritis and lower extremity function is associated with increased ability to perform activities of daily living, resulting in independence among older adults.13,14 We also include upper body strength measures to capture important functional movements such as reaching and pulling.15 Among those who participate in Gerofit, the greatest gains in physical function occur during the initial 3 months, which tend to be sustained over 12 months.16 For this reason, this study focused on the initial 3 months of the program.

Older adults with arthritis may have pain and functional limitations that exceed those of the general older adult population. Exercise programs for older adults that do not specifically target arthritis but are able to improve physical function among those with arthritis could potentially increase access to exercise for older adults living with arthritis. Therefore, the purpose of this study was to determine whether change in physical function with participation in Gerofit for 3 months varies by arthritis status, including no arthritis, any arthritis, lower body arthritis, or both upper and lower body arthritis compared with no arthritis.

Methods

This is a secondary analysis of previously collected data from 10 VHA Gerofit sites (Ann Arbor, Baltimore, Greater Los Angeles, Canandaigua, Cincinnati, Miami, Honolulu, Denver, Durham, and Pittsburgh) from 2002 to 2019. Implementation data regarding the consistency of the program delivery at Gerofit expansion sites have been previously published.16 Although the delivery of Gerofit transitioned to telehealth due to COVID-19, data for this analysis were collected from in-person exercise sessions prior to the pandemic.17 Data were collected for clinical purposes. This project was part of the Gerofit quality improvement initiative and was reviewed and approved by the Durham Institutional Review Board as quality improvement.

Participants in Gerofit who completed baseline and 3-month assessments were included to analyze the effects of exercise on physical function. At each of the time points, physical functional assessments included: (1) usual gait speed (> 10 meters [m/s], or 10- meter walk test [10MWT]); (2) lower body strength (chair stands [number completed in 30 seconds]); (3) upper body strength (number of arm curls [5-lb for females/8-lb for males] completed in 30 seconds); and (4) 6-minute walk distance [6MWD] in meters to measure aerobic endurance). These measures have been validated in older adults.18-21 Arm curls were added to the physical function assessments after the 10MWT, chair stands, and 6MWD; therefore, fewer participants had data for this measure. Participants self-reported at baseline on 45 common medical conditions, including arthritis or rheumatism (both upper body and lower body were offered as choices). Self-reporting has been shown to be an acceptable method of identifying arthritis in adults.22

Descriptive statistics at baseline were calculated for all participants. One-way analysis of variance and X2 tests were used to determine differences in baseline characteristics across arthritis status. The primary outcomes were changes in physical function measures from baseline to 3 months by arthritis status. Arthritis status was defined as: any arthritis, which includes individuals who reported upper body arthritis, lower body arthritis, or both; and arthritis status individuals reporting either upper body arthritis, lower body arthritis, or both. Categories of arthritis for arthritis status were mutually exclusive. Two separate linear models were constructed for each of the 4 physical function measures, with change from baseline to 3 months as the outcome (dependent variable) and arthritis status, age, and body mass index (BMI) as predictors (independent variables). The first model compared any arthritis with no arthritis and the second model compared arthritis status (both upper and lower body arthritis vs lower body arthritis) with no arthritis. These models were used to obtain mean changes and 95% CIs in physical function and to test for differences in the change in physical function measures by arthritis status. Statistical analyses were performed using R software, version 4.0.3.

Results

Baseline and 3-month data were available for 737 Gerofit participants and included in the analysis. The mean (SD) age was 73.5 (7.1) years. A total of 707 participants were male (95.9%) and 322 (43.6%) reported some arthritis, with arthritis in both the upper and lower body being reported by 168 participants (52.2%) (Table 1). There were no differences in age, sex, or race for those with any arthritis compared with those with no arthritis, but BMI was significantly higher in those reporting any arthritis compared with no arthritis. For the baseline functional measures, statistically significant differences were observed between those with no arthritis and those reporting any arthritis for the 10MWT (P = .001), chair stands (P = .046), and 6MWD (P = .001), but not for arm curls (P = .77), with those with no arthritis performing better.

FDP04202100_T1

All 4 arthritis status groups showed improvements in each of the physical function measures over 3 months. For the 10MWT the mean change (95% CI) in gait speed (m/s) was 0.06 (0.04-0.08) for patients with no arthritis, 0.07 (0.05- 0.08) for any arthritis, 0.07 (0.04-0.11) for lower body arthritis, and 0.07 (0.04- 0.09) for both lower and upper body arthritis. For the number of arm curls in 30 seconds the mean change (95% CI) was 2.3 (1.8-2.8) for patients with no arthritis, 2.1 (1.5-2.6) for any arthritis, 2.0 (1.1-3.0) for lower body arthritis, and 1.9 (1.1-2.7) for both lower and upper body arthritis. For the number of chair stands in 30 seconds the mean change (95% CI) was 2.1 (1.7-2.4) for patients with no arthritis, 2.2 (1.8-2.6) for any arthritis, 2.3 (1.6-2.9), for lower body arthritis, and 2.0 (1.5-2.5) for both lower and upper body arthritis. For the 6MWD distance in meters the mean change (95% CI) was 21.5 (15.5-27.4) for patients with no arthritis, 28.6 (21.9-35.3) for any arthritis, 30.4 (19.5-41.3) for lower body arthritis, and 28.6 (19.2-38.0) for both lower and upper body arthritis (Figure).

FDP04202100_F1

We used 2 models to measure the change from baseline to 3 months for each of the arthritis groups. Model 1 compared any arthritis vs no arthritis and model 2 compared lower body arthritis and both upper and lower body arthritis vs no arthritis for each physical function measure (Table 2). There were no statistically significant differences in 3-month change in physical function for any of the physical function measures between arthritis groups after adjusting for age and BMI.

FDP04202100_T2

Discussion

Participation in Gerofit was associated with functional gains among all participants over 3 months, regardless of arthritis status. Older veterans reporting any arthritis had significantly lower physical function scores upon enrollment into Gerofit compared with those veterans reporting no arthritis. However, compared with individuals who reported no arthritis, individuals who reported arthritis (any arthritis, lower body arthritis only, or both lower and upper body arthritis) experienced similar improvements (ie, no statistically significant differences in mean change from baseline to follow-up among those with and without arthritis). This study suggests that progressive, multicomponent exercise programs for older adults may be beneficial for those with arthritis.

Involvement of multiple sites of arthritis is associated with moderate to severe functional limitations as well as lower healthrelated quality of life.23 While it has been found that individuals with arthritis can improve function with supervised exercise, even though their baseline functional status is lower than individuals without arthritis, it was not clear whether individuals with multiple joint involvement also would benefit.12 The results of this study suggest that these individuals can improve across various domains of physical function despite variation in arthritis location and status. As incidence of arthritis increases with age, targeting older adults for exercise programs such as Gerofit may improve functional limitations and health-related quality of life associated with arthritis.2

We evaluated physical function using multiple measures to assess upper (arm curls) and lower (chair stands, 10MWT) extremity physical function and aerobic endurance (6MWD). Participants in this study reached clinically meaningful changes with 3 months of participation in Gerofit for most of the physical function measures. Gerofit participants had a mean gait speed improvement of 0.05 to 0.07 m/s compared with 0.10 to 0.30 m/s, which was reported previously. 24,25 In this study, nearly all groups achieved the clinically important improvements in the chair stand in 30 seconds (2.0 to 2.6) and the 6MWD (21.8 to 59.1 m) that have been reported in the literature.24-26

The Osteoarthritis Research Society International recommends the chair stand and 6MWD performance-based tests for individuals with hip and knee arthritis because they align with patient-reported outcomes and represent the types of activities relevant to this population.27 The findings of this study suggest that improvement in these physical function measures with participation in exercise align with data from arthritis-specific exercise programs designed for wide implementation. Hughes and colleagues reported improvements in the 6MWD after the 8-week Fit and Strong exercise intervention, which included walking and lower body resistance training.28 The Arthritis Foundation’s Walk With Ease program is a 6-week walking program that has shown improvements in chair stands and gait speed.29 Another Arthritis Foundation program, People with Arthritis Can Exercise, is an 8-week course consisting of a variety of resistance, aerobic, and balance activities. This program has been associated with increases in chair stands but not gait speed or 6MWD.30,31

This study found that participation in a VHA outpatient clinical supervised exercise program results in improvements in physical function that can be realized by older adults regardless of arthritis burden. Gerofit programs typically require 1.5 to 2.0 dedicated full-time equivalent employees to run the program effectively and additional administrative support, depending on size of the program.32 The cost savings generated by the program include reductions in hospitalization rates, emergency department visits, days in hospital, and medication use and provide a compelling argument for the program’s financial viability to health care systems through long-term savings and improved health outcomes for older adults.33-36

While evidenced-based arthritis programs exist, this study illustrates that an exercise program without a focus on arthritis also improves physical function, potentially reducing the risk of disability related to arthritis. The clinical implication for these findings is that arthritis-specific exercise programs may not be needed to achieve functional improvements in individuals with arthritis. This is critical for under-resourced or exercise- limited health care systems or communities. Therefore, if exercise programming is limited, or arthritis-specific programs and interventions are not available, nonspecific exercise programs will also be beneficial to individuals with arthritis. Thus, individuals with arthritis should be encouraged to participate in any available exercise programming to achieve improvements in physical function. In addition, many older adults have multiple comorbidities, most of which improve with participation in exercise. 37 Disease-specific exercise programs can offer tailored exercises and coaching related to common barriers in participation, such as joint pain for arthritis.31 It is unclear whether these additional programmatic components are associated with greater improvements in outcomes, such as physical function. More research is needed to explore the benefits of disease-specific tailored exercise programs compared with general exercise programs.

Strengths and Limitations

This study demonstrated the effect of participation in a clinical, supervised exercise program in a real-world setting. It suggests that even exercise programs not specifically targeted for arthritis populations can improve physical function among those with arthritis.

As a VHA clinical supervised exercise program, Gerofit may not be generalizable to all older adults or other exercise programs. In addition, this analysis only included a veteran population that was > 95% male and may not be generalizable to other populations. Arthritis status was defined by self-report and not verified in the health record. However, this approach has been shown to be acceptable in this setting and the most common type of arthritis in this population (OA) is a painful musculoskeletal condition associated with functional limitations.4,22,38,39 Self-reported arthritis or rheumatism is associated with functional limitations.1 Therefore, it is unlikely that the results would differ for physician-diagnosed or radiographically defined OA. Additionally, the study did not have data on the total number of joints with arthritis or arthritis severity but rather used upper body, lower body, and both upper and lower body arthritis as a proxy for arthritis status. While our models were adjusted for age and BMI, 2 known confounding factors for the association between arthritis and physical function, there are other potential confounding factors that were not included in the models. 40,41 Finally, this study only included individuals with completed baseline and 3-month follow-up assessments, and the individuals who participated for longer or shorter periods may have had different physical function outcomes than individuals included in this study.

Conclusions

Participation in 3 months VHA Gerofit outpatient supervised exercise programs can improve physical function for all older adults, regardless of arthritis status. These programs may increase access to exercise programming that is beneficial for common conditions affecting older adults, such as arthritis.

About half of US adults aged ≥ 65 years report arthritis, and of those, 44% have an arthritis-attributable activity limitation.1,2 Arthritis is a significant health issue for veterans, with veterans reporting higher rates of disability compared with the civilian population.3

Osteoarthritis (OA) is the most common type of arthritis.4 Among individuals aged ≥ 40 years, the incidence of OA is nearly twice as high among veterans compared with civilians and is a leading cause of separation from military service and disability.5,6 OA pain and disability have been shown to be associated with increases in health care and medication use, including opioids, nonsteroidal anti-inflammatory medications, and muscle relaxants.7,8 Because OA is chronic and has no cure, safe and effective management strategies—such as exercise— are critical to minimize pain and maintain physical function.9

Exercise can reduce pain and disability associated with OA and is a first-line recommendation in guidelines for the treatment of knee and hip OA.9 Given the limited exercise and high levels of physical inactivity among veterans with OA, there is a need to identify opportunities that support veterans with OA engaging in regular exercise.

