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Sadak T, Borson S. Six domains of health: a practical approach to identifying priorities in dementia care. FRONTIERS IN DEMENTIA 2023; 2:1188953. [PMID: 39081999 PMCID: PMC11284762 DOI: 10.3389/frdem.2023.1188953] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 03/18/2023] [Accepted: 05/05/2023] [Indexed: 08/02/2024]
Abstract
Background High-quality healthcare for people living with dementia encompasses both patients and care partners (CPs). A framework populated with simple assessment tools is needed to deconstruct this complexity into actionable domains that inform assessment and care planning for individuals and dyads, help differentiate care team roles, and can more fully estimate true population burden in health and social care systems. Design Researchers used a cross-sectional mixed-methods descriptive study to illustrate the use of an inductive Six Domain framework and simple assessment tools in a sample of dyads selected for complexity. Setting Data was collected from three university-affiliated hospitals with a shared electronic medical record (EMR). Participants Eighty-eight CPs for people living with dementia (care recipients) newly discharged home after an acute medical hospitalization participated. Measures Care recipients' outpatient and inpatient diagnoses, medications, and care were extracted from the EMR. CPs completed an in-home semi-structured interview and study measures. Data were sorted into six domains: three care recipient-focused domains (cognition, emotion/behavior, general and functional health); a single CP-focused domain (mood, cognition, stress, and self-rated health); a health-related social needs domain (enrollment of persons with dementia in low-income insurance, CP-reported financial strain); and a care delivery domain (CP-reported engagement with clinicians in care recipients' care planning, and match between CP-reported knowledge of care recipients' medical care needs and medical records). Results As expected, all people living with dementia had significant cognitive, neurobehavioral, and medical complexity requiring extensive oversight and management at home. Over a third of CPs reported high stress, depression, or anxiety. A fifth screened positive for one or more indicators of poor health, cognitive impairment, and/or health-related social needs. CP reports and care recipients' medical records were discordant for chronic conditions in 68% of cases and for prescribed medications in 44%. In 85% of cases, there were gaps in indicators of CP-clinician collaboration in care management. Conclusion and relevance The Six Domains of Health framework captures a broad array of challenges that are relevant to providing comprehensive dyadic care and setting individualized health and social care priorities. With further study, it could provide conceptual scaffolding for comparative population research and more equitable, fully integrated pathways for care.
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Affiliation(s)
- Tatiana Sadak
- Biobehavioral Nursing and Health Informatics, School of Nursing, University of Washington, Seattle, WA, United States
| | - Soo Borson
- Department of Family Medicine, School of Medicine, University of Southern California Keck, Los Angeles, CA, United States
- Department of Psychiatry and Behavioral Sciences, School of Medicine, University of Washington, Seattle, WA, United States
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Chalmer R, Ayers E, Weiss EF, Malik R, Ehrlich A, Wang C, Zwerling J, Ansari A, Possin KL, Verghese J. The 5-Cog paradigm to improve detection of cognitive impairment and dementia: clinical trial protocol. Neurodegener Dis Manag 2022; 12:171-184. [PMID: 35603666 PMCID: PMC9245592 DOI: 10.2217/nmt-2021-0043] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2022] [Accepted: 05/05/2022] [Indexed: 11/21/2022] Open
Abstract
Cognitive impairment related to dementia is under-diagnosed in primary care despite availability of numerous cognitive assessment tools; under-diagnosis is more prevalent for members of racial and ethnic minority groups. Clinical decision-support systems may improve rates of primary care providers responding to positive cognitive assessments with appropriate follow-up. The 5-Cog study is a randomized controlled trial in 1200 predominantly Black and Hispanic older adults from an urban underserved community who are presenting to primary care with cognitive concerns. The study will validate a novel 5-minute cognitive assessment coupled with an electronic medical record-embedded decision tree to overcome the barriers of current cognitive assessment paradigms in primary care and facilitate improved dementia care.
