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Johnson KG, Ford C, Clark AG, Greiner MA, Lusk JB, Perry C, O'Brien R, O'Brien EC. Neuropsychiatric Comorbidities and Psychotropic Medication Use in Medicare Beneficiaries With Dementia by Sex and Race. J Geriatr Psychiatry Neurol 2024:8919887241254470. [PMID: 38769750 DOI: 10.1177/08919887241254470] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/22/2024]
Abstract
BACKGROUND Neuropsychiatric symptoms affect the majority of dementia patients. Past studies report high rates of potentially inappropriate prescribing of psychotropic medications in this population. We investigate differences in neuropsychiatric diagnoses and psychotropic medication prescribing in a local US cohort by sex and race. METHODS We utilize Medicare claims and prescription fill records in a cohort of 100% Medicare North and South Carolina beneficiaries ages 50 and above for the year 2017 with a dementia diagnosis. We identify dementia and quantify diagnosis of anxiety, depression and psychosis using validated coding algorithms. We search Medicare claims for antianxiety, antidepressant and antipsychotic medications to determine prescriptions filled. RESULTS Anxiety and depression were diagnosed at higher rates in White patients; psychosis at higher rates in Black patients. (P < .001) Females were diagnosed with anxiety, depression and psychosis at higher rates than males (P < .001) and filled more antianxiety and antidepressant medications than males. (P < .001) Black and Other race patients filled more antipsychotic medications for anxiety, depression and psychosis than White patients. (P < .001) Antidepressants were prescribed at higher rates than antianxiety or antipsychotic medications across all patients and diagnoses. Of patients with no neuropsychiatric diagnosis, 11.4% were prescribed an antianxiety medication, 22.8% prescribed an antidepressant and 7.6% prescribed an antipsychotic. CONCLUSIONS The high fill rate of antianxiety (benzodiazepine) medications in dementia patients, especially females is a concern. Patients are prescribed psychotropic medications at high rates. This practice may represent potentially inappropriate prescribing. Patient/caregiver education with innovative community outreach and care delivery models may help decrease medication use.
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Affiliation(s)
- Kim G Johnson
- Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Duke University, Durham, NC, USA
- Department of Neurology, Duke University, Durham, NC, USA
| | - Cassie Ford
- Department of Population Health Sciences, Duke University, Durham, NC, USA
| | - Amy G Clark
- Department of Population Health Sciences, Duke University, Durham, NC, USA
| | - Melissa A Greiner
- Department of Population Health Sciences, Duke University, Durham, NC, USA
| | - Jay B Lusk
- School of Medicine, Duke University, Durham, NC, USA
- Fuqua School of Business, Duke University, Durham, NC, USA
| | - Cody Perry
- Trinity College of Arts and Sciences, Duke University, Durham, NC, USA
| | | | - Emily C O'Brien
- Department of Neurology, Duke University, Durham, NC, USA
- Department of Population Health Sciences, Duke University, Durham, NC, USA
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Waters L, Sohmer D, Goldman RE, Bluestein D, Burnham K, Clark PG, Slattum PW, Helm F, Marks J. Beyond knowledge and confidence: a mixed methods evaluation of a Project ECHO course on dementia for primary care. GERONTOLOGY & GERIATRICS EDUCATION 2023:1-14. [PMID: 37929922 DOI: 10.1080/02701960.2023.2278097] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/07/2023]
Abstract
Primary care clinicians have an important role in the management of dementia and have expressed interest in continuing education. The authors describe a model they used for providing dementia education in primary care, Project ECHO (Extension for Community Healthcare Outcomes), and an overview of its major features. A partnership including academic institutions and a national healthcare association is then outlined, including the unique features of the ECHO model developed through this partnership. A mixed-methods methodology was used for programmatic evaluation. This use of mixed methods adds vital new knowledge and learner perspectives that are key to planning subsequent ECHO courses related to dementia and primary care. The discussion includes an exploration of the significance of these findings for understanding the motivations of primary care providers for participation in the educational program, as well as the limitations of the current study. A final section explores the next steps in the continued development of the model and its implications for geriatrics education in dementia care, especially the supportive role that ECHO courses can play in meeting the challenges of dementia care.