Gerofit, an outpatient clinical exercise program available at 30 Veterans Health Administration (VHA) sites, may provide an opportunity for older veterans with arthritis to engage in exercise.10 Gerofit is specifically designed for veterans aged ≥ 65 years. It is not disease-specific and supports older veterans with multiple chronic conditions, including OA. Veterans aged ≥ 65 years with a referral from a VA clinician are eligible for Gerofit. Those who are unable to perform activities of daily living; unable to independently function without assistance; have a history of unstable angina, proliferative diabetic retinopathy, oxygen dependence, volatile behavioral issues, or are unable to work successfully in a group environment/setting; experience active substance abuse, homelessness, or uncontrolled incontinence; and have open wounds that cannot be appropriately dressed are excluded from Gerofit. Exercise sessions are held 3 times per week and last from 60 to 90 minutes. Sessions are supervised by Gerofit staff and include personalized exercise prescriptions based on functional assessments. Exercise prescriptions include aerobic, resistance, and balance/flexibility components and are modified by the Gerofit program staff as needed. Gerofit adopts a functional fitness approach and includes individual progression as appropriate according to evidence-based guidelines, using the Borg ratings of perceived exertion. 11 Assessments are performed at baseline, 3 months, 6 months, and annually thereafter. Clinical staff conduct all assessments, including physical function testing, and record them in a database. Assessments are reviewed with the veteran to chart progress and identify future goals or needs. Veterans perform personalized self-paced exercises in the Gerofit group setting. Exercise prescriptions are continuously modified to meet individualized needs and goals. Veterans may participate continuously with no end date.

Participation in supervised exercise is associated with improved physical function and individuals with arthritis can improve function even though their baseline functional status is lower than individuals without arthritis. 12 In this analysis, we examine the impact of exercise on the status and location of arthritis (upper body, lower body, or both). Lower body arthritis is more common than upper body arthritis and lower extremity function is associated with increased ability to perform activities of daily living, resulting in independence among older adults.13,14 We also include upper body strength measures to capture important functional movements such as reaching and pulling.15 Among those who participate in Gerofit, the greatest gains in physical function occur during the initial 3 months, which tend to be sustained over 12 months.16 For this reason, this study focused on the initial 3 months of the program.

Older adults with arthritis may have pain and functional limitations that exceed those of the general older adult population. Exercise programs for older adults that do not specifically target arthritis but are able to improve physical function among those with arthritis could potentially increase access to exercise for older adults living with arthritis. Therefore, the purpose of this study was to determine whether change in physical function with participation in Gerofit for 3 months varies by arthritis status, including no arthritis, any arthritis, lower body arthritis, or both upper and lower body arthritis compared with no arthritis.

Methods

This is a secondary analysis of previously collected data from 10 VHA Gerofit sites (Ann Arbor, Baltimore, Greater Los Angeles, Canandaigua, Cincinnati, Miami, Honolulu, Denver, Durham, and Pittsburgh) from 2002 to 2019. Implementation data regarding the consistency of the program delivery at Gerofit expansion sites have been previously published.16 Although the delivery of Gerofit transitioned to telehealth due to COVID-19, data for this analysis were collected from in-person exercise sessions prior to the pandemic.17 Data were collected for clinical purposes. This project was part of the Gerofit quality improvement initiative and was reviewed and approved by the Durham Institutional Review Board as quality improvement.

Participants in Gerofit who completed baseline and 3-month assessments were included to analyze the effects of exercise on physical function. At each of the time points, physical functional assessments included: (1) usual gait speed (> 10 meters [m/s], or 10- meter walk test [10MWT]); (2) lower body strength (chair stands [number completed in 30 seconds]); (3) upper body strength (number of arm curls [5-lb for females/8-lb for males] completed in 30 seconds); and (4) 6-minute walk distance [6MWD] in meters to measure aerobic endurance). These measures have been validated in older adults.18-21 Arm curls were added to the physical function assessments after the 10MWT, chair stands, and 6MWD; therefore, fewer participants had data for this measure. Participants self-reported at baseline on 45 common medical conditions, including arthritis or rheumatism (both upper body and lower body were offered as choices). Self-reporting has been shown to be an acceptable method of identifying arthritis in adults.22

Descriptive statistics at baseline were calculated for all participants. One-way analysis of variance and X2 tests were used to determine differences in baseline characteristics across arthritis status. The primary outcomes were changes in physical function measures from baseline to 3 months by arthritis status. Arthritis status was defined as: any arthritis, which includes individuals who reported upper body arthritis, lower body arthritis, or both; and arthritis status individuals reporting either upper body arthritis, lower body arthritis, or both. Categories of arthritis for arthritis status were mutually exclusive. Two separate linear models were constructed for each of the 4 physical function measures, with change from baseline to 3 months as the outcome (dependent variable) and arthritis status, age, and body mass index (BMI) as predictors (independent variables). The first model compared any arthritis with no arthritis and the second model compared arthritis status (both upper and lower body arthritis vs lower body arthritis) with no arthritis. These models were used to obtain mean changes and 95% CIs in physical function and to test for differences in the change in physical function measures by arthritis status. Statistical analyses were performed using R software, version 4.0.3.

Results

Baseline and 3-month data were available for 737 Gerofit participants and included in the analysis. The mean (SD) age was 73.5 (7.1) years. A total of 707 participants were male (95.9%) and 322 (43.6%) reported some arthritis, with arthritis in both the upper and lower body being reported by 168 participants (52.2%) (Table 1). There were no differences in age, sex, or race for those with any arthritis compared with those with no arthritis, but BMI was significantly higher in those reporting any arthritis compared with no arthritis. For the baseline functional measures, statistically significant differences were observed between those with no arthritis and those reporting any arthritis for the 10MWT (P = .001), chair stands (P = .046), and 6MWD (P = .001), but not for arm curls (P = .77), with those with no arthritis performing better.

FDP04202100_T1

All 4 arthritis status groups showed improvements in each of the physical function measures over 3 months. For the 10MWT the mean change (95% CI) in gait speed (m/s) was 0.06 (0.04-0.08) for patients with no arthritis, 0.07 (0.05- 0.08) for any arthritis, 0.07 (0.04-0.11) for lower body arthritis, and 0.07 (0.04- 0.09) for both lower and upper body arthritis. For the number of arm curls in 30 seconds the mean change (95% CI) was 2.3 (1.8-2.8) for patients with no arthritis, 2.1 (1.5-2.6) for any arthritis, 2.0 (1.1-3.0) for lower body arthritis, and 1.9 (1.1-2.7) for both lower and upper body arthritis. For the number of chair stands in 30 seconds the mean change (95% CI) was 2.1 (1.7-2.4) for patients with no arthritis, 2.2 (1.8-2.6) for any arthritis, 2.3 (1.6-2.9), for lower body arthritis, and 2.0 (1.5-2.5) for both lower and upper body arthritis. For the 6MWD distance in meters the mean change (95% CI) was 21.5 (15.5-27.4) for patients with no arthritis, 28.6 (21.9-35.3) for any arthritis, 30.4 (19.5-41.3) for lower body arthritis, and 28.6 (19.2-38.0) for both lower and upper body arthritis (Figure).

FDP04202100_F1

We used 2 models to measure the change from baseline to 3 months for each of the arthritis groups. Model 1 compared any arthritis vs no arthritis and model 2 compared lower body arthritis and both upper and lower body arthritis vs no arthritis for each physical function measure (Table 2). There were no statistically significant differences in 3-month change in physical function for any of the physical function measures between arthritis groups after adjusting for age and BMI.

FDP04202100_T2

Discussion

Participation in Gerofit was associated with functional gains among all participants over 3 months, regardless of arthritis status. Older veterans reporting any arthritis had significantly lower physical function scores upon enrollment into Gerofit compared with those veterans reporting no arthritis. However, compared with individuals who reported no arthritis, individuals who reported arthritis (any arthritis, lower body arthritis only, or both lower and upper body arthritis) experienced similar improvements (ie, no statistically significant differences in mean change from baseline to follow-up among those with and without arthritis). This study suggests that progressive, multicomponent exercise programs for older adults may be beneficial for those with arthritis.

Involvement of multiple sites of arthritis is associated with moderate to severe functional limitations as well as lower healthrelated quality of life.23 While it has been found that individuals with arthritis can improve function with supervised exercise, even though their baseline functional status is lower than individuals without arthritis, it was not clear whether individuals with multiple joint involvement also would benefit.12 The results of this study suggest that these individuals can improve across various domains of physical function despite variation in arthritis location and status. As incidence of arthritis increases with age, targeting older adults for exercise programs such as Gerofit may improve functional limitations and health-related quality of life associated with arthritis.2

We evaluated physical function using multiple measures to assess upper (arm curls) and lower (chair stands, 10MWT) extremity physical function and aerobic endurance (6MWD). Participants in this study reached clinically meaningful changes with 3 months of participation in Gerofit for most of the physical function measures. Gerofit participants had a mean gait speed improvement of 0.05 to 0.07 m/s compared with 0.10 to 0.30 m/s, which was reported previously. 24,25 In this study, nearly all groups achieved the clinically important improvements in the chair stand in 30 seconds (2.0 to 2.6) and the 6MWD (21.8 to 59.1 m) that have been reported in the literature.24-26

The Osteoarthritis Research Society International recommends the chair stand and 6MWD performance-based tests for individuals with hip and knee arthritis because they align with patient-reported outcomes and represent the types of activities relevant to this population.27 The findings of this study suggest that improvement in these physical function measures with participation in exercise align with data from arthritis-specific exercise programs designed for wide implementation. Hughes and colleagues reported improvements in the 6MWD after the 8-week Fit and Strong exercise intervention, which included walking and lower body resistance training.28 The Arthritis Foundation’s Walk With Ease program is a 6-week walking program that has shown improvements in chair stands and gait speed.29 Another Arthritis Foundation program, People with Arthritis Can Exercise, is an 8-week course consisting of a variety of resistance, aerobic, and balance activities. This program has been associated with increases in chair stands but not gait speed or 6MWD.30,31

This study found that participation in a VHA outpatient clinical supervised exercise program results in improvements in physical function that can be realized by older adults regardless of arthritis burden. Gerofit programs typically require 1.5 to 2.0 dedicated full-time equivalent employees to run the program effectively and additional administrative support, depending on size of the program.32 The cost savings generated by the program include reductions in hospitalization rates, emergency department visits, days in hospital, and medication use and provide a compelling argument for the program’s financial viability to health care systems through long-term savings and improved health outcomes for older adults.33-36

While evidenced-based arthritis programs exist, this study illustrates that an exercise program without a focus on arthritis also improves physical function, potentially reducing the risk of disability related to arthritis. The clinical implication for these findings is that arthritis-specific exercise programs may not be needed to achieve functional improvements in individuals with arthritis. This is critical for under-resourced or exercise- limited health care systems or communities. Therefore, if exercise programming is limited, or arthritis-specific programs and interventions are not available, nonspecific exercise programs will also be beneficial to individuals with arthritis. Thus, individuals with arthritis should be encouraged to participate in any available exercise programming to achieve improvements in physical function. In addition, many older adults have multiple comorbidities, most of which improve with participation in exercise. 37 Disease-specific exercise programs can offer tailored exercises and coaching related to common barriers in participation, such as joint pain for arthritis.31 It is unclear whether these additional programmatic components are associated with greater improvements in outcomes, such as physical function. More research is needed to explore the benefits of disease-specific tailored exercise programs compared with general exercise programs.

Strengths and Limitations

This study demonstrated the effect of participation in a clinical, supervised exercise program in a real-world setting. It suggests that even exercise programs not specifically targeted for arthritis populations can improve physical function among those with arthritis.

As a VHA clinical supervised exercise program, Gerofit may not be generalizable to all older adults or other exercise programs. In addition, this analysis only included a veteran population that was > 95% male and may not be generalizable to other populations. Arthritis status was defined by self-report and not verified in the health record. However, this approach has been shown to be acceptable in this setting and the most common type of arthritis in this population (OA) is a painful musculoskeletal condition associated with functional limitations.4,22,38,39 Self-reported arthritis or rheumatism is associated with functional limitations.1 Therefore, it is unlikely that the results would differ for physician-diagnosed or radiographically defined OA. Additionally, the study did not have data on the total number of joints with arthritis or arthritis severity but rather used upper body, lower body, and both upper and lower body arthritis as a proxy for arthritis status. While our models were adjusted for age and BMI, 2 known confounding factors for the association between arthritis and physical function, there are other potential confounding factors that were not included in the models. 40,41 Finally, this study only included individuals with completed baseline and 3-month follow-up assessments, and the individuals who participated for longer or shorter periods may have had different physical function outcomes than individuals included in this study.

Conclusions

Participation in 3 months VHA Gerofit outpatient supervised exercise programs can improve physical function for all older adults, regardless of arthritis status. These programs may increase access to exercise programming that is beneficial for common conditions affecting older adults, such as arthritis.

