Quality improvement in neurology

Beyond knowledge and confidence: a mixed methods evaluation of a Project ECHO course on dementia for primary care

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.

Predictors of Mortality in Individuals with Dementia in the National Alzheimer's Coordinating Center

BACKGROUND

Dementia is one of the top causes of death worldwide, but individuals with dementia and their caregivers report that knowing what to expect, including regarding approaching end of life, is an unmet need.

OBJECTIVE

To identify predictors of death in individuals with Alzheimer disease (AD) dementia, Lewy body dementia (LBD), vascular dementia, and frontotemporal dementia.

METHODS

The study used data from National Alzheimer's Coordinating Center participants with dementia and an etiologic diagnosis of AD, Lewy body disease, frontotemporal lobar degeneration (FTLD, with or without motor neuron disease), or vascular dementia. Analyses included median survival across dementia types and predictors of death at 5 years based on baseline demographics and clinical measure performance. Five-year survival probability tables were stratified by predictor values.

RESULTS

Individuals with AD had the longest survival (median 6 years), followed by FTLD (5 years), and vascular dementia and LBD (each 4 years). The strongest predictors of death for the full cohort were dementia type (higher risk with non-AD dementias), sex (higher risk with male sex), and race and ethnicity (higher risk with white and non-Hispanic participants). Age was associated with higher mortality risk across the non-Alzheimer dementias; other significant associations included worse cognitive status (FTLD, LBD) and more depression (LBD).

CONCLUSION

Results can help clinicians counsel individuals with dementia and families regarding average dementia trajectories; findings regarding individual risk factors can aid individualizing expectations. Further research is needed to investigate drivers of mortality in the non-AD dementias to improve counseling and help identify potentially modifiable factors.

Building an advocacy model to improve the dementia-capability of health plans in California

BACKGROUND

Given the high and growing prevalence of Alzheimer's disease and related dementias, and the intensity of this population's care needs, it is imperative that healthcare systems increase their capacity to effectively serve people living with dementia (PLwD). The Dementia Cal MediConnect (Dementia CMC) project proposes an advocacy model that may foster dementia-capable systems change.

METHODS

The Dementia CMC project was a 5-year partnership (2013-2018) between local Alzheimer's organizations and 10 managed care health plans (HPs) in California's duals demonstration. It used an advocacy model with the following steps: (1) Identify dementia-capable best practices to set as systems change indicators; (2) Identify and leverage public policies in support of systems change indicators; (3) Identify and engage champions; (4) Develop and advocate for a business case to improve dementia care; (5) Identify gaps in dementia-capable practices; (6) Provide technical assistance, tools, and staff training to address the gaps in dementia-capable practices; and (7) Track systems change. Systems change data were collected through participant observation with HPs and interviews with key informants representing partnering organizations or government entities.

RESULTS

Participating HPs reported making systems changes toward more dementia-capable practices such as: better pathways for detection and diagnosis; better identification, assessment, support, and engagement of caregivers; and improved systems of referral to community-based organizations (CBOs), including Alzheimer's CBOs. Some indicators of systems change were inconclusive due to flawed assumptions around HP's care coordination, and the availability of common electronic health records between HPs and providers.

CONCLUSION

The application of this advocacy model in California has led to systems changes that can improve care for PLwD and their caregivers and should be replicated to expand the dementia-capability of other health systems. Continued efforts to refine indicators are needed to capture systems change in complex and changing health systems.

Preferences for Communication About End-of-Life Care in Atypical Parkinsonism

BACKGROUND

Studies on preferences regarding discussions on end-of-life care (EOLC), advance care planning (ACP), medical assistance in dying (MAiD), and brain donation have not yet been conducted in patients with atypical parkinsonism (AP).

OBJECTIVE

The aim of this study was to know the preferences of patients with AP regarding discussions on EOLC, ACP, MAiD, and brain donation.

METHODS

This cross-sectional study was conducted in patients clinically diagnosed with AP. An adapted questionnaire that assessed various potential factors that affect patients' preferences regarding EOLC and ACP was sent through postal mail to 278 patients.