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Affiliation(s)
- Leland Waters
- Virginia Center on Aging, Virginia Commonwealth University, Richmond, Virginia, USA
| | - Dana Sohmer
- Alzheimer's Association, Chicago, Illinois, USA
| | - Roberta E Goldman
- Alpert Medical School of Brown University, Providence, Rhode Island, USA
| | - Daniel Bluestein
- Virginia Center on Aging, Virginia Commonwealth University, Richmond, Virginia, USA
| | | | - Phillip G Clark
- Rhode Island Geriatric Education Center, University of Rhode Island, Kingston, USA
| | - Patricia W Slattum
- Virginia Center on Aging, Virginia Commonwealth University, Richmond, Virginia, USA
| | - Faith Helm
- Rhode Island Geriatric Education Center, University of Rhode Island, Kingston, USA
| | - Jane Marks
- Johns Hopkins Geriatrics Workforce Enhancement Program, Division of Geriatric Medicine and Gerontology, Johns Hopkins University, Maryland, Baltimore, USA
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Welch ML, Hodgson JL, Didericksen KW, Lamson AL, Forbes TH. Family-Centered Primary Care for Older Adults with Cognitive Impairment. CONTEMPORARY FAMILY THERAPY 2021; 44:67-87. [PMID: 34803217 PMCID: PMC8591316 DOI: 10.1007/s10591-021-09617-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/01/2021] [Indexed: 12/27/2022]
Abstract
Cognitive impairment (e.g. dementia) presents challenges for individuals, their families, and healthcare professionals alike. The primary care setting presents a unique opportunity to care for older adults living with cognitive impairment, who present with complex care needs that may benefit from a family-centered approach. This indepth systematic review was completed to address three aims: (a) identify the ways in which families of older-adult patients with cognitive impairment are engaged in primary care settings, (b) examine the outcomes of family engagement practices, and (c) organize and discuss the findings using CJ Peek's Three World View. Researchers searched PubMed, Embase, and PsycINFO databases through July 2019. The results included 22 articles out of 6743 identified in the initial search. Researchers provided a description of the emerging themes for each of the three aims. It revealed that family-centered care and family engagement yields promising results including improved health outcomes, quality care, patient experience, and caregiver satisfaction. Furthermore, it promotes and advances the core values of medical family therapy: agency and communion. This review also exposed the inconsistent application of family-centered practices and the need for improved interprofessional education of primary care providers to prepare multidisciplinary teams to deliver family-centered care. Utilizing the vision of Patient- and Family-Centered Care and the lens of the Three World View, this systematic review provides Medical Family Therapists, healthcare administrators, policy makers, educators, and clinicians with information related to family engagement and how it can be implemented and enhanced in the care of patients with cognitive impairment.
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Affiliation(s)
- Melissa L. Welch
- Department of Human Development and Family Science, East Carolina University, Greenville, NC USA
- Department of Community Health and Family Medicine, University of Florida College of Medicine, Gainesville, FL USA
| | - Jennifer L. Hodgson
- Department of Human Development and Family Science, East Carolina University, Greenville, NC USA
| | - Katharine W. Didericksen
- Department of Human Development and Family Science, East Carolina University, Greenville, NC USA
| | - Angela L. Lamson
- Department of Human Development and Family Science, East Carolina University, Greenville, NC USA
| | - Thompson H. Forbes
- Department of Advanced Nursing Practice and Education, East Carolina University, Greenville, NC USA
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Fernandes B, Goodarzi Z, Holroyd-Leduc J. Optimizing the diagnosis and management of dementia within primary care: a systematic review of systematic reviews. BMC FAMILY PRACTICE 2021; 22:166. [PMID: 34380424 PMCID: PMC8359121 DOI: 10.1186/s12875-021-01461-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/09/2021] [Accepted: 05/13/2021] [Indexed: 01/08/2023]
Abstract
Background To understand how best to approach dementia care within primary care and its challenges, we examined the evidence related to diagnosing and managing dementia within primary care. Methods Databases searched include: MEDLINE, Embase, PsycINFO and The Cochrane Database of Systematic Reviews from inception to 11 May 2020. English-language systematic reviews, either quantitative or qualitative, were included if they described interventions involving the diagnosis, treatment and/or management of dementia within primary care/family medicine and outcome data was available. The risk of bias was assessed using AMSTAR 2. The review followed PRISMA guidelines and is registered with Open Science Framework. Results Twenty-one articles are included. The Mini-Cog and the MMSE were the most widely studied cognitive screening tools. The Abbreviated Mental Test Score (AMTS) achieved high sensitivity (100 %, 95 % CI: 70-100 %) and specificity (82 %, 95 % CI: 72-90 %) within the shortest amount of time (3.16 to 5 min) within primary care. Five of six studies found that family physicians had an increased likelihood of suspecting dementia after attending an educational seminar. Case management improved behavioural symptoms, while decreasing hospitalization and emergency visits. The primary care educational intervention, Enhancing Alzheimer’s Caregiver Health (Department of Veterans Affairs), was successful at increasing carer ability to manage problem behaviours and improving outcomes for caregivers. Conclusions There are clear tools to help identify cognitive impairment in primary care, but strategies for management require further research. The findings from this systematic review will inform family physicians on how to improve dementia diagnosis and management within their primary care practice. Supplementary Information The online version contains supplementary material available at 10.1186/s12875-021-01461-5.