References
  1. Centers for Disease Control and Prevention. Prevalence and most common causes of disability among adults- -United States, 2005. MMWR Morb Mortal Wkly Rep. 2009;58:421-426.
  2. Theis KA, Murphy LB, Guglielmo D, et al. Prevalence of arthritis and arthritis-attributable activity limitation—United States, 2016–2018. MMWR Morb Mortal Wkly Rep. 2021;70:1401-1407. doi:10.15585/mmwr.mm7040a2
  3. Murphy LB, Helmick CG, Allen KD, et al. Arthritis among veterans—United States, 2011–2013. MMWR Morb Mortal Wkly Rep. 2014;63:999-1003.
  4. Park J, Mendy A, Vieira ER. Various types of arthritis in the United States: prevalence and age-related trends from 1999 to 2014. Am J Public Health. 2018;108:256-258.
  5. Cameron KL, Hsiao MS, Owens BD, Burks R, Svoboda SJ. Incidence of physician-diagnosed osteoarthritis among active duty United States military service members. Arthritis Rheum. 2011;63:2974-2982. doi:10.1002/art.30498
  6. Patzkowski JC, Rivera JC, Ficke JR, Wenke JC. The changing face of disability in the US Army: the Operation Enduring Freedom and Operation Iraqi Freedom effect. J Am Acad Orthop Surg. 2012;20(suppl 1):S23-S30. doi:10.5435/JAAOS-20-08-S23
  7. Rivera JC, Amuan ME, Morris RM, Johnson AE, Pugh MJ. Arthritis, comorbidities, and care utilization in veterans of Operations Enduring and Iraqi Freedom. J Orthop Res. 2017;35:682-687. doi:10.1002/jor.23323
  8. Singh JA, Nelson DB, Fink HA, Nichol KL. Health-related quality of life predicts future health care utilization and mortality in veterans with self-reported physician-diagnosed arthritis: the Veterans Arthritis Quality of Life Study. Semin Arthritis Rheum. 2005;34:755- 765. doi:10.1016/j.semarthrit.2004.08.001
  9. Nelson AE, Allen KD, Golightly YM, Goode AP, Jordan JM. A systematic review of recommendations and guidelines for the management of osteoarthritis: the Chronic Osteoarthritis Management Initiative of the U.S. Bone and Joint Initiative. Semin Arthritis Rheum. 2014;43:701-712. doi:10.1016/j.semarthrit.2013.11.012
  10. Morey MC, Crowley GM, Robbins MS, Cowper PA, Sullivan RJ Jr. The Gerofit Program: a VA innovation. South Med J. 1994;87:S83-S87.
  11. Chen MJ, Fan X, Moe ST. Criterion-related validity of the Borg ratings of perceived exertion scale in healthy individuals: a meta-analysis. J Sports Sci. 2002;20:873-899. doi:10.1080/026404102320761787
  12. Morey MC, Pieper CF, Sullivan RJ Jr, Crowley GM, Cowper PA, Robbins MS. Five-year performance trends for older exercisers: a hierarchical model of endurance, strength, and flexibility. J Am Geriatr Soc. 1996;44:1226-1231. doi:10.1111/j.1532-5415.1996.tb01374.x
  13. Allen KD, Gol ight ly YM. State of the evidence. Curr Opin Rheumatol. 2015;27:276-283. doi:10.1097/BOR.0000000000000161
  14. den Ouden MEM, Schuurmans MJ, Arts IEMA, van der Schouw YT. Association between physical performance characteristics and independence in activities of daily living in middle-aged and elderly men. Geriatr Gerontol Int. 2013;13:274-280. doi:10.1111/j.1447-0594.2012.00890.x
  15. Daly M, Vidt ME, Eggebeen JD, et al. Upper extremity muscle volumes and functional strength after resistance training in older adults. J Aging Phys Act. 2013;21:186-207. doi:10.1123/japa.21.2.186
  16. Morey MC, Lee CC, Castle S, et al. Should structured exercise be promoted as a model of care? Dissemination of the Department of Veterans Affairs Gerofit Program. J Am Geriatr Soc. 2018;66:1009-1016. doi:10.1111/jgs.15276
  17. Jennings SC, Manning KM, Bettger JP, et al. Rapid transition to telehealth group exercise and functional assessments in response to COVID-19. Gerontol Geriatr Med. 2020;6:2333721420980313. doi:10.1177/ 2333721420980313
  18. Studenski S, Perera S, Wallace D, et al. Physical performance measures in the clinical setting. J Am Geriatr Soc. 2003;51:314-322. doi:10.1046/j.1532-5415.2003.51104.x
  19. Jones CJ, Rikli RE, Beam WC. A 30-s chair-stand test as a measure of lower body strength in community residing older adults. Res Q Exerc Sport. 1999;70:113- 119. doi:10.1080/02701367.1999.10608028
  20. Rikli RE, Jones CJ. Development and validation of a functional fitness test for community-residing older adults. J Aging Phys Act. 1999;7:129-161. doi:10.1123/japa.7.2.129
  21. Harada ND, Chiu V, Stewart AL. Mobility-related function in older adults: assessment with a 6-minute walk test. Arch Phys Med Rehabil. 1999;80:837-841. doi:10.1016/s0003-9993(99)90236-8
  22. Peeters GGME, Alshurafa M, Schaap L, de Vet HCW. Diagnostic accuracy of self-reported arthritis in the general adult population is acceptable. J Clin Epidemiol. 2015;68:452-459. doi:10.1016/j.jclinepi.2014.09.019
  23. Cuperus N, Vliet Vlieland TPM, Mahler EAM, Kersten CC, Hoogeboom TJ, van den Ende CHM. The clinical burden of generalized osteoarthritis represented by self-reported health-related quality of life and activity limitations: a cross-sectional study. Rheumatol Int. 2015;35:871-877. doi:10.1007/s00296-014-3149-1
  24. Coleman G, Dobson F, Hinman RS, Bennell K, White DK. Measures of physical performance. Arthritis Care Res (Hoboken). 2020;72(suppl 10):452-485. doi:10.1002/acr.24373
  25. Perera S, Mody SH, Woodman RC, Studenski SA. Meaningful change and responsiveness in common physical performance measures in older adults. J Am Geriatr Soc. 2006;54:743-749. doi:10.1111/j.1532-5415.2006.00701.x
  26. Wright AA, Cook CE, Baxter GD, Dockerty JD, Abbott JH. A comparison of 3 methodological approaches to defining major clinically important improvement of 4 performance measures in patients with hip osteoarthritis. J Orthop Sports Phys Ther. 2011;41:319-327. doi:10.2519/jospt.2011.3515
  27. Dobson F, Hinman R, Roos EM, et al. OARSI recommended performance-based tests to assess physical function in people diagnosed with hip or knee osteoarthritis. Osteoarthritis Cartilage. 2013;21:1042- 1052. doi:10.1016/j.joca.2013.05.002
  28. Hughes SL, Seymour RB, Campbell R, Pollak N, Huber G, Sharma L. Impact of the fit and strong intervention on older adults with osteoarthritis. Gerontologist. 2004;44:217-228. doi:10.1093/geront/44.2.217
  29. Callahan LF, Shreffler JH, Altpeter M, et al. Evaluation of group and self-directed formats of the Arthritis Foundation's Walk With Ease Program. Arthritis Care Res (Hoboken). 2011;63:1098-1107. doi:10.1002/acr.20490
  30. Boutaugh ML. Arthritis Foundation community-based physical activity programs: effectiveness and implementation issues. Arthritis Rheum. 2003;49:463-470. doi:10.1002/art.11050
  31. Callahan LF, Mielenz T, Freburger J, et al. A randomized controlled trial of the People with Arthritis Can Exercise Program: symptoms, function, physical activity, and psychosocial outcomes. Arthritis Rheum. 2008;59:92-101. doi:10.1002/art.23239
  32. Hall KS, Jennings SC, Pearson MP. Outpatient care models: the Gerofit model of care for exercise promotion in older adults. In: Malone ML, Boltz M, Macias Tejada J, White H, eds. Geriatrics Models of Care. Springer; 2024:205-213. doi:10.1007/978-3-031-56204-4_21
  33. Pepin MJ, Valencia WM, Bettger JP, et al. Impact of supervised exercise on one-year medication use in older veterans with multiple morbidities. Gerontol Geriatr Med. 2020;6:2333721420956751. doi:10.1177/ 2333721420956751
  34. Abbate L, Li J, Veazie P, et al. Does Gerofit exercise reduce veterans’ use of emergency department and inpatient care? Innov Aging. 2020;4(suppl 1):771. doi:10.1093/geroni/igaa057.2786
  35. Morey MC, Pieper CF, Crowley GM, Sullivan RJ Jr, Puglisi CM. Exercise adherence and 10-year mortality in chronically ill older adults. J Am Geriatr Soc. 2002;50:1929-1933. doi:10.1046/j.1532-5415.2002.50602.x
  36. Manning KM, Hall KS, Sloane R, et al. Longitudinal analysis of physical function in older adults: the effects of physical inactivity and exercise training. Aging Cell. 2024;23:e13987. doi:10.1111/acel.13987
  37. Bean JF, Vora A, Frontera WR. Benefits of exercise for community-dwelling older adults. Arch Phys Med Rehabil. 2004;85(7 suppl 3):S31-S42; quiz S3-S4. doi:10.1016/j.apmr.2004.03.010
  38. Covinsky KE, Lindquist K, Dunlop DD, Yelin E. Pain, functional limitations, and aging. J Am Geriatr Soc. 2009; 57:1556-1561. doi:10.1111/j.1532-5415.2009.02388.x
  39. Katz JN, Wright EA, Baron JA, Losina E. Development and validation of an index of musculoskeletal functional limitations. BMC Musculoskelet Disord. 2009;10:62. doi:10.1186/1471-2474-10-62
  40. Allen KD, Thoma LM, Golightly YM. Epidemiology of osteoarthritis. Osteoarthritis Cartilage. 2022;30:184-195. doi:10.1016/j.joca.2021.04.020
  41. Riebe D, Blissmer BJ, Greaney ML, Ewing Garber C, Lees FD, Clark PG. The relationship between obesity, physical activity, and physical function in older adults. J Aging Health. 2009;21:1159-1178. doi:10.1177/0898264309350076
References
  1. Centers for Disease Control and Prevention. Prevalence and most common causes of disability among adults- -United States, 2005. MMWR Morb Mortal Wkly Rep. 2009;58:421-426.
  2. Theis KA, Murphy LB, Guglielmo D, et al. Prevalence of arthritis and arthritis-attributable activity limitation—United States, 2016–2018. MMWR Morb Mortal Wkly Rep. 2021;70:1401-1407. doi:10.15585/mmwr.mm7040a2
  3. Murphy LB, Helmick CG, Allen KD, et al. Arthritis among veterans—United States, 2011–2013. MMWR Morb Mortal Wkly Rep. 2014;63:999-1003.
  4. Park J, Mendy A, Vieira ER. Various types of arthritis in the United States: prevalence and age-related trends from 1999 to 2014. Am J Public Health. 2018;108:256-258.
  5. Cameron KL, Hsiao MS, Owens BD, Burks R, Svoboda SJ. Incidence of physician-diagnosed osteoarthritis among active duty United States military service members. Arthritis Rheum. 2011;63:2974-2982. doi:10.1002/art.30498
  6. Patzkowski JC, Rivera JC, Ficke JR, Wenke JC. The changing face of disability in the US Army: the Operation Enduring Freedom and Operation Iraqi Freedom effect. J Am Acad Orthop Surg. 2012;20(suppl 1):S23-S30. doi:10.5435/JAAOS-20-08-S23
  7. Rivera JC, Amuan ME, Morris RM, Johnson AE, Pugh MJ. Arthritis, comorbidities, and care utilization in veterans of Operations Enduring and Iraqi Freedom. J Orthop Res. 2017;35:682-687. doi:10.1002/jor.23323
  8. Singh JA, Nelson DB, Fink HA, Nichol KL. Health-related quality of life predicts future health care utilization and mortality in veterans with self-reported physician-diagnosed arthritis: the Veterans Arthritis Quality of Life Study. Semin Arthritis Rheum. 2005;34:755- 765. doi:10.1016/j.semarthrit.2004.08.001
  9. Nelson AE, Allen KD, Golightly YM, Goode AP, Jordan JM. A systematic review of recommendations and guidelines for the management of osteoarthritis: the Chronic Osteoarthritis Management Initiative of the U.S. Bone and Joint Initiative. Semin Arthritis Rheum. 2014;43:701-712. doi:10.1016/j.semarthrit.2013.11.012
  10. Morey MC, Crowley GM, Robbins MS, Cowper PA, Sullivan RJ Jr. The Gerofit Program: a VA innovation. South Med J. 1994;87:S83-S87.
  11. Chen MJ, Fan X, Moe ST. Criterion-related validity of the Borg ratings of perceived exertion scale in healthy individuals: a meta-analysis. J Sports Sci. 2002;20:873-899. doi:10.1080/026404102320761787
  12. Morey MC, Pieper CF, Sullivan RJ Jr, Crowley GM, Cowper PA, Robbins MS. Five-year performance trends for older exercisers: a hierarchical model of endurance, strength, and flexibility. J Am Geriatr Soc. 1996;44:1226-1231. doi:10.1111/j.1532-5415.1996.tb01374.x
  13. Allen KD, Gol ight ly YM. State of the evidence. Curr Opin Rheumatol. 2015;27:276-283. doi:10.1097/BOR.0000000000000161
  14. den Ouden MEM, Schuurmans MJ, Arts IEMA, van der Schouw YT. Association between physical performance characteristics and independence in activities of daily living in middle-aged and elderly men. Geriatr Gerontol Int. 2013;13:274-280. doi:10.1111/j.1447-0594.2012.00890.x
  15. Daly M, Vidt ME, Eggebeen JD, et al. Upper extremity muscle volumes and functional strength after resistance training in older adults. J Aging Phys Act. 2013;21:186-207. doi:10.1123/japa.21.2.186
  16. Morey MC, Lee CC, Castle S, et al. Should structured exercise be promoted as a model of care? Dissemination of the Department of Veterans Affairs Gerofit Program. J Am Geriatr Soc. 2018;66:1009-1016. doi:10.1111/jgs.15276
  17. Jennings SC, Manning KM, Bettger JP, et al. Rapid transition to telehealth group exercise and functional assessments in response to COVID-19. Gerontol Geriatr Med. 2020;6:2333721420980313. doi:10.1177/ 2333721420980313
  18. Studenski S, Perera S, Wallace D, et al. Physical performance measures in the clinical setting. J Am Geriatr Soc. 2003;51:314-322. doi:10.1046/j.1532-5415.2003.51104.x
  19. Jones CJ, Rikli RE, Beam WC. A 30-s chair-stand test as a measure of lower body strength in community residing older adults. Res Q Exerc Sport. 1999;70:113- 119. doi:10.1080/02701367.1999.10608028
  20. Rikli RE, Jones CJ. Development and validation of a functional fitness test for community-residing older adults. J Aging Phys Act. 1999;7:129-161. doi:10.1123/japa.7.2.129
  21. Harada ND, Chiu V, Stewart AL. Mobility-related function in older adults: assessment with a 6-minute walk test. Arch Phys Med Rehabil. 1999;80:837-841. doi:10.1016/s0003-9993(99)90236-8
  22. Peeters GGME, Alshurafa M, Schaap L, de Vet HCW. Diagnostic accuracy of self-reported arthritis in the general adult population is acceptable. J Clin Epidemiol. 2015;68:452-459. doi:10.1016/j.jclinepi.2014.09.019
  23. Cuperus N, Vliet Vlieland TPM, Mahler EAM, Kersten CC, Hoogeboom TJ, van den Ende CHM. The clinical burden of generalized osteoarthritis represented by self-reported health-related quality of life and activity limitations: a cross-sectional study. Rheumatol Int. 2015;35:871-877. doi:10.1007/s00296-014-3149-1
  24. Coleman G, Dobson F, Hinman RS, Bennell K, White DK. Measures of physical performance. Arthritis Care Res (Hoboken). 2020;72(suppl 10):452-485. doi:10.1002/acr.24373
  25. Perera S, Mody SH, Woodman RC, Studenski SA. Meaningful change and responsiveness in common physical performance measures in older adults. J Am Geriatr Soc. 2006;54:743-749. doi:10.1111/j.1532-5415.2006.00701.x
  26. Wright AA, Cook CE, Baxter GD, Dockerty JD, Abbott JH. A comparison of 3 methodological approaches to defining major clinically important improvement of 4 performance measures in patients with hip osteoarthritis. J Orthop Sports Phys Ther. 2011;41:319-327. doi:10.2519/jospt.2011.3515
  27. Dobson F, Hinman R, Roos EM, et al. OARSI recommended performance-based tests to assess physical function in people diagnosed with hip or knee osteoarthritis. Osteoarthritis Cartilage. 2013;21:1042- 1052. doi:10.1016/j.joca.2013.05.002
  28. Hughes SL, Seymour RB, Campbell R, Pollak N, Huber G, Sharma L. Impact of the fit and strong intervention on older adults with osteoarthritis. Gerontologist. 2004;44:217-228. doi:10.1093/geront/44.2.217
  29. Callahan LF, Shreffler JH, Altpeter M, et al. Evaluation of group and self-directed formats of the Arthritis Foundation's Walk With Ease Program. Arthritis Care Res (Hoboken). 2011;63:1098-1107. doi:10.1002/acr.20490
  30. Boutaugh ML. Arthritis Foundation community-based physical activity programs: effectiveness and implementation issues. Arthritis Rheum. 2003;49:463-470. doi:10.1002/art.11050
  31. Callahan LF, Mielenz T, Freburger J, et al. A randomized controlled trial of the People with Arthritis Can Exercise Program: symptoms, function, physical activity, and psychosocial outcomes. Arthritis Rheum. 2008;59:92-101. doi:10.1002/art.23239
  32. Hall KS, Jennings SC, Pearson MP. Outpatient care models: the Gerofit model of care for exercise promotion in older adults. In: Malone ML, Boltz M, Macias Tejada J, White H, eds. Geriatrics Models of Care. Springer; 2024:205-213. doi:10.1007/978-3-031-56204-4_21
  33. Pepin MJ, Valencia WM, Bettger JP, et al. Impact of supervised exercise on one-year medication use in older veterans with multiple morbidities. Gerontol Geriatr Med. 2020;6:2333721420956751. doi:10.1177/ 2333721420956751
  34. Abbate L, Li J, Veazie P, et al. Does Gerofit exercise reduce veterans’ use of emergency department and inpatient care? Innov Aging. 2020;4(suppl 1):771. doi:10.1093/geroni/igaa057.2786
  35. Morey MC, Pieper CF, Crowley GM, Sullivan RJ Jr, Puglisi CM. Exercise adherence and 10-year mortality in chronically ill older adults. J Am Geriatr Soc. 2002;50:1929-1933. doi:10.1046/j.1532-5415.2002.50602.x
  36. Manning KM, Hall KS, Sloane R, et al. Longitudinal analysis of physical function in older adults: the effects of physical inactivity and exercise training. Aging Cell. 2024;23:e13987. doi:10.1111/acel.13987
  37. Bean JF, Vora A, Frontera WR. Benefits of exercise for community-dwelling older adults. Arch Phys Med Rehabil. 2004;85(7 suppl 3):S31-S42; quiz S3-S4. doi:10.1016/j.apmr.2004.03.010
  38. Covinsky KE, Lindquist K, Dunlop DD, Yelin E. Pain, functional limitations, and aging. J Am Geriatr Soc. 2009; 57:1556-1561. doi:10.1111/j.1532-5415.2009.02388.x
  39. Katz JN, Wright EA, Baron JA, Losina E. Development and validation of an index of musculoskeletal functional limitations. BMC Musculoskelet Disord. 2009;10:62. doi:10.1186/1471-2474-10-62
  40. Allen KD, Thoma LM, Golightly YM. Epidemiology of osteoarthritis. Osteoarthritis Cartilage. 2022;30:184-195. doi:10.1016/j.joca.2021.04.020
  41. Riebe D, Blissmer BJ, Greaney ML, Ewing Garber C, Lees FD, Clark PG. The relationship between obesity, physical activity, and physical function in older adults. J Aging Health. 2009;21:1159-1178. doi:10.1177/0898264309350076
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Impact of 3 Months of Supervised Exercise on Function by Arthritis Status