RESULTS

A total of 90 completed questionnaires were returned. Most patients preferred to discuss at the time of diagnosis information about the disease, its natural course, treatment options, and prognosis. In contrast, they preferred that EOLC and ACP be discussed when the disease has progressed. No demographic or disease-related factors were found to be predictors of the patient's preferences. Notably, most patients (63.3%) had previous actual discussions on these issues. Less than a third of patients were open to discussions about MAiD and brain donation; older age and the importance of spirituality and religion decreased the odds of discussing these.

CONCLUSIONS

Our study demonstrates that patients with AP have preferences regarding the timing of the discussion of the different themes surrounding EOLC and ACP. A needs-based approach in initiating and conducting timely discussions on these difficult but essential issues is proposed. A thorough explanation and recognition of a patient's beliefs are recommended when initiating conversations about MAiD and brain donation. © 2021 International Parkinson and Movement Disorder Society.

Administration of Dexamethasone for Bacterial Meningitis: An Unreliable Quality Measure

Objective

To validate the use of administrative data to identify patients with bacterial meningitis and quantify the rate of dexamethasone administration as defined in the American Academy of Neurology Inpatient and Emergency Care Quality Measurement Set.

Methods

The Vizient Clinical Data Base and Resource Manager was used to identify patients with International Classification of Diseases, Tenth Revision (ICD-10) codes for bacterial meningitis from October 2015 to June 2019. Chart review was performed on patients identified at a single quaternary-care hospital. The positive predictive value (PPV) of Vizient was determined. Demographic, clinical, and laboratory data were assessed using descriptive statistics.

Results

Of all hospitals that submitted complete data to Vizient during the study period, a median of 19 patients per hospital had ICD-10 codes for bacterial meningitis in the 45-month period. We identified 79 patients using Vizient at our institution of whom 69 had a diagnosis of bacterial meningitis confirmed by chart review (PPV = 87%). 15 patients were eligible to receive dexamethasone per the quality measurement set. Six of these patients (40%) received dexamethasone.

Conclusion

It is feasible to use the Vizient Clinical Data Base and Resource Manager to identify patients with bacterial meningitis. Due to low prevalence across multiple institutions and high rate of exclusion criteria at our institution, this study suggests that the rate of dexamethasone administration in bacterial meningitis may be an unreliable indicator of quality of care provided by inpatient neurologists. The creation of a registry for hospitalized neurology patients could enhance development of future quality measures.

Enabling Advance Care Planning in Dementia Care: A Primary Care Approach

BACKGROUND

Lack of tools to support advance care planning (ACP) has been identified as a significant barrier to implementing these discussions.

AIM

We pilot tested an ACP framework tool for use with persons living with dementia (PLWD) in primary care-based memory clinics and an Adult Day Program; this study describes user and recipient experiences with this framework.

METHODS

We used a mixed methods approach. Health professionals completed an online survey following pilot testing and PLWD and substitute decision makers (SDM) completed survey immediately following the ACP discussion assessing their satisfaction (5-point scale) with the framework and exploring potential outcomes. Interviews with health professionals, PLWD, and SDM were conducted to gather more in-depth information on their perceptions of the ACP framework/ discussion.

RESULTS

Surveys were completed by 12 health professionals, 13 PLWD, and 16 SDM. While PLWD and SDM were satisfied with the ACP discussion (M = 4.0/5), health professionals were minimally satisfied with the ease of use of the framework (M = 2.0/5), acceptability for patients (M = 2.4/5) and feasibility in practice (M = 1.9/5). Sixteen interviews were completed with 8 health professionals, 1 PLWD, and 7 SDM. While health professionals valued ACP, lack of time and training were identified barriers to framework use. SDM felt better prepared for future decisions and PLWD were put at ease, knowing that their wishes for care were understood.

CONCLUSION

PLWD and SDM value the opportunity for ACP, and although health professionals identified some concerns with framework administration, they acknowledge the value and importance of ACP. Continuing efforts to refine ACP processes are justified.

Quality assurance as a foundational element for an integrated system of dementia care

PURPOSE

Many countries are developing primary care collaborative memory clinics (PCCMCs) to address the rising challenge of dementia. Previous research suggests that quality assurance should be a foundational element of an integrated system of dementia care. The purpose of this paper is to understand physicians' and specialists' perspectives on such a system and identify barriers to its implementation.

DESIGN/METHODOLOGY/APPROACH

The authors used interviews and a constructivist framework to understand the perspectives on a quality assurance framework for dementia care and barriers to its implementation from ten primary care and ten specialist physicians affiliated with PCCMCs.