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Affiliation(s)
- Rachel Chalmer
- Department of Medicine, Division of Geriatrics, Montefiore Medical Center & Albert Einstein College of Medicine, Bronx, NY 10467, USA
| | - Emmeline Ayers
- Department of Neurology, Montefiore Medical Center & Albert Einstein College of Medicine, Bronx, NY 10467, USA
| | - Erica F Weiss
- Department of Neurology, Montefiore Medical Center & Albert Einstein College of Medicine, Bronx, NY 10467, USA
| | - Rubina Malik
- Department of Medicine, Division of Geriatrics, Montefiore Medical Center & Albert Einstein College of Medicine, Bronx, NY 10467, USA
| | - Amy Ehrlich
- Department of Medicine, Division of Geriatrics, Montefiore Medical Center & Albert Einstein College of Medicine, Bronx, NY 10467, USA
| | - Cuiling Wang
- Department of Epidemiology & Population Health, Montefiore Medical Center & Albert Einstein College of Medicine, Bronx, NY 10461, USA
| | - Jessica Zwerling
- Department of Neurology, Montefiore Medical Center & Albert Einstein College of Medicine, Bronx, NY 10467, USA
| | - Asif Ansari
- Department of Medicine, Division of Geriatrics, Montefiore Medical Center & Albert Einstein College of Medicine, Bronx, NY 10467, USA
| | - Katherine L Possin
- Department of Neurology, Memory & Aging Center, University of California San Francisco, San Francisco, CA 94158, USA
| | - Joe Verghese
- Department of Medicine, Division of Geriatrics, Montefiore Medical Center & Albert Einstein College of Medicine, Bronx, NY 10467, USA
- Department of Neurology, Montefiore Medical Center & Albert Einstein College of Medicine, Bronx, NY 10467, USA
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Innovation in care for individuals with cognitive impairment: Can reimbursement policy spread best practices? Alzheimers Dement 2017; 13:1168-1173. [DOI: 10.1016/j.jalz.2017.09.001] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Housden L, Browne AJ, Wong ST, Dawes M. Attending to power differentials: How NP-led group medical visits can influence the management of chronic conditions. Health Expect 2017; 20:862-870. [PMID: 28071841 PMCID: PMC5600247 DOI: 10.1111/hex.12525] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/06/2016] [Indexed: 11/28/2022] Open
Abstract
Objective In Canada, primary care reform has encouraged innovations, including nurse practitioners (NPs) and group medical visits (GMVs). NP‐led GMVs provide an opportunity to examine barriers and enablers to implementing this innovation in primary care. Design An instrumental case study design (n=3): two cases where NPs were using GMVs and one case where NPs were not using GMVs, was completed. In‐depth interviews with patients and providers (N=24) and 10 hours of direct observation were completed. Interpretive descriptive methods were used to analyse data. Results/Findings Two main themes were identified: (i) acquisition of knowledge and (ii) GMVs help shift relationships between patients and health‐care providers. Participants discussed how patients and providers learn from one another to facilitate self‐management of chronic conditions. They also discussed how the GMV shifts inherent power differentials between providers and between patients and providers. Discussion NP‐led GMVs are a method of care delivery that harness NPs’ professional agency through increased leadership and interprofessional collaboration. GMVs also facilitate an environment that is patient‐centred and interprofessional, providing patients with increased confidence to manage their chronic conditions. The GMV provides the opportunity to meet both team‐based and patient‐centred health‐care objectives and may disrupt inherent power differentials that exist in primary care.