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Impact of 3 Months of Supervised Exercise on Function by Arthritis Status

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Common Ground: Primary Care and Specialty Clinicians’ Perceptions of E-Consults in the Veterans Health Administration

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Author(s)
Chelsea Leonard, PhD
Rachael R. Kenney,MA
Marcie Lee, MA, MPH
Preston Greene, PhDb
Melanie Whittington, PhD
Susan Kirsh, MD, MPA
P. Michael Ho, MD, PhD
George Sayre, PsyD
Joseph Simonetti, MD, MPH

Electronic consultation (e-consult) is designed to increase access to specialty care by facilitating communication between primary care and specialty clinicians without the need for outpatient face-to-face encounters.1–4 In 2011, the US Department of Veterans Affairs (VA) implemented an e-consult program as a component of its overall strategy to increase access to specialty services, reduce costs of care, and reduce appointment travel burden on patients.

E-consult has substantially increased within the VA since its implementation.5,6 Consistent with limited evaluations from other health care systems, evaluations of the VA e-consult program demonstrated reduced costs, reduced travel time for patients, and improved access to specialty care.2,5–11 However, there is wide variation in e-consult use across VA specialties, facilities, and regions.5,6,12,13 For example, hematology, preoperative evaluation, neurosurgery, endocrinology, and infectious diseases use e-consults more frequently when compared with in-person consults in the VA.6 Reasons for this variation or specific barriers and facilitators of using e-consults have not been described.

Prior qualitative studies report that primary care practitioners (PCPs) describe e-consults as convenient, educational, beneficial for patient care, and useful for improving patient access to specialty care.8,14,15 One study identified limited PCP knowledge of e-consults as a barrier to use.16 Specialists have reported that e-consult improves clinical communication, but increases their workload.1,14,17,18 These studies did not assess perspectives from both clinicians who initiate e-consults and those who respond to them. This is the first qualitative study to assess e-consult perceptions from perspectives of both PCPs and specialists among a large, national sample of VA clinicians who use e-consults. The objective of this study was to understand perspectives of e-consults between PCPs and specialists that may be relevant to increasing adoption in the VA.

 

Methods

The team (CL, ML, PG, 2 analysts under the guidance of GS and JS and support from RRK, and a biostatistician) conducted semistructured interviews with PCPs, specialists, and specialty division leaders who were employed by VA in 2016 and 2017. Specialties of interest were identified by the VA Office of Specialty Care and included cardiology, endocrinology, gastroenterology, and hematology.

E-Consult Procedures

Within the VA, the specific procedures used to initiate, triage and manage e-consults are coordinated at VA medical centers (VAMCs) and at the Veterans Integrated Service Network (VISN) regional level. E-consult can be requested by any clinician. Generally, e-consults are initiated by PCPs through standardized, specialty-specific templates. Recipients, typically specialists, respond by answering questions, suggesting additional testing and evaluation, or requesting an in-person visit. Communication is documented in the patient’s electronic health record (EHR). Specialists receive different levels of workload credit for responding to e-consults similar to a relative value unit reimbursement model. Training in the use of e-consults is available to practitioners but may vary at local and regional levels.

Recruitment

Our sample included PCPs, specialists, and specialty care division leaders. We first quantified e-consult rates (e-consults per 100 patient visits) between July 2016 and June 2017 at VA facilities within primary care and the 4 priority specialties and identified the 30 sites with the highest e-consult rates and 30 sites with the lowest e-consult rates. Sites with < 500 total visits, < 3 specialties, or without any e-consult visit during the study period were excluded. E-consult rates at community-based outpatient clinics were included with associated VAMCs. We then stratified PCPs by whether they were high or low users of e-consults (determined by the top and bottom users within each site) and credentials (MD vs nurse practitioner [NP] or physician assistant [PA]). Specialists were sampled based on their rate of use relative to colleagues within their site and the use rate of their division. We sampled division chiefs and individuals who had > 300 total visits and 1 e-consult during the study period. To recruit participants, the primary investigator sent an initial email and 2 reminder emails. The team followed up with respondents to schedule an interview.

Interview guides were designed to elicit rich descriptions of barriers and facilitators to e-consult use (eAppendix available at doi:10.12788/fp.0214). The team used the Practical Robust Implementation and Sustainability Model (PRISM), which considers factors along 6 domains for intervention planning, implementation, and sustainment.19 Telephone interviews lasted about 20 minutes and were conducted between September 2017 and March 2018. Interviews were recorded and transcribed verbatim.

Analysis

The team used an iterative, team-based, inductive/deductive approach to conventional content analysis.20,21 Initial code categories were created so that we could identify e-consult best practices—facilitators of e-consult that were recommended by both PCPs and specialists. Inductive codes or labels applied to identify meaningful quotations, phrases, or key terms were used to identify emergent ideas and were added throughout coding after discussion among team members. Consensus was reached using a team-based approach.21 Four analysts independently coded the same 3 transcripts and met to discuss points of divergence and convergence. Analyses continued with emergent themes, categories, and conclusions. Atlas.ti. v.7 was used for coding and data management.22

 

 

Results

We conducted 34 interviews with clinicians (Table 1) from 13 VISNs. Four best-practice themes emerged among both PCPs and specialists, including that e-consults (1) are best suited for certain clinical questions and patients; (2) require relevant background information from requesting clinicians and clear recommendations from responding clinicians; (3) are a novel opportunity to provide efficient, transparent care; and (4) may not be fully adopted due to low awareness. Supporting quotations for the following findings are provided in Table 2.