FINDINGS

Interviewees found that the framework reflects quality dementia care, though most could not relate quality assurance to clinical practice. Quality assurance was viewed as an imposition on practitioners rather than as a measure of system integration. Disparities in resources among providers were seen as barriers to quality care. Greater integration with specialists was seen as a potential quality improvement mechanism. Standardized electronic medical records were seen as important to support both quality assurance and clinical care.

PRACTICAL IMPLICATIONS

This work identified several challenges to the implementation of a quality assurance framework to support an integrated system of dementia care. Clinicians require education to better understand quality assurance. Additional challenges include inadequate resources, a need for closer collaboration between specialists and PCCMCs, and a need for a standardized electronic medical record.

ORIGINALITY/VALUE

Greater health system integration is necessary to provide quality dementia care, and quality assurance could be considered a foundational element driving system integration.

Lewy Body Dementias

PURPOSE OF REVIEW

This article describes current diagnostic criteria relating to the diagnosis of Lewy body dementia, highlights diagnostic controversies, and reviews treatment approaches.

RECENT FINDINGS

Clinical diagnostic criteria for both Parkinson disease and dementia with Lewy bodies have been recently updated. These criteria result in overlap between individuals diagnosed with Parkinson disease and those with dementia with Lewy bodies. Although clinical features and symptomatic treatment overlap, differences remain in epidemiology and expected progression. The high prevalence of cognitive impairment in Parkinson disease supports regular screening for cognitive changes and counseling patients and families regarding what to expect. Treatment for Lewy body dementia involves avoiding medications that may cause or exacerbate symptoms; prescribing pharmacologic agents to address bothersome cognitive, behavioral, movement, and other nonmotor symptoms; recommending physical exercise and therapy; and providing education, counseling, caregiver support, and palliative care.

SUMMARY

Lewy body dementia includes both dementia with Lewy bodies and Parkinson disease dementia, overlapping clinicopathologic entities with differences relating to diagnosis and expected progression. Treatment is symptomatic and thus largely overlapping for the two conditions.

Care Needs of Community-Residing Male Patients with Vascular Cognitive Impairment

PURPOSE

The aim of this study was to identify the care needs of male patients with vascular cognitive impairment (VCI) and their caregivers.

PATIENTS AND METHODS

This cross-sectional study enrolled 389 male patients with VCI and their caregivers who were cared for by the dementia collaborative care team at Changhua Christian Hospital, Taiwan. Fifteen care needs consisting of most of quality measures for people living with dementia and their caregivers were developed by the care team. Through face-to-face evaluations, individualized care needs were collected. The Apriori algorithm was used to identify care bundles for the patients and their caregivers.

RESULTS

Six basic care needs for patients and their caregivers were identified, including appropriate schedule of activities, regular outpatient follow-up treatment, introduction and referral of social resources, referral to family support groups and care skills training, care for the mood of the caregiver, and health education for dementia and behavioral and psychological symptoms of dementia. Compared to subjects with all dementia subtypes from the previous studies, care for the mood of the caregiver was an important and frequent care need for the male patients with VCI and their caregivers. A comparison among the study and similar studies was made to highlight the strength of this study concentrating on the precise selection of care needs.

CONCLUSION

Collaborative dementia care teams should monitor for caregivers' depression and include this care need into the care bundle when assessing male subjects with VCI.

End-of-life experiences in dementia with Lewy bodies: Qualitative interviews with former caregivers

BACKGROUND

Dementia caregivers describe knowing what to expect as an unmet need and many are unaware that dementia can be a terminal condition. Dementia with Lewy bodies (DLB) is a common neurodegenerative dementia with unique features which may affect the end of life (EOL). Given the paucity of data on EOL experiences in dementia and unique aspects of DLB affecting EOL, we investigated EOL experiences as reported by caregivers of individuals with DLB.

METHOD

We conducted telephone interviews with caregivers and family members of individuals who died with DLB in the last 5 years using a semi-structured questionnaire to identify and describe EOL experiences. We used a qualitative descriptive approach to analyze interview transcripts and identify common themes.

RESULTS

Thirty individuals participated in interviews. Key themes included lack of knowledge regarding what to expect, end-of-life time course (including end-of-life symptoms, declines after hospitalization and falls, and varied EOL trajectories), advance care planning, lack of family understanding, hospice, views regarding right-to-die, medications at the end of life, approaching end of life, the death experience, and activities that enhanced end of life. Lack of communication between health care teams and families and difficulty predicting death timing were two frequently expressed challenges.