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Affiliation(s)
- Laura Housden
- School of Nursing, University of British Columbia, Vancouver, BC, Canada
| | - Annette J Browne
- School of Nursing, University of British Columbia, Vancouver, BC, Canada.,CRiHHI: Critical Research in Health and Healthcare Inequities, University of British Columbia, Vancouver, BC, Canada
| | - Sabrina T Wong
- School of Nursing, University of British Columbia, Vancouver, BC, Canada.,Centre for Health Services and Policy Research, University of British Columbia, Vancouver, BC, Canada.,CRiHHI: Critical Research in Health and Healthcare Inequities, University of British Columbia, Vancouver, BC, Canada
| | - Martin Dawes
- Department of Family Practice, Faculty of Medicine, Vancouver, BC, Canada
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Abstract
The number of people with diabetes is expected to rise to over 592 million by the year 2035. Past work provides evidence that the conventional method of primary care delivery may not meet many patients' needs. An alternative to the conventional one-on-one appointment is care offered to a group of patients through group medical visits (GMVs). Group medical visits for diabetes have a positive impact on physiologic and self-care outcomes including improved HbA1c, blood pressure control and self-management skills. Less work has examined the impacts of GMVs on systems of care; however, evidence suggests improved primary and secondary prevention strategies and the potential for GMVs to decrease emergency room visits and hospitalizations. Additional work is needed to examine the effect of GMVs on patient reported quality of life, functional health status and cost-savings. Further work is also needed on which patients GMVs work best for and patient barriers to attending GMVs.
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Affiliation(s)
- Laura M Housden
- University of British Columbia School of Nursing, T201 2211 Wesbrook Mall, Vancouver, BC, V6T 2B5, Canada.
| | - Sabrina T Wong
- Centre for Health Services and Policy Research, University of British Columbia School of Nursing, T201 2211 Wesbrook Mall, Vancouver, BC, V6T 2B5, Canada
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Sadak T, Wright J, Borson S. Managing Your Loved One’s Health: Development of a New Care Management Measure for Dementia Family Caregivers. J Appl Gerontol 2016; 37:620-643. [DOI: 10.1177/0733464816657472] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
The National Alzheimer’s Plan calls for improving health care for people living with dementia and supporting their caregivers as capable health care partners. Clinically useful measurement tools are needed to monitor caregivers’ knowledge and skills for managing patients’ often complex health care needs as well as their own self-care. We created and validated a comprehensive, caregiver-centered measure, Managing Your Loved One’s Health (MYLOH), based on a core set of health care management domains endorsed by both providers and caregivers. In this article, we describe its development and preliminary cultural tailoring. MYLOH is a questionnaire containing 29 items, grouped into six domains, which requires <20 min to complete. MYLOH can be used to guide conversations between clinicians and caregivers around health care management of people with dementia, as the basis for targeted health care coaching, and as an outcome measure in comprehensive dementia care management interventions.
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Affiliation(s)
| | - Jacob Wright
- Dementia Care Research and Consulting, Palm Springs, CA, USA
| | - Soo Borson
- University of Washington, Seattle, WA, USA
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Sadak T, Souza A, Borson S. Toward Assessment of Dementia Caregiver Activation for Health Care: An Integrative Review of Related Constructs and Measures. Res Gerontol Nurs 2016; 9:145-55. [DOI: 10.3928/19404921-20151019-02] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2015] [Accepted: 08/21/2015] [Indexed: 01/12/2023]
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Borisovskaya A, Chen K, Borson S. Are we providing the best possible care for dementia patients? Neurodegener Dis Manag 2015; 5:217-24. [DOI: 10.2217/nmt.15.9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
SUMMARY Healthcare for patients with dementia is often reactive, poorly organized and fragmented. We discuss opportunities for improvements in the care of individuals living with dementia at home that can be implemented by physicians in their practices today. In particular, we argue that systematic identification and diagnosis of cognitive impairment and dementia in their early stages, coupled with a coherent, evidence-informed management framework, would benefit patients with dementia substantially and ease the burden of their caregivers. We emphasize that dementia influences all aspects of patient care, and each medical decision must be passed through the filter of knowledge that patients with dementia have special needs that can be identified and addressed.