Supporting Quotations

Description of Participants

Specific Clinical Questions and Patients

PCPs described specific patients and questions for which they most frequently used e-consults, such as for medication changes (Q1), determining treatment steps (Q2,3), and or clarifying laboratory or imaging findings. PCPs frequently used e-consults for patients who did not require a physical examination or when specialists could make recommendations without seeing patients face-to-face (Q3). An important use of e-consults described by PCPs was for treating conditions they could manage within primary care if additional guidance were available (Q4). Several PCPs and specialists also noted that e-consults were particularly useful for patients who were unable to travel or did not want face-to-face appointments (Q5). Notably, PCPs and specialists mentioned situations for which e-consults were inappropriate, including when a detailed history or physical examination was needed, or if a complex condition was suspected (Q6).

Background Data and Clear Recommendations

Participants described necessary data that should be included in high-quality e-consults. Specialists voiced frustration in time-consuming chart reviews that were often necessary when these data were not provided by the requestor. In some cases, specialists were unable to access necessary EHR data, which delayed responses (Q7). PCPs noted that the most useful responses carefully considered the question, used current patient information to determine treatments, provided clear recommendations, and defined who was responsible for next steps (Q8). PCPs and specialists stated that e-consult templates that required relevant information facilitated high-quality e-consults. Neither wanted to waste the other clinician's time (Q8).

A Novel Opportunity

Many PCPs felt that e-consults improved communication (eg, efficiency, response time), established new communication between clinicians, and reduced patients’ appointment burden (Q10, Q11). Many specialists felt that e-consults improved documentation of communication between clinicians and increased transparency of clinical decisions (Q12). Additionally, many specialists mentioned that e-consults capture previously informal curbside consults, enabling them to receive workload credit (Q13).

Lack of Awareness

Some noted that the biggest barrier to e-consults was not being aware of them generally, or which specialties offer e-consults (Q14). One PCP described e-consults as the best kept secret and found value in sharing the utility of e-consults with colleagues (Q15). All participants, including those who did not frequently use e-consults, felt that e-consults improved the quality of care by providing more timely care or better answers to clinical questions (Q16). Several practitioners also felt that e-consults increased access to specialty care. For example, specialists reported that e-consults enabled them to better manage patient load by using e-consults to answer relatively simple questions, reserving face-to-face consults for more complex patients (Q17).

Discussion

The objective of this study was to identify potential best practices for e-consults that may help increase their quality and use within the VA. We built on prior studies that offered insights on PCP and specialists’ overall satisfaction with e-consult by identifying several themes relevant to the further adoption of e-consults in the VA and elsewhere without a face-to-face visit.8,13,14,16–18 Future work may be beneficial in identifying whether the study themes identified can explain variation in e-consult use or whether addressing these factors might lead to increased or higher quality e-consult use. We are unaware of any qualitative study of comparable scale in a different health care system. Further, this is the first study to assess perspectives on e-consults among those who initiate and respond to them within the same health care system. Perhaps the most important finding from this study is that e-consults are generally viewed favorably, which is a necessary leverage point to increase their adoption within the system.

 

 

Clinicians reported several benefits to e-consults, including timely responses to clinical questions, efficient communication, allow for documentation of specialist recommendations, and help capture workload. These benefits are consistent with prior literature that indicates both PCPs and specialists in the VA and other health care systems feel that e-consults improves communication, decreases unnecessary visits, and improves quality of care.1,14,17,18 In particular, clinicians reported that e-consults improve their practice efficiency and efficacy. This is of critical importance given the pressures of providing timely access to primary and specialty care within the VA. Interestingly, many VA practitioners were unaware which specialties offered e-consults within their facilities, reflecting previous work showing that PCPs are often unaware of e-consult options.16 This may partially explain variation in e-consult use. Increasing awareness and educating clinicians on the benefits of e-consults may help promote use among non- and low users.

A common theme reported by both groups was the importance of providing necessary information within e-consult questions and responses. Specialists felt there was a need to ensure that PCPs provide relevant and patient-specific information that would enable them to efficiently and accurately answer questions without the need for extensive EHR review. This reflects previous work showing that specialists are often unable to respond to e-consult requests because they do not contain sufficient information.22 PCPs described a need to ensure that specialists’ responses included information that was detailed enough to make clinical decisions without the need for a reconsult. This highlights a common challenge to medical consultation, in that necessary or relevant information may not be apparent to all clinicians. To address this, there may be a role in developing enhanced, flexible templating that elicits necessary patient-specific information. Such a template may automatically pull relevant data from the EHR and prompt clinicians to provide important information. We did not assess how perspectives of templates varied, and further work could help define precisely what constitutes an effective template, including how it should capture appropriate patient data and how this impacts acceptability or use of e-consults generally. Collaboratively developed service agreements and e-consult templates could help guide PCPs and specialists to engage in efficient communication.

Another theme among both groups was that e-consult is most appropriate within specific clinical scenarios. Examples included review of laboratory results, questions about medication changes, or for patients who were reluctant to travel to appointments. Identifying and promoting specific opportunities for e-consults may help increase their use and align e-consult practices with scenarios that are likely to provide the most benefit to patients. For example, it could be helpful to understand the distance patients must travel for specialty care. Providing that information during clinical encounters could trigger clinicians to consider e-consults as an option. Future work might aim to identify clinical scenarios that clinicians feel are not well suited for e-consults and determine how to adapt them for those scenarios.

Limitations

Generalizability of these findings is limited given the qualitative study design. Participants’ descriptions of experiences with e-consults reflect the experiences of clinicians in the VA and may not reflect clinicians in other settings. We also interviewed a sample of clinicians who were already using e-consults. Important information could be learned from future work with those who have not yet adopted e-consult procedures or adopted and abandoned them.

Conclusions

E-consult is perceived as beneficial by VA PCPs and specialists. Participants suggested using e-consults for appropriate questions or patients and including necessary information and next steps in both the initial e-consult and response. Finding ways to facilitate e-consults with these suggestions in mind may increase delivery of high-quality e-consults. Future work could compare the findings of this work to similar work assessing clinicians perceptions of e-consults outside of the VA.

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econsult_appendix.pdf
References

1. Battaglia C, Lambert-Kerzner A, Aron DC, et al. Evaluation of e-consults in the VHA: provider perspectives. Fed Pract. 2015;32(7):42-48.

2. Haverhals LM, Sayre G, Helfrich CD, et al. E-consult implementation: lessons learned using consolidated framework for implementation research. Am J Manag Care. 2015;21(12):e640-e647. Published 2015 Dec 1.

3. Sewell JL, Telischak KS, Day LW, Kirschner N, Weissman A. Preconsultation exchange in the United States: use, awareness, and attitudes. Am J Manag Care. 2014;20(12):e556-e564. Published 2014 Dec 1.

4. Horner K, Wagner E, Tufano J. Electronic consultations between primary and specialty care clinicians: early insights. Issue Brief (Commonw Fund). 2011;23:1-14.

5. Kirsh S, Carey E, Aron DC, et al. Impact of a national specialty e-consultation implementation project on access. Am J Manag Care. 2015;21(12):e648-654. Published 2015 Dec 1.

6. Saxon DR, Kaboli PJ, Haraldsson B, Wilson C, Ohl M, Augustine MR. Growth of electronic consultations in the Veterans Health Administration. Am J Manag Care. 2021;27(1):12-19. doi:10.37765/ajmc.2021.88572

7. Olayiwola JN, Anderson D, Jepeal N, et al. Electronic consultations to improve the primary care-specialty care interface for cardiology in the medically underserved: a cluster-randomized controlled trial. Ann Fam Med. 2016;14(2):133-140. doi:10.1370/afm.1869

8. Schettini P, Shah KP, O’Leary CP, et al. Keeping care connected: e-Consultation program improves access to nephrology care. J Telemed Telecare. 2019;25(3):142-150. doi:10.1177/1357633X17748350

9. Whittington MD, Ho PM, Kirsh SR, et al. Cost savings associated with electronic specialty consultations. Am J Manag Care. 2021;27(1):e16-e23. Published 2021 Jan 1. doi:10.37765/ajmc.2021.88579

10. Shipherd JC, Kauth MR, Matza A. Nationwide interdisciplinary e-consultation on transgender care in the Veterans Health Administration. Telemed J E Health. 2016;22(12):1008-1012. doi:10.1089/tmj.2016.0013

11. Strymish J, Gupte G, Afable MK, et al. Electronic consultations (E-consults): advancing infectious disease care in a large Veterans Affairs Healthcare System. Clin Infect Dis. 2017;64(8):1123-1125. doi:10.1093/cid/cix058

12. Williams KM, Kirsh S, Aron D, et al. Evaluation of the Veterans Health Administration’s Specialty Care Transformational Initiatives to promote patient-centered delivery of specialty care: a mixed-methods approach. Telemed J E-Health. 2017;23(7):577-589. doi:10.1089/tmj.2016.0166

13. US Department of Veterans Affairs, Veterans Health Administration, Specialty Care Transformational Initiative Evaluation Center. Evaluation of specialty care initiatives. Published 2013.

14. Vimalananda VG, Gupte G, Seraj SM, et al. Electronic consultations (e-consults) to improve access to specialty care: a systematic review and narrative synthesis. J Telemed Telecare. 2015;21(6):323-330. doi:10.1177/1357633X15582108

15. Lee M, Leonard C, Greene P, et al. Perspectives of VA primary care clinicians toward electronic consultation-related workload burden. JAMA Netw Open. 2020;3(10):e2018104. Published 2020 Oct 1. doi:10.1001/jamanetworkopen.2020.18104

16. Deeds SA, Dowdell KJ, Chew LD, Ackerman SL. Implementing an opt-in eConsult program at seven academic medical centers: a qualitative analysis of primary care provider experiences. J Gen Intern Med. 2019;34(8):1427-1433. doi:10.1007/s11606-019-05067-7

17. Rodriguez KL, Burkitt KH, Bayliss NK, et al. Veteran, primary care provider, and specialist satisfaction with electronic consultation. JMIR Med Inform. 2015;3(1):e5. Published 2015 Jan 14. doi:10.2196/medinform.3725

18. Gupte G, Vimalananda V, Simon SR, DeVito K, Clark J, Orlander JD. Disruptive innovation: implementation of electronic consultations in a Veterans Affairs Health Care System. JMIR Med Inform. 2016;4(1):e6. Published 2016 Feb 12. doi:10.2196/medinform.4801

19. Feldstein AC, Glasgow RE. A practical, robust implementation and sustainability model (PRISM) for integrating research findings into practice. Jt Comm J Qual Patient Saf. 2008;34(4):228-243. doi:10.1016/s1553-7250(08)34030-6

20. Patton MQ. Qualitative Research and Evaluation Methods. 3rd ed. Sage Publications; 2002.

21. Bradley EH, Curry LA, Devers KJ. Qualitative data analysis for health services research: developing taxonomy, themes, and theory. Health Serv Res. 2007;42(4):1758-1772. doi:10.1111/j.1475-6773.2006.00684.x

22. Kim EJ, Orlander JD, Afable M, et al. Cardiology electronic consultation (e-consult) use by primary care providers at VA medical centres in New England. J Telemed Telecare. 2019;25(6):370-377. doi:10.1177/1357633X18774468

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Author and Disclosure Information

Chelsea Leonard, PhDa; Rachael R. Kenney, MAa; Marcie Lee, MA, MPHa; Preston Greene, PhDb; Melanie Whittington, PhDa,c; Susan Kirsh, MD, MPAd; P. Michael Ho, MD, PhDa; George Sayre, PsyDb; and Joseph Simonetti, MD, MPHe
Correspondence: Chelsea.Leonard ([email protected])

Author affiliations

aDenver/Seattle Center of Innovation for Veteran-Centered and Value-Driven Care, Aurora, Colorado
bDenver/Seattle Center of Innovation for Veteran-Centered and Value-Driven Care, Seattle, Washington
cDepartment of Clinical Pharmacy at the University of Colorado Anschutz Medical Campus, Aurora
dCase Western Reserve University School of Medicine, Cleveland, Ohio; Veteran Affairs Central Office, Washington, DC
eDivision of Hospital Medicine, University of Colorado School of Medicine, Aurora

Author disclosures

Dr. Ho is supported by research grants from NHLBI, VA HSR&D, and University of Colorado School of Medicine. He has a research agreement with Bristol-Myers Squibb administered by the University of Colorado. The authors report no other actual or potential conflicts of interest with regard to this article.