CONCLUSIONS

Study results emphasize the need for improved EOL counseling in DLB, recognition of EOL symptoms, earlier hospice involvement, tailoring EOL care to DLB-specific needs, and clinician-family communication. Suggestions for patient and family education are provided. Further research should confirm predictors of approaching EOL in DLB, identify strategies to improve physician recognition of EOL, and develop tools to aid communication and quality EOL care.

The Effect of a Comprehensive Dementia Care Management Program on End-of-Life Care

BACKGROUND/OBJECTIVES

Although Alzheimer disease and other dementias are life limiting, only a minority of these patients or their proxy decision makers participate in advance care planning. We describe end-of-life care preferences and acute care and hospice use in the last 6 months of life for persons enrolled in a comprehensive dementia care management program.

DESIGN

Observational, retrospective cohort.

SETTING

Urban, academic medical center.

PARTICIPANTS

A total of 322 persons enrolled in dementia care management after July 1, 2012, who died before July 1, 2016.

INTERVENTION

Dementia care comanagement model using nurse practitioners partnered with primary care providers and community organizations to provide comprehensive dementia care, including advance care planning.

MEASUREMENTS

Advance care preferences, use of Physician Orders for Life Sustaining Treatment (POLST), hospice enrollment, and hospitalizations and emergency department (ED) visits in the last 6 months of life obtained from electronic health record data.

RESULTS

Nearly all decedents (99.7%, N = 321) had a goals-of-care conversation documented (median = 3 conversations; interquartile range = 2-4 conversations), and 64% had advance care preferences recorded. Among those with recorded preferences, 88% indicated do not resuscitate, 48% limited medical interventions, and 35% chose comfort-focused care. Most patients (89%) specified limited artificial nutrition, including withholding feeding tubes. Over half (54%) had no hospitalizations or ED visits in the last 6 months of life, and intensive care unit stays were rare (5% of decedents). Overall, 69% died on hospice. Decedents who had completed a POLST were more likely to die in hospice care (74% vs 62%; P = .03) and die at home (70% vs 59%; P = .04).

CONCLUSIONS

Enrollees in a comprehensive dementia care comanagement program had high engagement in advance care planning, high rates of hospice use, and low acute care utilization near the end of life. Wider implementation of such programs may improve end-of-life care for persons with dementia. J Am Geriatr Soc 67:443-448, 2019.

Updating quality indicators for low-risk labour care in Japan using current clinical practice guidelines: a modified Delphi method

OBJECTIVES

Quality indicators are measurable elements widely used to assess the quality of care. They are often developed from the results of systematic reviews or clinical practice guidelines. These sources are regularly updated in line with new clinical evidence, but there are few articles on updating quality indicators based on clinical practice guidelines. This study aimed to update the quality indicators developed for low-risk labour care in Japan in 2012, mainly drawing on new or updated clinical practice guidelines, and making the process clearly visible and assessable.

DESIGN AND SETTING

We used a modified Delphi method for the update. The procedure included four steps: (1) updating the definition of low-risk labour; (2) reviewing the literature published between June 2012 and December 2015 using five guidelines and two quality indicator databases to extract potential candidate indicators; (3) formation of a multidisciplinary panel including mothers and (4) panel ratings (two rounds between February and April 2016) on the validity of the candidate indicators, and judging the validity of the previous quality indicators drawing on the new evidence.

PARTICIPANTS

A multidisciplinary panel of 13 clinicians, including obstetricians, paediatricians and midwives, plus 3 non-clinician mothers.

RESULTS

The literature review identified 276 new recommendations from 27 clinical practice guidelines including 2 published in Japan and 21 quality indicators. We developed 13 new candidate indicators from these sources and panel recommendations, 12 of which were approved by the multidisciplinary panel. The panel also accepted all 23 existing quality indicators as still valid, resulting in a total of 35 quality indicators for low-risk labour.

CONCLUSIONS

We successfully updated the quality indicators for low-risk labour care in Japan. The procedure developed may be useful for updating other quality indicators based on new clinical practice guidelines.