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Affiliation(s)
- Anna Borisovskaya
- University of Washington, Veterans’ Affairs Medical Center, 1660 South Columbian Way, S-116, Seattle, WA 98108, USA
- University of Washington, Department of Psychiatry & Behavioral Sciences, 1959 NE Pacific Street, Seattle, WA 98108, USA
| | - Kathryn Chen
- University of Washington, Veterans’ Affairs Medical Center, 1660 South Columbian Way, S-116, Seattle, WA 98108, USA
| | - Soo Borson
- University of Washington, Veterans’ Affairs Medical Center, 1660 South Columbian Way, S-116, Seattle, WA 98108, USA
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Borisovskaya A, Pascualy M, Borson S. Cognitive and neuropsychiatric impairments in Alzheimer's disease: current treatment strategies. Curr Psychiatry Rep 2014; 16:470. [PMID: 25023513 DOI: 10.1007/s11920-014-0470-z] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
This update on Alzheimer's disease (AD) discusses treatment strategies for cognitive and neuropsychiatric symptoms (such as agitation, psychosis, anxiety, and depression) common in this illness, emphasizing in particular nonpharmacologic strategies such as cognitive interventions, physical exercise, and psychotherapy. We provide an overview of cognitive enhancers and their combination strategies and medications commonly used for treatment of neuropsychiatric symptoms in AD. Finally, we give recommendations for providing support to caregivers and suggest how to identify caregiver/patient pairs most in need of intensive dementia care services.
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Affiliation(s)
- Anna Borisovskaya
- VA Puget Sound Healthcare System, Department of Psychiatry and Behavioral Sciences, University of Washington, 1660 S. Columbian Way, S-116, Seattle, WA, 98108, USA,
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Borson S, Scanlan JM, Sadak T, Lessig M, Vitaliano P. Dementia Services Mini-Screen: a simple method to identify patients and caregivers in need of enhanced dementia care services. Am J Geriatr Psychiatry 2014; 22:746-55. [PMID: 24315560 PMCID: PMC4018424 DOI: 10.1016/j.jagp.2013.11.001] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2012] [Revised: 11/01/2013] [Accepted: 11/06/2013] [Indexed: 10/26/2022]
Abstract
OBJECTIVE Improving dementia care in health systems requires estimates of need in the population served. We explored whether dementia-specific service needs and gaps for patients and caregivers could be predicted by simple information readily captured in routine care settings. METHOD Primary family caregivers (n = 215) rated their own current stress, challenging patient behaviors, and prior-year needs and gaps in 16 medical and psychosocial services. These were evaluated with other patient and caregiver characteristics in multivariate regressions to identify unique predictors of service needs and gaps. RESULTS Caregiver stress and patient behavior problems together accounted for an average of 24% of the whole-sample variance in total needs and gaps. All other variables combined (comorbid chronic disease, dementia severity, age, caregiver relationship, and residence) accounted for a mean of 3%, with none yielding more than 4% in any equation. We combined stress and behavior problem indicators into a simple screen. In early/mild dementia dyads (n = 111) typical in primary care settings, the screen identified gaps in total (84%) and psychosocial (77%) care services for high stress/high behavior problem dyads vs. 25% and 23%, respectively, of low stress/low behavior problem dyads. Medical care gaps were dramatically higher in high stress/high behavior problem dyads (66%) than all others (12%). CONCLUSION The Dementia Services Mini-Screen is a simple tool that could help clinicians and health systems rapidly identify dyads needing enhanced dementia care, track key patient and caregiver outcomes of interventions, and estimate population needs for new service development.