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Affiliation(s)
| | - Zahra Goodarzi
- Departments of Medicine and Community Health Sciences, Cumming School of Medicine, Foothills Medical Centre, University of Calgary, North Tower (Rm 930), 1403 29 St NW, Calgary, AB, T2N 2T9, Canada
| | - Jayna Holroyd-Leduc
- Departments of Medicine and Community Health Sciences, Cumming School of Medicine, Foothills Medical Centre, University of Calgary, North Tower (Rm 930), 1403 29 St NW, Calgary, AB, T2N 2T9, Canada
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Mansfield E, Noble N, Sanson-Fisher R, Mazza D, Bryant J. Primary Care Physicians' Perceived Barriers to Optimal Dementia Care: A Systematic Review. THE GERONTOLOGIST 2020; 59:e697-e708. [PMID: 29939234 DOI: 10.1093/geront/gny067] [Citation(s) in RCA: 38] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2017] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Primary care physicians (PCPs) have a key role in providing care for people with dementia and their carers, however, a range of barriers prevent them from delivering optimal care. We reviewed studies on PCPs' perceptions of barriers to providing optimal dementia care, including their methodological quality, whether they focused on barriers related to diagnosis and/or management, and the patient-, provider-, and system-level barriers identified. RESEARCH DESIGN AND METHODS Studies were included if they were quantitative studies published since 2006 which reported on PCPs' perceptions of the barriers to providing dementia care. The methodological quality of identified studies was assessed using an adapted version of accepted rating criteria for quantitative studies. Data were extracted from studies which were rated as "moderate" or "strong" quality. RESULTS A total of 20 studies were identified, 16 of which were rated as "moderate" or "strong" methodological quality. Patient-related barriers included a reluctance to acknowledge cognitive decline and patient nonadherence to management plans. Provider-related barriers included a lack of training and confidence. System-related barriers included a lack of time during consultations and lack of support services. DISCUSSION AND IMPLICATIONS This review highlights a range of barriers to dementia diagnosis and management from studies rated as being methodologically adequate. Future studies should also utilize theory-driven approaches to exploring a comprehensive range of barriers to optimal dementia care across the care trajectory.
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Affiliation(s)
- Elise Mansfield
- Health Behaviour Research Collaborative, Priority Research Centre for Health Behaviour, School of Medicine and Public Health, Faculty of Health and Medicine, University of Newcastle, Callaghan, Australia.,Hunter Medical Research Institute, New Lambton Heights, Australia
| | - Natasha Noble
- Health Behaviour Research Collaborative, Priority Research Centre for Health Behaviour, School of Medicine and Public Health, Faculty of Health and Medicine, University of Newcastle, Callaghan, Australia.,Hunter Medical Research Institute, New Lambton Heights, Australia
| | - Rob Sanson-Fisher
- Health Behaviour Research Collaborative, Priority Research Centre for Health Behaviour, School of Medicine and Public Health, Faculty of Health and Medicine, University of Newcastle, Callaghan, Australia.,Hunter Medical Research Institute, New Lambton Heights, Australia
| | - Danielle Mazza
- Department of General Practice, Medicine, Nursing and Health Sciences, Monash University, Melbourne, Australia
| | - Jamie Bryant
- Health Behaviour Research Collaborative, Priority Research Centre for Health Behaviour, School of Medicine and Public Health, Faculty of Health and Medicine, University of Newcastle, Callaghan, Australia.,Hunter Medical Research Institute, New Lambton Heights, Australia
