Improving Osteoporosis Clinic Access With Nurse‐Led Telephone Call for Veterans on Bisphosphonates

Guidelines, including American Association of Clinical Endocrinology (AACE), emphasize pharmacologic and nonpharmacologic treatments for osteoporosis to prevent fractures and falls [1]. Despite the availability of effective therapies, osteoporotic fractures remain a major cause of morbidity and mortality among Veterans [2, 3]. Hip fracture incidence is rising in male Veterans, yet only 6% of those who sustain a fracture undergo DXA screening [4]. Although treatments such as bisphosphonates are effective, adherence remains challenging [5]. To improve care for aging, geographically dispersed Veterans at VA Puget Sound Health Care System (VAPSHCS), we implemented registered nurse (RN) telephone follow-ups for bisphosphonate therapy management. This approach aimed to reduce the need for physician visits while maintaining close monitoring of adherence and addressing patient concerns. From May 2019 to November 2020, Veterans on oral alendronate (ALN) or IV zoledronic acid (ZA) received RN follow-up calls 6 months after treatment initiation. Standardized call templates assessed medication adherence, side effects, dental work, supplementation, falls, fractures, and mobility (Figures S1 and S2). If unreachable after three attempts, patients were scheduled for routine 6-month physician visits. RN notified physicians of nonadherence, new fractures, or concerning clinical changes such as hospitalizations. Veterans without issues were scheduled for annual physician follow-ups. Demographic and clinical data (age, sex, zip code, Care Assessment Need [CAN] score [6]) were extracted from electronic medical records. Primary outcomes were physician time saved and travel time avoided. Secondary outcomes included maintenance of annual follow-up and patient satisfaction. Drive distance/time were calculated using Google Maps [7]. A subset of Veterans with extended follow-ups completed a four-item satisfaction survey on concern resolution, visit frequency, and phone call helpfulness (Figure S3). In May 2025, we reviewed long-term outcomes: treatment completion (3 years of ZA, 5 years of ALN), fracture incidence, and mortality. The VAPSHCS Human Research Protection Program determined this quality improvement initiative was not human subjects research. Of 45 Veterans on bisphosphonate therapy (13 ALN, 32 ZA), 34 (75%) were male (mean age: 72.6 ± 9.4 years) (Table 1). RN calls confirmed: 93% of patients received their medications; 77% of ALN users were taking it correctly. Patient concerns about side effects, falls, fractures, and dental work were elicited during the phone call. Most concerns were resolved by the RN, but 11 patients required lab orders or physical therapy referrals, 4 required physician phone calls, and 15 (33%) required physician visits before 1 year due to falls (N = 5), fractures (N = 2), medication side effects (N = 2), treatment plan questions (N = 4), or other concerns (N = 2) (Figure S4). RN calls averaged 15.7 ± 5.0 min, with 1.2 ± 0.4 calls per patient, totaling 11.4 RN hours. Thirty patients extended to 1-year follow-ups, saving 15 physician-hours. The intervention yielded a net 3.6 provider-hours saved, and each Veteran avoided on average 100 min of travel. Among those who recalled the RN call, 100% rated it helpful, citing convenience, reduced travel, cost savings, and lower caregiver burden (Table S1). As of May 2025, 1 Veteran prescribed ZA did not complete the recommended bisphosphonate course due to adherence issues and acute dental needs. Of 45 patients, 3 total fractures occurred, with 3 deaths following fractures. Two Veterans who fractured while on bisphosphonates switched to osteoanabolic agents. Sixteen of the 45 Veterans have died, all of whom were prescribed ZA (Table 1). The RN-led telephone call intervention for Veterans on bisphosphonate therapy at VAPSHCS expanded clinic capacity, maintained close adherence and safety monitoring, and spared Veterans significant travel time. Prior telephone-based follow-up studies yielded mixed results [8, 9]. Waalen et al. found higher medication use at 1 year among women in telephone follow-up versus usual care. Unlike our RN-led model, Waalen et al. [8] depended on physicians to make the phone calls, which may limit feasibility in other settings. Solomon et al. ran a large pragmatic trial testing motivational phone calls to improve adherence and found a small (8%) increase in medication adherence, but this did not meet statistical significance, likely due to inadequate sample size. Limitations include a single-site design, small sample size, and absence of a control group. Our RN-led approach shows promise for broader application, including non-VA clinics and could be led by other members of the healthcare team. This intervention positively impacted provider time and care delivery, highlighting the potential for structured, nurse-led follow-up to enhance osteoporosis management and support chronic disease care more broadly. RN-led telephone calls for bisphosphonate users improved clinic capacity, reduced patient travel time, and maintained identification of falls, fractures, and patient concerns. This model offers a guideline-concordant [1], scalable, patient-centered approach to osteoporosis care, supporting older, medically complex Veterans while optimizing provider efficiency. Wider adoption of such strategies could strengthen adherence monitoring and safety oversight in osteoporosis care. Radhika Narla, Magdalena Wojtowicz, Kathryn T. Dinh, Katherine Ritchey, and Katherine D. Wysham contributed to the study conception and design, reviewed and revised the manuscript for intellectual content, and provided final approval for this version to be published. Radhika Narla and Katherine D. Wysham drafted and finalized the manuscript. Sponsor's role: Veterans Administration Puget Sound Health Care System (VAPSHCS) Geriatric Research, Education and Clinical Center (GRECC). This quality improvement project was reviewed jointly by the Human Research Protection program and Quality, Safety & Value service line at the VA Puget Sound Health Care System and determined not to constitute human subjects' research. The authors declare no conflicts of interest. Figure S1: Three-month RN telephone call template for patients prescribed IV zoledronic acid. Figure S2: Three-month RN telephone call template for patients prescribed oral bisphosphonate. Figure S3: Patient satisfaction survey performed by the treating physician at the 1-year follow-up. Figure S4: Flowchart of study population with number of RN (nurse) telephone calls completed, breakdown of oral versus IV bisphosphonate, breakdown of number of patients that required early MD follow-up, number of patients safely extended to annual MD follow-up, and then patient survey breakdown numbers. Table S1: Patient satisfaction questionnaire results by those who remembered receiving the RN phone call and those who did not. Please note: The publisher is not responsible for the content or functionality of any supporting information supplied by the authors. Any queries (other than missing content) should be directed to the corresponding author for the article.