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Affiliation(s)
- Soo Borson
- Department of Psychiatry and Behavioral Sciences, University of Washington School of Medicine, Seattle, WA; Department of Psychosocial and Community Health, University of Washington School of Nursing, Seattle, WA.
| | - James M Scanlan
- Department of Psychiatry and Behavioral Sciences, University of Washington School of Medicine, Seattle, WA; Screen Inc., Seattle, WA
| | - Tatiana Sadak
- Department of Psychosocial and Community Health, University of Washington School of Nursing, Seattle, WA
| | - Mary Lessig
- Department of Psychiatry and Behavioral Sciences, University of Washington School of Medicine, Seattle, WA
| | - Peter Vitaliano
- Department of Psychiatry and Behavioral Sciences, University of Washington School of Medicine, Seattle, WA
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12
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Borson S, Frank L, Bayley PJ, Boustani M, Dean M, Lin PJ, McCarten JR, Morris JC, Salmon DP, Schmitt FA, Stefanacci RG, Mendiondo MS, Peschin S, Hall EJ, Fillit H, Ashford JW. Improving dementia care: the role of screening and detection of cognitive impairment. Alzheimers Dement 2013; 9:151-9. [PMID: 23375564 DOI: 10.1016/j.jalz.2012.08.008] [Citation(s) in RCA: 167] [Impact Index Per Article: 15.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2012] [Accepted: 08/21/2012] [Indexed: 12/20/2022]
Abstract
The value of screening for cognitive impairment, including dementia and Alzheimer's disease, has been debated for decades. Recent research on causes of and treatments for cognitive impairment has converged to challenge previous thinking about screening for cognitive impairment. Consequently, changes have occurred in health care policies and priorities, including the establishment of the annual wellness visit, which requires detection of any cognitive impairment for Medicare enrollees. In response to these changes, the Alzheimer's Foundation of America and the Alzheimer's Drug Discovery Foundation convened a workgroup to review evidence for screening implementation and to evaluate the implications of routine dementia detection for health care redesign. The primary domains reviewed were consideration of the benefits, harms, and impact of cognitive screening on health care quality. In conference, the workgroup developed 10 recommendations for realizing the national policy goals of early detection as the first step in improving clinical care and ensuring proactive, patient-centered management of dementia.
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Affiliation(s)
- Soo Borson
- Memory Disorders Clinic and Dementia Health Services, University of Washington School of Medicine, Seattle, WA, USA
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Koch T, Iliffe S. Dementia diagnosis and management: a narrative review of changing practice. Br J Gen Pract 2011; 61:e513-25. [PMID: 21801564 PMCID: PMC3145536 DOI: 10.3399/bjgp11x588493] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2010] [Revised: 05/04/2010] [Accepted: 05/20/2010] [Indexed: 10/31/2022] Open
Abstract
BACKGROUND Early detection and management of dementia in primary care are difficult problems for practitioners. England's National Dementia Strategy 2009 seeks to improve these areas but there is limited evidence on how to achieve this most effectively. AIM This review aims to identify and appraise empirical studies of interventions designed to improve the performance of primary care practitioners in these areas. DESIGN A narrative review of primary-care based studies. METHOD Publications up to February 2010 were identified by searching the electronic databases MEDLINE, Embase, and PsycINFO, and bibliographies. The criterion for inclusion was that studies had to be of interventions aimed at improving detection or management of dementia in primary care. Exclusion criteria included studies in non-English publications, pharmacological interventions, and screening instrument studies. Quality was assessed using the PEDro (Physiotherapy Evidence Database) scale. RESULTS Fifteen studies were identified, of which 11 were randomised controlled trials. Eight reported educational interventions, and seven trialled service redesign, either by changing the service pathway or by introducing case management. Educationally, only facilitated sessions and decision-support software improved GPs' diagnosis of dementia, as did trials of service-pathway modification. Some of the case-management trials showed improved stakeholder satisfaction, decreased symptoms, and care that was more concordant with guidelines. CONCLUSION The quality of the studies varied considerably. Educational interventions are effective when learners are able to set their own educational agenda. Although modifying the service pathway and using case management can assist in several aspects of dementia care, these would require the provision of extra resources, and their value is yet to be tested in different health systems.
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Affiliation(s)
- Tamar Koch
- Department of Primary Care and Population Health, University College, London, UK.