Disclaimer

The opinions expressed herein are those of the authors and do not necessarily reflect those of Federal Practitioner, Frontline Medical Communications Inc., the US Government, or any of its agencies.

Ethics and consent

The activities were undertaken in support of a Veterans Health Administration (VHA) operational project and did not constitute research, in whole or in part, in compliance with VHA Handbook 1058.05. Therefore, institutional review board approval was not required.

Funding

This work was funded by the VHA Office of Rural Health and sponsored by the VHA Office of Veterans Access to Care, Department of Veterans Affairs, Washington, DC through a MyVA Access Improvement Project Grant: “VISN 19 VA Denver Developing best practices for subspecialty e‐consultation procedures.”

 

 

 

 

Issue
Federal Practitioner - 39(1)a
Publications
Federal Practitioner
Topics
Hospital Medicine
Page Number
42-48
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Original Research
Author(s)
Chelsea Leonard, PhD
Rachael R. Kenney,MA
Marcie Lee, MA, MPH
Preston Greene, PhDb
Melanie Whittington, PhD
Susan Kirsh, MD, MPA
P. Michael Ho, MD, PhD
George Sayre, PsyD
Joseph Simonetti, MD, MPH
Author(s)
Chelsea Leonard, PhD
Rachael R. Kenney,MA
Marcie Lee, MA, MPH
Preston Greene, PhDb
Melanie Whittington, PhD
Susan Kirsh, MD, MPA
P. Michael Ho, MD, PhD
George Sayre, PsyD
Joseph Simonetti, MD, MPH
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Chelsea Leonard, PhDa; Rachael R. Kenney, MAa; Marcie Lee, MA, MPHa; Preston Greene, PhDb; Melanie Whittington, PhDa,c; Susan Kirsh, MD, MPAd; P. Michael Ho, MD, PhDa; George Sayre, PsyDb; and Joseph Simonetti, MD, MPHe
Correspondence: Chelsea.Leonard ([email protected])

Author affiliations

aDenver/Seattle Center of Innovation for Veteran-Centered and Value-Driven Care, Aurora, Colorado
bDenver/Seattle Center of Innovation for Veteran-Centered and Value-Driven Care, Seattle, Washington
cDepartment of Clinical Pharmacy at the University of Colorado Anschutz Medical Campus, Aurora
dCase Western Reserve University School of Medicine, Cleveland, Ohio; Veteran Affairs Central Office, Washington, DC
eDivision of Hospital Medicine, University of Colorado School of Medicine, Aurora

Author disclosures

Dr. Ho is supported by research grants from NHLBI, VA HSR&D, and University of Colorado School of Medicine. He has a research agreement with Bristol-Myers Squibb administered by the University of Colorado. The authors report no other actual or potential conflicts of interest with regard to this article.

Disclaimer

The opinions expressed herein are those of the authors and do not necessarily reflect those of Federal Practitioner, Frontline Medical Communications Inc., the US Government, or any of its agencies.

Ethics and consent

The activities were undertaken in support of a Veterans Health Administration (VHA) operational project and did not constitute research, in whole or in part, in compliance with VHA Handbook 1058.05. Therefore, institutional review board approval was not required.

Funding

This work was funded by the VHA Office of Rural Health and sponsored by the VHA Office of Veterans Access to Care, Department of Veterans Affairs, Washington, DC through a MyVA Access Improvement Project Grant: “VISN 19 VA Denver Developing best practices for subspecialty e‐consultation procedures.”

 

 

 

 

Author and Disclosure Information

Chelsea Leonard, PhDa; Rachael R. Kenney, MAa; Marcie Lee, MA, MPHa; Preston Greene, PhDb; Melanie Whittington, PhDa,c; Susan Kirsh, MD, MPAd; P. Michael Ho, MD, PhDa; George Sayre, PsyDb; and Joseph Simonetti, MD, MPHe
Correspondence: Chelsea.Leonard ([email protected])

Author affiliations

aDenver/Seattle Center of Innovation for Veteran-Centered and Value-Driven Care, Aurora, Colorado
bDenver/Seattle Center of Innovation for Veteran-Centered and Value-Driven Care, Seattle, Washington
cDepartment of Clinical Pharmacy at the University of Colorado Anschutz Medical Campus, Aurora
dCase Western Reserve University School of Medicine, Cleveland, Ohio; Veteran Affairs Central Office, Washington, DC
eDivision of Hospital Medicine, University of Colorado School of Medicine, Aurora

Author disclosures

Dr. Ho is supported by research grants from NHLBI, VA HSR&D, and University of Colorado School of Medicine. He has a research agreement with Bristol-Myers Squibb administered by the University of Colorado. The authors report no other actual or potential conflicts of interest with regard to this article.

Disclaimer

The opinions expressed herein are those of the authors and do not necessarily reflect those of Federal Practitioner, Frontline Medical Communications Inc., the US Government, or any of its agencies.

Ethics and consent

The activities were undertaken in support of a Veterans Health Administration (VHA) operational project and did not constitute research, in whole or in part, in compliance with VHA Handbook 1058.05. Therefore, institutional review board approval was not required.

Funding

This work was funded by the VHA Office of Rural Health and sponsored by the VHA Office of Veterans Access to Care, Department of Veterans Affairs, Washington, DC through a MyVA Access Improvement Project Grant: “VISN 19 VA Denver Developing best practices for subspecialty e‐consultation procedures.”

 

 

 

 

Article PDF
fdp03901042.pdf
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Evaluation of E-Consults in the VHA: Provider Perspectives

Electronic consultation (e-consult) is designed to increase access to specialty care by facilitating communication between primary care and specialty clinicians without the need for outpatient face-to-face encounters.1–4 In 2011, the US Department of Veterans Affairs (VA) implemented an e-consult program as a component of its overall strategy to increase access to specialty services, reduce costs of care, and reduce appointment travel burden on patients.

E-consult has substantially increased within the VA since its implementation.5,6 Consistent with limited evaluations from other health care systems, evaluations of the VA e-consult program demonstrated reduced costs, reduced travel time for patients, and improved access to specialty care.2,5–11 However, there is wide variation in e-consult use across VA specialties, facilities, and regions.5,6,12,13 For example, hematology, preoperative evaluation, neurosurgery, endocrinology, and infectious diseases use e-consults more frequently when compared with in-person consults in the VA.6 Reasons for this variation or specific barriers and facilitators of using e-consults have not been described.

Prior qualitative studies report that primary care practitioners (PCPs) describe e-consults as convenient, educational, beneficial for patient care, and useful for improving patient access to specialty care.8,14,15 One study identified limited PCP knowledge of e-consults as a barrier to use.16 Specialists have reported that e-consult improves clinical communication, but increases their workload.1,14,17,18 These studies did not assess perspectives from both clinicians who initiate e-consults and those who respond to them. This is the first qualitative study to assess e-consult perceptions from perspectives of both PCPs and specialists among a large, national sample of VA clinicians who use e-consults. The objective of this study was to understand perspectives of e-consults between PCPs and specialists that may be relevant to increasing adoption in the VA.

 

Methods

The team (CL, ML, PG, 2 analysts under the guidance of GS and JS and support from RRK, and a biostatistician) conducted semistructured interviews with PCPs, specialists, and specialty division leaders who were employed by VA in 2016 and 2017. Specialties of interest were identified by the VA Office of Specialty Care and included cardiology, endocrinology, gastroenterology, and hematology.

E-Consult Procedures

Within the VA, the specific procedures used to initiate, triage and manage e-consults are coordinated at VA medical centers (VAMCs) and at the Veterans Integrated Service Network (VISN) regional level. E-consult can be requested by any clinician. Generally, e-consults are initiated by PCPs through standardized, specialty-specific templates. Recipients, typically specialists, respond by answering questions, suggesting additional testing and evaluation, or requesting an in-person visit. Communication is documented in the patient’s electronic health record (EHR). Specialists receive different levels of workload credit for responding to e-consults similar to a relative value unit reimbursement model. Training in the use of e-consults is available to practitioners but may vary at local and regional levels.

Recruitment

Our sample included PCPs, specialists, and specialty care division leaders. We first quantified e-consult rates (e-consults per 100 patient visits) between July 2016 and June 2017 at VA facilities within primary care and the 4 priority specialties and identified the 30 sites with the highest e-consult rates and 30 sites with the lowest e-consult rates. Sites with < 500 total visits, < 3 specialties, or without any e-consult visit during the study period were excluded. E-consult rates at community-based outpatient clinics were included with associated VAMCs. We then stratified PCPs by whether they were high or low users of e-consults (determined by the top and bottom users within each site) and credentials (MD vs nurse practitioner [NP] or physician assistant [PA]). Specialists were sampled based on their rate of use relative to colleagues within their site and the use rate of their division. We sampled division chiefs and individuals who had > 300 total visits and 1 e-consult during the study period. To recruit participants, the primary investigator sent an initial email and 2 reminder emails. The team followed up with respondents to schedule an interview.

Interview guides were designed to elicit rich descriptions of barriers and facilitators to e-consult use (eAppendix available at doi:10.12788/fp.0214). The team used the Practical Robust Implementation and Sustainability Model (PRISM), which considers factors along 6 domains for intervention planning, implementation, and sustainment.19 Telephone interviews lasted about 20 minutes and were conducted between September 2017 and March 2018. Interviews were recorded and transcribed verbatim.

Analysis

The team used an iterative, team-based, inductive/deductive approach to conventional content analysis.20,21 Initial code categories were created so that we could identify e-consult best practices—facilitators of e-consult that were recommended by both PCPs and specialists. Inductive codes or labels applied to identify meaningful quotations, phrases, or key terms were used to identify emergent ideas and were added throughout coding after discussion among team members. Consensus was reached using a team-based approach.21 Four analysts independently coded the same 3 transcripts and met to discuss points of divergence and convergence. Analyses continued with emergent themes, categories, and conclusions. Atlas.ti. v.7 was used for coding and data management.22

 

 

Results

We conducted 34 interviews with clinicians (Table 1) from 13 VISNs. Four best-practice themes emerged among both PCPs and specialists, including that e-consults (1) are best suited for certain clinical questions and patients; (2) require relevant background information from requesting clinicians and clear recommendations from responding clinicians; (3) are a novel opportunity to provide efficient, transparent care; and (4) may not be fully adopted due to low awareness. Supporting quotations for the following findings are provided in Table 2.

Supporting Quotations

Description of Participants

Specific Clinical Questions and Patients

PCPs described specific patients and questions for which they most frequently used e-consults, such as for medication changes (Q1), determining treatment steps (Q2,3), and or clarifying laboratory or imaging findings. PCPs frequently used e-consults for patients who did not require a physical examination or when specialists could make recommendations without seeing patients face-to-face (Q3). An important use of e-consults described by PCPs was for treating conditions they could manage within primary care if additional guidance were available (Q4). Several PCPs and specialists also noted that e-consults were particularly useful for patients who were unable to travel or did not want face-to-face appointments (Q5). Notably, PCPs and specialists mentioned situations for which e-consults were inappropriate, including when a detailed history or physical examination was needed, or if a complex condition was suspected (Q6).

Background Data and Clear Recommendations

Participants described necessary data that should be included in high-quality e-consults. Specialists voiced frustration in time-consuming chart reviews that were often necessary when these data were not provided by the requestor. In some cases, specialists were unable to access necessary EHR data, which delayed responses (Q7). PCPs noted that the most useful responses carefully considered the question, used current patient information to determine treatments, provided clear recommendations, and defined who was responsible for next steps (Q8). PCPs and specialists stated that e-consult templates that required relevant information facilitated high-quality e-consults. Neither wanted to waste the other clinician's time (Q8).

A Novel Opportunity

Many PCPs felt that e-consults improved communication (eg, efficiency, response time), established new communication between clinicians, and reduced patients’ appointment burden (Q10, Q11). Many specialists felt that e-consults improved documentation of communication between clinicians and increased transparency of clinical decisions (Q12). Additionally, many specialists mentioned that e-consults capture previously informal curbside consults, enabling them to receive workload credit (Q13).

Lack of Awareness

Some noted that the biggest barrier to e-consults was not being aware of them generally, or which specialties offer e-consults (Q14). One PCP described e-consults as the best kept secret and found value in sharing the utility of e-consults with colleagues (Q15). All participants, including those who did not frequently use e-consults, felt that e-consults improved the quality of care by providing more timely care or better answers to clinical questions (Q16). Several practitioners also felt that e-consults increased access to specialty care. For example, specialists reported that e-consults enabled them to better manage patient load by using e-consults to answer relatively simple questions, reserving face-to-face consults for more complex patients (Q17).