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Lee E, Gatz M, Tseng C, Schneider LS, Pawluczyk S, Wu AH, Deapen D. Evaluation of Medicare Claims Data as a Tool to Identify Dementia. J Alzheimers Dis 2020; 67:769-778. [PMID: 30689589 DOI: 10.3233/jad-181005] [Citation(s) in RCA: 49] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Medicare claims record linkage has been used to identify diagnosed dementia cases in order to estimate dementia prevalence and cost of care. Claims records in the 1990 s and early 2000 s have been found to provide 85% - ∼90% sensitivity and specificity. OBJECTIVE Considering that dementia awareness has improved over time, we sought to examine sensitivity and specificity of more recent Medicare claims records against a standard criterion, clinical diagnosis of dementia. METHODS For a sample of patients evaluated at the University of Southern California Alzheimer Disease Research Center (ADRC), we performed database linkage with Medicare claims files for a six-year period, 2007-2012. We used clinical diagnosis at the ADRC as the criterion diagnosis in order to calculate sensitivity and specificity. RESULTS Medicare claims correctly identified 85% of dementia patients and 77% of individuals with normal cognition. About half of patients clinically diagnosed with mild cognitive impairment had dementia diagnoses in Medicare claims. Misclassified dementia patients (i.e., missed diagnosis by Medicare claims) had more favorable Mini-Mental State Examination and Clinical Dementia Rating scores and were less likely to present behavioral symptoms than correctly-classified dementia patients. CONCLUSIONS Database linkage to Medicare claims records is an efficient and reasonably accurate tool to identify dementia cases in a population-based cohort. However, possibilities of obtaining biased results due to misclassification of dementia status need to be carefully considered to use Medicare claims diagnosis for etiologic research studies. Additional confirmation of dementia diagnosis may also be considered. A larger study is warranted to confirm our findings.
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Affiliation(s)
- Eunjung Lee
- Department of Preventive Medicine, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Margaret Gatz
- USC Dornsife Center for Economic and Social Research, University of Southern California, Los Angeles, CA, USA
| | - Chiuchen Tseng
- Department of Preventive Medicine, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Lon S Schneider
- USC Davis School of Gerontology, Los Angeles, CA, USA.,Department of Neurology, Keck School of Medicine of USC, Los Angeles, CA, USA.,Department of Psychiatry and the Behavioral Sciences, Keck School of Medicine of USC, Los Angeles, CA, USA
| | - Sonia Pawluczyk
- Department of Psychiatry and the Behavioral Sciences, Keck School of Medicine of USC, Los Angeles, CA, USA
| | - Anna H Wu
- Department of Preventive Medicine, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Dennis Deapen
- Department of Preventive Medicine, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
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Thoits T, Dutkiewicz A, Raguckas S, Lawrence M, Parker J, Keeley J, Andersen N, VanDyken M, Hatfield-Eldred M. Association Between Dementia Severity and Recommended Lifestyle Changes: A Retrospective Cohort Study. Am J Alzheimers Dis Other Demen 2018; 33:242-246. [PMID: 29439581 PMCID: PMC10852487 DOI: 10.1177/1533317518758785] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVE Early diagnosis of dementia leads to early treatment which is beneficial to patients and the community. We reviewed initial evaluations from the Spectrum Health Medical Group Neurocognitive Clinic (SHMGNC) to evaluate dementia stage at the time of diagnosis. METHODS We retrospectively reviewed 110 randomly chosen initial evaluations from September 2008 to December 2015 at the SHMGNC. Patients underwent a neurological examination, Montreal Cognitive Assessment, and a battery of neuropsychological testing. RESULTS Of all, 78.9% had moderate or severe dementia at diagnosis. The SHMGNC recommended lifestyle changes (medication assistance, financial assistance, driving restrictions, and institutional care) in 75.8% of patients with dementia. The severity of dementia was associated with the number of lifestyle changes recommended. Cohabitation with a caregiver did not lead to an early diagnosis of dementia. CONCLUSIONS Patients are not undergoing evaluation at the onset of the dementia process. Diagnosis is delayed. Home-based, patient-centered care may improve early screening and detection of dementia.