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Dorsey ER, Deuel LM, Beck CA, Gardiner IF, Scoglio NJ, Scott JC, Marshall FJ, Biglan KM. Group patient visits for Parkinson disease: a randomized feasibility trial. Neurology 2011; 76:1542-7. [PMID: 21525426 DOI: 10.1212/wnl.0b013e3182194bad] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND Group patient visits are medical appointments shared among patients with a common medical condition. This care delivery method has demonstrated benefits for individuals with chronic conditions but has not been evaluated for Parkinson disease (PD). METHODS We conducted a 12-month, randomized trial of group patient visits vs usual (one-on-one) care for patients with PD. Visits were led by one of 3 study physicians, included patients and caregivers, and lasted approximately 90 minutes. Those receiving group visits had 4 sessions over 12 months. The primary outcome measure was feasibility as measured by the ability to recruit participants and by the proportion of participants who completed the study. The primary efficacy outcome was quality of life as measured by the PD Questionnaire-39. RESULTS Thirty patients and 27 caregivers enrolled in the study. Thirteen of the 15 patients randomized to group patient visits and 14 of the 15 randomized to usual care completed the study. Quality of life measured 12 months after baseline between the 2 groups was not different (25.9 points for group patient visits vs 26.0 points for usual care; p = 0.99). CONCLUSIONS Group patient visits may be a feasible means of providing care to individuals with PD and may offer an alternative or complementary method of care delivery for some patients and physicians. CLASSIFICATION OF EVIDENCE This study provides Class II evidence that group patient visits did not improve quality of life for individuals with PD over a 1-year period.
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Affiliation(s)
- E R Dorsey
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD, USA.
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Fillit H, Cummings J, Neumann P, McLaughlin T, Salavtore P, Leibman C. Novel approaches to incorporating pharmacoeconomic studies into phase III clinical trials for Alzheimer's disease. J Nutr Health Aging 2010; 14:640-7. [PMID: 20922340 DOI: 10.1007/s12603-010-0310-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
The societal and individual costs of Alzheimer's disease are significant, worldwide. As the world ages, these costs are increasing rapidly, while health systems face finite budgets. As a result, many regulators and payers will require or at least consider phase III cost-effectiveness data (in addition to safety and efficacy data) for drug approval and reimbursement, increasing the risks and costs of drug development. Incorporating pharmacoeconomic studies in phase III clinical trials for Alzheimer's disease presents a number of challenges. We propose several specific suggestions to improve the design of pharmacoeconomic studies in phase III clinical trials. We propose that acute episodes of care are key outcome measures for pharmacoeconomic studies. To improve the possibility of detecting a pharmacoeconomic impact in phase III, we suggest several strategies including; study designs for enrichment of pharmacoeconomic outcomes that include co-morbidity of patients; reducing variability of care that can affect pharmacoeconomic outcomes through standardized care management; employing administrative claims data to better capture meaningful pharmacoeconomic data; and extending clinical trials in open label follow-up periods in which pharmacoeconomic data are captured electronically by administrative claims. Specific aspects of power analysis for pharmacoeconomic studies are presented. The particular pharmacoeconomic challenges caused by the use of biomarkers in clinical trials, the increasing use of multinational studies, and the pharmacoeconomic challenges presented by biologicals in development for Alzheimer's disease are discussed. In summary, since we are entering an era in which pharmacoeconomic studies will be essential in drug development for supporting regulatory approval, payor reimbursement and integration of new therapies into clinical care, we must consider the design and incorporation of pharmacoeconomic studies in phase III clinical trials more seriously and more creatively.