Discussion

The objective of this study was to identify potential best practices for e-consults that may help increase their quality and use within the VA. We built on prior studies that offered insights on PCP and specialists’ overall satisfaction with e-consult by identifying several themes relevant to the further adoption of e-consults in the VA and elsewhere without a face-to-face visit.8,13,14,16–18 Future work may be beneficial in identifying whether the study themes identified can explain variation in e-consult use or whether addressing these factors might lead to increased or higher quality e-consult use. We are unaware of any qualitative study of comparable scale in a different health care system. Further, this is the first study to assess perspectives on e-consults among those who initiate and respond to them within the same health care system. Perhaps the most important finding from this study is that e-consults are generally viewed favorably, which is a necessary leverage point to increase their adoption within the system.

 

 

Clinicians reported several benefits to e-consults, including timely responses to clinical questions, efficient communication, allow for documentation of specialist recommendations, and help capture workload. These benefits are consistent with prior literature that indicates both PCPs and specialists in the VA and other health care systems feel that e-consults improves communication, decreases unnecessary visits, and improves quality of care.1,14,17,18 In particular, clinicians reported that e-consults improve their practice efficiency and efficacy. This is of critical importance given the pressures of providing timely access to primary and specialty care within the VA. Interestingly, many VA practitioners were unaware which specialties offered e-consults within their facilities, reflecting previous work showing that PCPs are often unaware of e-consult options.16 This may partially explain variation in e-consult use. Increasing awareness and educating clinicians on the benefits of e-consults may help promote use among non- and low users.

A common theme reported by both groups was the importance of providing necessary information within e-consult questions and responses. Specialists felt there was a need to ensure that PCPs provide relevant and patient-specific information that would enable them to efficiently and accurately answer questions without the need for extensive EHR review. This reflects previous work showing that specialists are often unable to respond to e-consult requests because they do not contain sufficient information.22 PCPs described a need to ensure that specialists’ responses included information that was detailed enough to make clinical decisions without the need for a reconsult. This highlights a common challenge to medical consultation, in that necessary or relevant information may not be apparent to all clinicians. To address this, there may be a role in developing enhanced, flexible templating that elicits necessary patient-specific information. Such a template may automatically pull relevant data from the EHR and prompt clinicians to provide important information. We did not assess how perspectives of templates varied, and further work could help define precisely what constitutes an effective template, including how it should capture appropriate patient data and how this impacts acceptability or use of e-consults generally. Collaboratively developed service agreements and e-consult templates could help guide PCPs and specialists to engage in efficient communication.

Another theme among both groups was that e-consult is most appropriate within specific clinical scenarios. Examples included review of laboratory results, questions about medication changes, or for patients who were reluctant to travel to appointments. Identifying and promoting specific opportunities for e-consults may help increase their use and align e-consult practices with scenarios that are likely to provide the most benefit to patients. For example, it could be helpful to understand the distance patients must travel for specialty care. Providing that information during clinical encounters could trigger clinicians to consider e-consults as an option. Future work might aim to identify clinical scenarios that clinicians feel are not well suited for e-consults and determine how to adapt them for those scenarios.

Limitations

Generalizability of these findings is limited given the qualitative study design. Participants’ descriptions of experiences with e-consults reflect the experiences of clinicians in the VA and may not reflect clinicians in other settings. We also interviewed a sample of clinicians who were already using e-consults. Important information could be learned from future work with those who have not yet adopted e-consult procedures or adopted and abandoned them.

Conclusions

E-consult is perceived as beneficial by VA PCPs and specialists. Participants suggested using e-consults for appropriate questions or patients and including necessary information and next steps in both the initial e-consult and response. Finding ways to facilitate e-consults with these suggestions in mind may increase delivery of high-quality e-consults. Future work could compare the findings of this work to similar work assessing clinicians perceptions of e-consults outside of the VA.

Electronic consultation (e-consult) is designed to increase access to specialty care by facilitating communication between primary care and specialty clinicians without the need for outpatient face-to-face encounters.1–4 In 2011, the US Department of Veterans Affairs (VA) implemented an e-consult program as a component of its overall strategy to increase access to specialty services, reduce costs of care, and reduce appointment travel burden on patients.

E-consult has substantially increased within the VA since its implementation.5,6 Consistent with limited evaluations from other health care systems, evaluations of the VA e-consult program demonstrated reduced costs, reduced travel time for patients, and improved access to specialty care.2,5–11 However, there is wide variation in e-consult use across VA specialties, facilities, and regions.5,6,12,13 For example, hematology, preoperative evaluation, neurosurgery, endocrinology, and infectious diseases use e-consults more frequently when compared with in-person consults in the VA.6 Reasons for this variation or specific barriers and facilitators of using e-consults have not been described.

Prior qualitative studies report that primary care practitioners (PCPs) describe e-consults as convenient, educational, beneficial for patient care, and useful for improving patient access to specialty care.8,14,15 One study identified limited PCP knowledge of e-consults as a barrier to use.16 Specialists have reported that e-consult improves clinical communication, but increases their workload.1,14,17,18 These studies did not assess perspectives from both clinicians who initiate e-consults and those who respond to them. This is the first qualitative study to assess e-consult perceptions from perspectives of both PCPs and specialists among a large, national sample of VA clinicians who use e-consults. The objective of this study was to understand perspectives of e-consults between PCPs and specialists that may be relevant to increasing adoption in the VA.

 

Methods

The team (CL, ML, PG, 2 analysts under the guidance of GS and JS and support from RRK, and a biostatistician) conducted semistructured interviews with PCPs, specialists, and specialty division leaders who were employed by VA in 2016 and 2017. Specialties of interest were identified by the VA Office of Specialty Care and included cardiology, endocrinology, gastroenterology, and hematology.

E-Consult Procedures

Within the VA, the specific procedures used to initiate, triage and manage e-consults are coordinated at VA medical centers (VAMCs) and at the Veterans Integrated Service Network (VISN) regional level. E-consult can be requested by any clinician. Generally, e-consults are initiated by PCPs through standardized, specialty-specific templates. Recipients, typically specialists, respond by answering questions, suggesting additional testing and evaluation, or requesting an in-person visit. Communication is documented in the patient’s electronic health record (EHR). Specialists receive different levels of workload credit for responding to e-consults similar to a relative value unit reimbursement model. Training in the use of e-consults is available to practitioners but may vary at local and regional levels.

Recruitment

Our sample included PCPs, specialists, and specialty care division leaders. We first quantified e-consult rates (e-consults per 100 patient visits) between July 2016 and June 2017 at VA facilities within primary care and the 4 priority specialties and identified the 30 sites with the highest e-consult rates and 30 sites with the lowest e-consult rates. Sites with < 500 total visits, < 3 specialties, or without any e-consult visit during the study period were excluded. E-consult rates at community-based outpatient clinics were included with associated VAMCs. We then stratified PCPs by whether they were high or low users of e-consults (determined by the top and bottom users within each site) and credentials (MD vs nurse practitioner [NP] or physician assistant [PA]). Specialists were sampled based on their rate of use relative to colleagues within their site and the use rate of their division. We sampled division chiefs and individuals who had > 300 total visits and 1 e-consult during the study period. To recruit participants, the primary investigator sent an initial email and 2 reminder emails. The team followed up with respondents to schedule an interview.

Interview guides were designed to elicit rich descriptions of barriers and facilitators to e-consult use (eAppendix available at doi:10.12788/fp.0214). The team used the Practical Robust Implementation and Sustainability Model (PRISM), which considers factors along 6 domains for intervention planning, implementation, and sustainment.19 Telephone interviews lasted about 20 minutes and were conducted between September 2017 and March 2018. Interviews were recorded and transcribed verbatim.

Analysis

The team used an iterative, team-based, inductive/deductive approach to conventional content analysis.20,21 Initial code categories were created so that we could identify e-consult best practices—facilitators of e-consult that were recommended by both PCPs and specialists. Inductive codes or labels applied to identify meaningful quotations, phrases, or key terms were used to identify emergent ideas and were added throughout coding after discussion among team members. Consensus was reached using a team-based approach.21 Four analysts independently coded the same 3 transcripts and met to discuss points of divergence and convergence. Analyses continued with emergent themes, categories, and conclusions. Atlas.ti. v.7 was used for coding and data management.22

 

 

Results

We conducted 34 interviews with clinicians (Table 1) from 13 VISNs. Four best-practice themes emerged among both PCPs and specialists, including that e-consults (1) are best suited for certain clinical questions and patients; (2) require relevant background information from requesting clinicians and clear recommendations from responding clinicians; (3) are a novel opportunity to provide efficient, transparent care; and (4) may not be fully adopted due to low awareness. Supporting quotations for the following findings are provided in Table 2.

Supporting Quotations

Description of Participants

Specific Clinical Questions and Patients

PCPs described specific patients and questions for which they most frequently used e-consults, such as for medication changes (Q1), determining treatment steps (Q2,3), and or clarifying laboratory or imaging findings. PCPs frequently used e-consults for patients who did not require a physical examination or when specialists could make recommendations without seeing patients face-to-face (Q3). An important use of e-consults described by PCPs was for treating conditions they could manage within primary care if additional guidance were available (Q4). Several PCPs and specialists also noted that e-consults were particularly useful for patients who were unable to travel or did not want face-to-face appointments (Q5). Notably, PCPs and specialists mentioned situations for which e-consults were inappropriate, including when a detailed history or physical examination was needed, or if a complex condition was suspected (Q6).

Background Data and Clear Recommendations

Participants described necessary data that should be included in high-quality e-consults. Specialists voiced frustration in time-consuming chart reviews that were often necessary when these data were not provided by the requestor. In some cases, specialists were unable to access necessary EHR data, which delayed responses (Q7). PCPs noted that the most useful responses carefully considered the question, used current patient information to determine treatments, provided clear recommendations, and defined who was responsible for next steps (Q8). PCPs and specialists stated that e-consult templates that required relevant information facilitated high-quality e-consults. Neither wanted to waste the other clinician's time (Q8).

A Novel Opportunity

Many PCPs felt that e-consults improved communication (eg, efficiency, response time), established new communication between clinicians, and reduced patients’ appointment burden (Q10, Q11). Many specialists felt that e-consults improved documentation of communication between clinicians and increased transparency of clinical decisions (Q12). Additionally, many specialists mentioned that e-consults capture previously informal curbside consults, enabling them to receive workload credit (Q13).

Lack of Awareness

Some noted that the biggest barrier to e-consults was not being aware of them generally, or which specialties offer e-consults (Q14). One PCP described e-consults as the best kept secret and found value in sharing the utility of e-consults with colleagues (Q15). All participants, including those who did not frequently use e-consults, felt that e-consults improved the quality of care by providing more timely care or better answers to clinical questions (Q16). Several practitioners also felt that e-consults increased access to specialty care. For example, specialists reported that e-consults enabled them to better manage patient load by using e-consults to answer relatively simple questions, reserving face-to-face consults for more complex patients (Q17).

Discussion

The objective of this study was to identify potential best practices for e-consults that may help increase their quality and use within the VA. We built on prior studies that offered insights on PCP and specialists’ overall satisfaction with e-consult by identifying several themes relevant to the further adoption of e-consults in the VA and elsewhere without a face-to-face visit.8,13,14,16–18 Future work may be beneficial in identifying whether the study themes identified can explain variation in e-consult use or whether addressing these factors might lead to increased or higher quality e-consult use. We are unaware of any qualitative study of comparable scale in a different health care system. Further, this is the first study to assess perspectives on e-consults among those who initiate and respond to them within the same health care system. Perhaps the most important finding from this study is that e-consults are generally viewed favorably, which is a necessary leverage point to increase their adoption within the system.

 

 

Clinicians reported several benefits to e-consults, including timely responses to clinical questions, efficient communication, allow for documentation of specialist recommendations, and help capture workload. These benefits are consistent with prior literature that indicates both PCPs and specialists in the VA and other health care systems feel that e-consults improves communication, decreases unnecessary visits, and improves quality of care.1,14,17,18 In particular, clinicians reported that e-consults improve their practice efficiency and efficacy. This is of critical importance given the pressures of providing timely access to primary and specialty care within the VA. Interestingly, many VA practitioners were unaware which specialties offered e-consults within their facilities, reflecting previous work showing that PCPs are often unaware of e-consult options.16 This may partially explain variation in e-consult use. Increasing awareness and educating clinicians on the benefits of e-consults may help promote use among non- and low users.