Using The Apriori Algorithm To Classify The Care Needs Of Patients With Different Types Of Dementia

PURPOSE

To elucidate specific combinations of care needs for people living with dementia (PLWD) and their caregivers according to specific subtypes of dementia.

PATIENTS AND METHODS

A cross-sectional study at memory clinics in Changhua Christian Hospital, Taiwan, was conducted. Five hundred and eight people living with dementia and their caregivers joined the dementia collaborative care model. The care team established 15 care needs containing most of quality measures for PLWD and their caregivers. Individualized care plans including different combinations of care needs were addressed through face-to-face assessments. Apriori algorithm was used to find specific combinations of care needs for particular groups of PLWD and their caregivers.

RESULTS

This study identified the basic care needs of PLWD and caregivers including appropriate scheduling of activities, regular outpatient follow-up treatment, introduction and referral of social resources, referral to family support groups and care skills training, and health education for dementia and behavioral and psychological symptoms of dementia. Patients with Alzheimer's dementia required more care to prevent traffic accidents and getting lost, while patients with vascular dementia required more care to prevent falls. The older (≥75 years old) PLWD were associated with more needs of fall prevention and care for the mood of the caregiver, especially in the female patients with mild Alzheimer's dementia (CDR = 1).

CONCLUSION

Bundling the needed care needs might be a more effective means to care for a wide variety of patients with dementia.

Persons with dementia and care partners’ perspectives on memory clinics in primary care

Aims: To understand persons with dementia (PWD) and care partners’ experiences with the Primary Care Collaborative Memory Clinic (PCCMC) care model. Methods: Interviews were conducted with a purposeful sample of PWD (n = 12) and care partners (N = 16) to identify their perspectives of care received in the clinic and suggestions for improvement. Results: PWD and care partners were satisfied with care received within the PCCMC, had positive interactions with and perceived a strong sense of support from team members and felt listened to; the necessity of cognitive testing was recognized but disliked. Conclusions: The PCCMC care model can address many existing gaps in dementia care as experienced by PWD and care partners.

Cerebral Microbleeds in Advanced Dementia: Clinical and Pathological Correlates

OBJECTIVE

We conducted a longitudinal study to explore the clinical and pathological correlates of cerebral microbleeds (CMBs) in institutionalized patients with dementia.

METHODS

Clinical and magnetic resonance imaging (MRI) data were extracted from 182 nursing home patients (mean age [standard deviation]: 81.3 [6.9], 78.0% female, and 83.4% moderate to severe dementia), which were divided according to the CMBs number and location. One-year follow-up data were obtained from 153 patients, and postmortem pathological diagnosis was available in 40 patients.

RESULTS

Cerebral microbleeds were observed in 42.9% of patients and were associated with MRI ischemic lesions ( P < .0005). In the adjusted analysis, lobar CMB predicted worsening of parkinsonism (standardized β: 0.43) and gait (standardized β: 0.24). A pathological diagnosis of Alzheimer's disease was less frequent in the brains of patients with lobar and deep CMB (33.3% vs 85.3%; P < .05).

CONCLUSION

Cerebral microbleeds were linked to cerebrovascular disease and predicted motor deterioration in institutionalized people with advanced dementia.

Neuropalliative care: Priorities to move the field forward

Neuropalliative care is an emerging subspecialty in neurology and palliative care. On April 26, 2017, we convened a Neuropalliative Care Summit with national and international experts in the field to develop a clinical, educational, and research agenda to move the field forward. Clinical priorities included the need to develop and implement effective models to integrate palliative care into neurology and to develop and implement informative quality measures to evaluate and compare palliative approaches. Educational priorities included the need to improve the messaging of palliative care and to create standards for palliative care education for neurologists and neurology education for palliative specialists. Research priorities included the need to improve the evidence base across the entire research spectrum from early-stage interventional research to implementation science. Highest priority areas include focusing on outcomes important to patients and families, developing serious conversation triggers, and developing novel approaches to patient and family engagement, including improvements to decision quality. As we continue to make remarkable advances in the prevention, diagnosis, and treatment of neurologic illness, neurologists will face an increasing need to guide and support patients and families through complex choices involving immense uncertainty and intensely important outcomes of mind and body. This article outlines opportunities to improve the quality of care for all patients with neurologic illness and their families through a broad range of clinical, educational, and investigative efforts that include complex symptom management, communication skills, and models of care.