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Practice variation and practice guidelines: Attitudes of generalist and specialist physicians, nurse practitioners, and physician assistants. PLoS One 2018; 13:e0191943. [PMID: 29385203 PMCID: PMC5792011 DOI: 10.1371/journal.pone.0191943] [Citation(s) in RCA: 51] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2017] [Accepted: 01/13/2018] [Indexed: 11/21/2022] Open
Abstract
Objective To understand clinicians' beliefs about practice variation and how variation might be reduced. Methods We surveyed board-certified physicians (N = 178), nurse practitioners (N = 60), and physician assistants (N = 12) at an academic medical center and two community clinics, representing family medicine, general internal medicine, and cardiology, from February—April 2016. The Internet-based questionnaire ascertained clinicians' beliefs regarding practice variation, clinical practice guidelines, and costs. Results Respondents agreed that practice variation should be reduced (mean [SD] 4.5 [1.1]; 1 = strongly disagree, 6 = strongly agree), but agreed less strongly (4.1 [1.0]) that it can realistically be reduced. They moderately agreed that variation is justified by situational differences (3.9 [1.2]). They strongly agreed (5.2 [0.8]) that clinicians should help reduce healthcare costs, but agreed less strongly (4.4 [1.1]) that reducing practice variation would reduce costs. Nearly all respondents (234/249 [94%]) currently depend on practice guidelines. Clinicians rated differences in clinician style and experience as most influencing practice variation, and inaccessibility of guidelines as least influential. Time to apply standards, and patient decision aids, were rated most likely to help standardize practice. Nurse practitioners and physicians assistants (vs physicians) and less experienced (vs senior) clinicians rated more favorably several factors that might help to standardize practice. Differences by specialty and academic vs community practice were small. Conclusions Clinicians believe that practice variation should be reduced, but are less certain that this can be achieved. Accessibility of guidelines is not a significant barrier to practice standardization, whereas more time to apply standards is viewed as potentially helpful.
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Sanders AE, Nininger J, Absher J, Bennett A, Shugarman S, Roca R. Quality improvement in neurology. Neurology 2017; 88:1951-1957. [DOI: 10.1212/wnl.0000000000003917] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2016] [Accepted: 02/17/2017] [Indexed: 11/15/2022] Open
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Sivananthan SN, McGrail KM. Diagnosis and Disruption: Population-Level Analysis Identifying Points of Care at Which Transitions Are Highest for People with Dementia and Factors That Contribute to Them. J Am Geriatr Soc 2016; 64:569-77. [PMID: 27000330 DOI: 10.1111/jgs.14033] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
OBJECTIVES To examine transitions that individuals with dementia experience longitudinally and to identify points of care when transitions are highest and the factors that contribute to those transitions. DESIGN Population-based 10-year retrospective cohort study from 2000 to 2011. SETTING General community. PARTICIPANTS All individuals aged 65 and older newly diagnosed with dementia in British Columbia, Canada. MEASUREMENTS The frequency and timing of transitions over 10 years, participant characteristics associated with greater number of transitions, and the influence of recommended dementia care and high-quality primary care on number of transitions. RESULTS Individuals experience a spike in transitions during the year of diagnosis, driven primarily by hospitalizations, despite accounting for end of life or newly moving to a long-term care facility (LTCF). This occurs regardless of survival time or care location. Regardless of survival time, individuals not in LTCFs experience a marked increase in hospitalizations in the year before and the year of death, often exceeding hospitalizations in the year of diagnosis. Receipt of recommended dementia care and receipt of high-quality primary care were independently associated with fewer transitions across care settings. CONCLUSION The spike in transitions in the year of diagnosis highlights a distressing period for individuals with dementia during which unwanted or unnecessary transitions might occur and suggests a useful target for interventions. There is an association between recommended dementia care and outcomes and evidence of the continued value of high-quality primary care in a complex population at a critical point when gaps in continuity are especially likely.
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Affiliation(s)
- Saskia N Sivananthan
- Centre for Health Services and Policy Research, University of British Columbia, Vancouver, British Columbia, Canada
| | - Kimberlyn M McGrail
- Centre for Health Services and Policy Research, University of British Columbia, Vancouver, British Columbia, Canada
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Sivananthan SN, Lavergne MR, McGrail KM. Caring for dementia: A population‐based study examining variations in guideline‐consistent medical care. Alzheimers Dement 2015; 11:906-16. [DOI: 10.1016/j.jalz.2015.02.008] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2014] [Revised: 02/01/2015] [Accepted: 02/03/2015] [Indexed: 11/26/2022]
Affiliation(s)
- Saskia N. Sivananthan
- UBC Centre for Health Services and Policy Research School of Population and Public Health Vancouver BC Canada
| | - M. Ruth Lavergne
- UBC Centre for Health Services and Policy Research School of Population and Public Health Vancouver BC Canada
| | - Kimberlyn M. McGrail
- UBC Centre for Health Services and Policy Research School of Population and Public Health Vancouver BC Canada
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