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Affiliation(s)
- H Fillit
- The Alzheimer's Drug Discovery Foundation, NY, NY, USA
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When help becomes a hindrance: mental health referral systems as barriers to care for primary care physicians treating patients with Alzheimer's disease. Am J Geriatr Psychiatry 2010; 18:576-85. [PMID: 20593538 PMCID: PMC2955197 DOI: 10.1097/jgp.0b013e3181a76df7] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES To describe structural barriers to mental health specialists and consequences of these barriers to care for patients with dementia and neuropsychological symptoms and their primary care physicians (PCPs). DESIGN Cross-sectional qualitative interview study of PCPs. SETTING Physicians' offices, primarily managed care. PARTICIPANTS Forty PCPs in Northern California. MEASUREMENTS Open-ended interviews lasted 30-60 minutes. The interview guide covered clinician background, practice setting, clinical care of a particular patient, and general approach to managing patients with Alzheimer disease or related dementias.Interviews were transcribed and themes reflecting referrals identified. RESULTS Ninety-three percentage of the PCPs described problematic access to and communication with mental health specialists (in particular psychiatrists and neuropsychologists) as impediments to effective care for dementia patients. Thematic analysis identified structural barriers to mental health referrals ranging from problems with managed care and reimbursement policies to lack of trained providers and poor geographic distribution of specialists. Structural barriers compromised care for patients with dementia because the barriers limited PCP treatment options, and resources, impacted office staff and time with other patients, impeded and delayed care, and fostered poor communication and lack of coordinated care. Negative consequences for PCPs included increased frustration,conflict, and burnout. CONCLUSION PCPs viewed problems created by onerous referral systems, such as mental health carve outs, as particularly burdensome for elderly patients with comorbid dementia and neuropsychiatric problems. These problems were cited by PCPs across different types of practice settings. PCPs managed treatment of neurobehavioral symptoms as best they could despite lack of specialist support.
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Borson S, Scanlan J, Hummel J, Gibbs K, Lessig M, Zuhr E. Implementing routine cognitive screening of older adults in primary care: process and impact on physician behavior. J Gen Intern Med 2007; 22:811-7. [PMID: 17447100 PMCID: PMC2219855 DOI: 10.1007/s11606-007-0202-8] [Citation(s) in RCA: 61] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2006] [Revised: 03/08/2007] [Accepted: 03/26/2007] [Indexed: 01/19/2023]
Abstract
BACKGROUND Early detection of cognitive impairment is a goal of high-quality geriatric medical care, but new approaches are needed to reduce rates of missed cases. OBJECTIVE To evaluate whether adding routine cognitive screening to primary care visits for older adults increases rates of dementia diagnosis, specialist referral, or prescribing of antidementia medications. SETTING Four primary care clinics in a university-affiliated primary care network. DESIGN A quality improvement screening project and quasiexperimental comparison of 2 intervention clinics and 2 control clinics. The Mini-Cog was administered by medical assistants to intervention clinic patients aged 65+ years. Rates of dementia diagnoses, referrals, and medication prescribing were tracked over time using computerized administrative data. RESULTS Twenty-six medical assistants successfully screened 70% (n = 524) of all eligible patients who made at least 1 clinic visit during the intervention period; 18% screened positive. There were no complaints about workflow interruption. Relative to baseline rates and control clinics, Mini-Cog screening was associated with increased dementia diagnoses, specialist referrals, and prescribing of cognitive enhancing medications. Patients without previous dementia indicators who had a positive Mini-Cog were more likely than all other patients to receive a new dementia diagnosis, specialty referral, or cognitive enhancing medication. However, relevant physician action occurred in only 17% of screen-positive patients. Responses were most related to the lowest Mini-Cog score level (0/5) and advanced age. CONCLUSION Mini-Cog screening by office staff is feasible in primary care practice and has measurable effects on physician behavior. However, new physician action relevant to dementia was likely to occur only when impairment was severe, and additional efforts are needed to help primary care physicians follow up appropriately on information suggesting cognitive impairment in older patients.
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Affiliation(s)
- Soo Borson
- Department of Psychiatry and Behavioral Sciences, University of Washington, 1959 NE Pacific Street, Campus Box 356560, Seattle, WA 98195, USA.
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