A common theme reported by both groups was the importance of providing necessary information within e-consult questions and responses. Specialists felt there was a need to ensure that PCPs provide relevant and patient-specific information that would enable them to efficiently and accurately answer questions without the need for extensive EHR review. This reflects previous work showing that specialists are often unable to respond to e-consult requests because they do not contain sufficient information.22 PCPs described a need to ensure that specialists’ responses included information that was detailed enough to make clinical decisions without the need for a reconsult. This highlights a common challenge to medical consultation, in that necessary or relevant information may not be apparent to all clinicians. To address this, there may be a role in developing enhanced, flexible templating that elicits necessary patient-specific information. Such a template may automatically pull relevant data from the EHR and prompt clinicians to provide important information. We did not assess how perspectives of templates varied, and further work could help define precisely what constitutes an effective template, including how it should capture appropriate patient data and how this impacts acceptability or use of e-consults generally. Collaboratively developed service agreements and e-consult templates could help guide PCPs and specialists to engage in efficient communication.

Another theme among both groups was that e-consult is most appropriate within specific clinical scenarios. Examples included review of laboratory results, questions about medication changes, or for patients who were reluctant to travel to appointments. Identifying and promoting specific opportunities for e-consults may help increase their use and align e-consult practices with scenarios that are likely to provide the most benefit to patients. For example, it could be helpful to understand the distance patients must travel for specialty care. Providing that information during clinical encounters could trigger clinicians to consider e-consults as an option. Future work might aim to identify clinical scenarios that clinicians feel are not well suited for e-consults and determine how to adapt them for those scenarios.

Limitations

Generalizability of these findings is limited given the qualitative study design. Participants’ descriptions of experiences with e-consults reflect the experiences of clinicians in the VA and may not reflect clinicians in other settings. We also interviewed a sample of clinicians who were already using e-consults. Important information could be learned from future work with those who have not yet adopted e-consult procedures or adopted and abandoned them.

Conclusions

E-consult is perceived as beneficial by VA PCPs and specialists. Participants suggested using e-consults for appropriate questions or patients and including necessary information and next steps in both the initial e-consult and response. Finding ways to facilitate e-consults with these suggestions in mind may increase delivery of high-quality e-consults. Future work could compare the findings of this work to similar work assessing clinicians perceptions of e-consults outside of the VA.

References

1. Battaglia C, Lambert-Kerzner A, Aron DC, et al. Evaluation of e-consults in the VHA: provider perspectives. Fed Pract. 2015;32(7):42-48.

2. Haverhals LM, Sayre G, Helfrich CD, et al. E-consult implementation: lessons learned using consolidated framework for implementation research. Am J Manag Care. 2015;21(12):e640-e647. Published 2015 Dec 1.

3. Sewell JL, Telischak KS, Day LW, Kirschner N, Weissman A. Preconsultation exchange in the United States: use, awareness, and attitudes. Am J Manag Care. 2014;20(12):e556-e564. Published 2014 Dec 1.

4. Horner K, Wagner E, Tufano J. Electronic consultations between primary and specialty care clinicians: early insights. Issue Brief (Commonw Fund). 2011;23:1-14.

5. Kirsh S, Carey E, Aron DC, et al. Impact of a national specialty e-consultation implementation project on access. Am J Manag Care. 2015;21(12):e648-654. Published 2015 Dec 1.

6. Saxon DR, Kaboli PJ, Haraldsson B, Wilson C, Ohl M, Augustine MR. Growth of electronic consultations in the Veterans Health Administration. Am J Manag Care. 2021;27(1):12-19. doi:10.37765/ajmc.2021.88572

7. Olayiwola JN, Anderson D, Jepeal N, et al. Electronic consultations to improve the primary care-specialty care interface for cardiology in the medically underserved: a cluster-randomized controlled trial. Ann Fam Med. 2016;14(2):133-140. doi:10.1370/afm.1869

8. Schettini P, Shah KP, O’Leary CP, et al. Keeping care connected: e-Consultation program improves access to nephrology care. J Telemed Telecare. 2019;25(3):142-150. doi:10.1177/1357633X17748350

9. Whittington MD, Ho PM, Kirsh SR, et al. Cost savings associated with electronic specialty consultations. Am J Manag Care. 2021;27(1):e16-e23. Published 2021 Jan 1. doi:10.37765/ajmc.2021.88579

10. Shipherd JC, Kauth MR, Matza A. Nationwide interdisciplinary e-consultation on transgender care in the Veterans Health Administration. Telemed J E Health. 2016;22(12):1008-1012. doi:10.1089/tmj.2016.0013

11. Strymish J, Gupte G, Afable MK, et al. Electronic consultations (E-consults): advancing infectious disease care in a large Veterans Affairs Healthcare System. Clin Infect Dis. 2017;64(8):1123-1125. doi:10.1093/cid/cix058

12. Williams KM, Kirsh S, Aron D, et al. Evaluation of the Veterans Health Administration’s Specialty Care Transformational Initiatives to promote patient-centered delivery of specialty care: a mixed-methods approach. Telemed J E-Health. 2017;23(7):577-589. doi:10.1089/tmj.2016.0166

13. US Department of Veterans Affairs, Veterans Health Administration, Specialty Care Transformational Initiative Evaluation Center. Evaluation of specialty care initiatives. Published 2013.

14. Vimalananda VG, Gupte G, Seraj SM, et al. Electronic consultations (e-consults) to improve access to specialty care: a systematic review and narrative synthesis. J Telemed Telecare. 2015;21(6):323-330. doi:10.1177/1357633X15582108

15. Lee M, Leonard C, Greene P, et al. Perspectives of VA primary care clinicians toward electronic consultation-related workload burden. JAMA Netw Open. 2020;3(10):e2018104. Published 2020 Oct 1. doi:10.1001/jamanetworkopen.2020.18104

16. Deeds SA, Dowdell KJ, Chew LD, Ackerman SL. Implementing an opt-in eConsult program at seven academic medical centers: a qualitative analysis of primary care provider experiences. J Gen Intern Med. 2019;34(8):1427-1433. doi:10.1007/s11606-019-05067-7

17. Rodriguez KL, Burkitt KH, Bayliss NK, et al. Veteran, primary care provider, and specialist satisfaction with electronic consultation. JMIR Med Inform. 2015;3(1):e5. Published 2015 Jan 14. doi:10.2196/medinform.3725

18. Gupte G, Vimalananda V, Simon SR, DeVito K, Clark J, Orlander JD. Disruptive innovation: implementation of electronic consultations in a Veterans Affairs Health Care System. JMIR Med Inform. 2016;4(1):e6. Published 2016 Feb 12. doi:10.2196/medinform.4801

19. Feldstein AC, Glasgow RE. A practical, robust implementation and sustainability model (PRISM) for integrating research findings into practice. Jt Comm J Qual Patient Saf. 2008;34(4):228-243. doi:10.1016/s1553-7250(08)34030-6

20. Patton MQ. Qualitative Research and Evaluation Methods. 3rd ed. Sage Publications; 2002.

21. Bradley EH, Curry LA, Devers KJ. Qualitative data analysis for health services research: developing taxonomy, themes, and theory. Health Serv Res. 2007;42(4):1758-1772. doi:10.1111/j.1475-6773.2006.00684.x

22. Kim EJ, Orlander JD, Afable M, et al. Cardiology electronic consultation (e-consult) use by primary care providers at VA medical centres in New England. J Telemed Telecare. 2019;25(6):370-377. doi:10.1177/1357633X18774468

References

1. Battaglia C, Lambert-Kerzner A, Aron DC, et al. Evaluation of e-consults in the VHA: provider perspectives. Fed Pract. 2015;32(7):42-48.

2. Haverhals LM, Sayre G, Helfrich CD, et al. E-consult implementation: lessons learned using consolidated framework for implementation research. Am J Manag Care. 2015;21(12):e640-e647. Published 2015 Dec 1.

3. Sewell JL, Telischak KS, Day LW, Kirschner N, Weissman A. Preconsultation exchange in the United States: use, awareness, and attitudes. Am J Manag Care. 2014;20(12):e556-e564. Published 2014 Dec 1.

4. Horner K, Wagner E, Tufano J. Electronic consultations between primary and specialty care clinicians: early insights. Issue Brief (Commonw Fund). 2011;23:1-14.

5. Kirsh S, Carey E, Aron DC, et al. Impact of a national specialty e-consultation implementation project on access. Am J Manag Care. 2015;21(12):e648-654. Published 2015 Dec 1.

6. Saxon DR, Kaboli PJ, Haraldsson B, Wilson C, Ohl M, Augustine MR. Growth of electronic consultations in the Veterans Health Administration. Am J Manag Care. 2021;27(1):12-19. doi:10.37765/ajmc.2021.88572

7. Olayiwola JN, Anderson D, Jepeal N, et al. Electronic consultations to improve the primary care-specialty care interface for cardiology in the medically underserved: a cluster-randomized controlled trial. Ann Fam Med. 2016;14(2):133-140. doi:10.1370/afm.1869

8. Schettini P, Shah KP, O’Leary CP, et al. Keeping care connected: e-Consultation program improves access to nephrology care. J Telemed Telecare. 2019;25(3):142-150. doi:10.1177/1357633X17748350

9. Whittington MD, Ho PM, Kirsh SR, et al. Cost savings associated with electronic specialty consultations. Am J Manag Care. 2021;27(1):e16-e23. Published 2021 Jan 1. doi:10.37765/ajmc.2021.88579

10. Shipherd JC, Kauth MR, Matza A. Nationwide interdisciplinary e-consultation on transgender care in the Veterans Health Administration. Telemed J E Health. 2016;22(12):1008-1012. doi:10.1089/tmj.2016.0013

11. Strymish J, Gupte G, Afable MK, et al. Electronic consultations (E-consults): advancing infectious disease care in a large Veterans Affairs Healthcare System. Clin Infect Dis. 2017;64(8):1123-1125. doi:10.1093/cid/cix058

12. Williams KM, Kirsh S, Aron D, et al. Evaluation of the Veterans Health Administration’s Specialty Care Transformational Initiatives to promote patient-centered delivery of specialty care: a mixed-methods approach. Telemed J E-Health. 2017;23(7):577-589. doi:10.1089/tmj.2016.0166

13. US Department of Veterans Affairs, Veterans Health Administration, Specialty Care Transformational Initiative Evaluation Center. Evaluation of specialty care initiatives. Published 2013.

14. Vimalananda VG, Gupte G, Seraj SM, et al. Electronic consultations (e-consults) to improve access to specialty care: a systematic review and narrative synthesis. J Telemed Telecare. 2015;21(6):323-330. doi:10.1177/1357633X15582108

15. Lee M, Leonard C, Greene P, et al. Perspectives of VA primary care clinicians toward electronic consultation-related workload burden. JAMA Netw Open. 2020;3(10):e2018104. Published 2020 Oct 1. doi:10.1001/jamanetworkopen.2020.18104

16. Deeds SA, Dowdell KJ, Chew LD, Ackerman SL. Implementing an opt-in eConsult program at seven academic medical centers: a qualitative analysis of primary care provider experiences. J Gen Intern Med. 2019;34(8):1427-1433. doi:10.1007/s11606-019-05067-7

17. Rodriguez KL, Burkitt KH, Bayliss NK, et al. Veteran, primary care provider, and specialist satisfaction with electronic consultation. JMIR Med Inform. 2015;3(1):e5. Published 2015 Jan 14. doi:10.2196/medinform.3725

18. Gupte G, Vimalananda V, Simon SR, DeVito K, Clark J, Orlander JD. Disruptive innovation: implementation of electronic consultations in a Veterans Affairs Health Care System. JMIR Med Inform. 2016;4(1):e6. Published 2016 Feb 12. doi:10.2196/medinform.4801

19. Feldstein AC, Glasgow RE. A practical, robust implementation and sustainability model (PRISM) for integrating research findings into practice. Jt Comm J Qual Patient Saf. 2008;34(4):228-243. doi:10.1016/s1553-7250(08)34030-6

20. Patton MQ. Qualitative Research and Evaluation Methods. 3rd ed. Sage Publications; 2002.

21. Bradley EH, Curry LA, Devers KJ. Qualitative data analysis for health services research: developing taxonomy, themes, and theory. Health Serv Res. 2007;42(4):1758-1772. doi:10.1111/j.1475-6773.2006.00684.x

22. Kim EJ, Orlander JD, Afable M, et al. Cardiology electronic consultation (e-consult) use by primary care providers at VA medical centres in New England. J Telemed Telecare. 2019;25(6):370-377. doi:10.1177/1357633X18774468

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