1
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Marras C, Meyer Z, Liu H, Luo S, Mantri S, Allen A, Baybayan S, Beck JC, Brown AE, Cheung F, Dahodwala N, Davis TL, Engeland M, Fearon C, Jones N, Mills K, Miyasaki JM, Naito A, Neault M, Nelson EC, Onyinanya E, Ropa C, Weintraub D. Improving Parkinson's Disease Care through Systematic Screening for Depression. Mov Disord Clin Pract 2024. [PMID: 39030949 DOI: 10.1002/mdc3.14163] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2024] [Revised: 04/24/2024] [Accepted: 06/01/2024] [Indexed: 07/22/2024] Open
Abstract
BACKGROUND Depression is common in Parkinson's disease (PD) but is underrecognized clinically. Although systematic screening is a recommended strategy to improve depression recognition in primary care practice, it has not been widely used in PD care. METHODS The 15-item Geriatric Depression Scale (GDS-15) was implemented at 5 movement disorders clinics to screen PD patients. Sites developed processes suited to their clinical workflow. Qualitative interviews with clinicians and patients provided information on feasibility, acceptability, and perceived utility. RESULTS Prior to implementation, depression screening was recorded in 12% using a formal instrument; 64% were screened informally by clinical interview, and no screening was recorded in 24%. Of 1406 patients seen for follow-up care during the implementation period, 88% were screened, 59% using the GDS-15 (self-administered in 51% and interviewer administered in 8%), a nearly 5-fold increase in formal screening. Lack of clinician or staff time and inability to provide the GDS-15 to the patient ahead of the visit were the most commonly cited reasons for lack of screening using the GDS-15; 378 (45%) patients completing the GDS-15 screened positive for depression, and 137 were enrolled for a 12-month prospective follow-up. Mean GDS-15 scores improved from 8.8 to 7.0 (P < 0.0001) and the 39-item Parkinson's Disease Questionnaire emotional subscore from 42.2 to 36.7 (P = 0.0007). CONCLUSIONS Depression screening in PD using a formal instrument can be achieved at much higher levels than is currently practiced, but there are barriers to implementing this in clinical practice. An individual site-specific process is necessary to optimize screening rates.
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Affiliation(s)
- Connie Marras
- The Edmond J. Safra Program in Parkinson's Disease and the Morton and Gloria Shulman Movement Disorders Center, Toronto Western Hospital, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | | | - Hongliang Liu
- Department of Biostatistics and Bioinformatics, Duke University, Durham, North Carolina, USA
| | - Sheng Luo
- Department of Biostatistics and Bioinformatics, Duke University, Durham, North Carolina, USA
| | - Sneha Mantri
- Department of Neurology, Duke University School of Medicine, Durham, North Carolina, USA
| | - Allison Allen
- Department of Neurology, Duke University School of Medicine, Durham, North Carolina, USA
| | - Sydney Baybayan
- Department of Neurology, The Parkinson's Disease and Movement Disorders Center, Johns Hopkins University, Baltimore, Maryland, USA
| | | | - Amy E Brown
- Department of Neurology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Francis Cheung
- Division of Neurology, Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Nabila Dahodwala
- Department of Neurology, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania, USA
| | - Thomas L Davis
- Department of Neurology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Megan Engeland
- Department of Neurology, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania, USA
| | - Conor Fearon
- The Edmond J. Safra Program in Parkinson's Disease and the Morton and Gloria Shulman Movement Disorders Center, Toronto Western Hospital, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Nicole Jones
- Department of Neurology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Kelly Mills
- Department of Neurology, The Parkinson's Disease and Movement Disorders Center, Johns Hopkins University, Baltimore, Maryland, USA
| | - Janis M Miyasaki
- Division of Neurology, Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Anna Naito
- Parkinson's Foundation, New York, New York, USA
| | | | - Eugene C Nelson
- Department of Community and Family Medicine at Geisel School of Medicine at Dartmouth College, The Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, New Hampshire, USA
| | - Ebubechukwu Onyinanya
- Department of Neurology, The Parkinson's Disease and Movement Disorders Center, Johns Hopkins University, Baltimore, Maryland, USA
| | - Carlos Ropa
- The Edmond J. Safra Program in Parkinson's Disease and the Morton and Gloria Shulman Movement Disorders Center, Toronto Western Hospital, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Daniel Weintraub
- Departments of Psychiatry and Neurology, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania, USA
- Department of Psychiatry, Parkinson's Disease Research, Education and Clinical Center, Philadelphia Veterans Affairs Medical Center, Philadelphia, Pennsylvania, USA
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3
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Chou KL, Martello J, Atem J, Elrod M, Foster ER, Freshwater K, Gunzler SA, Kim H, Mahajan A, Sarva H, Stebbins GT, Lee E, Yang L. Quality Improvement in Neurology: 2020 Parkinson Disease Quality Measurement Set Update. Neurology 2021; 97:239-245. [PMID: 34341076 DOI: 10.1212/wnl.0000000000012198] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2020] [Accepted: 04/07/2021] [Indexed: 12/13/2022] Open
Affiliation(s)
- Kelvin L Chou
- From the University of Michigan Medical School (K.L.C.), Ann Arbor; Christiana Care (J.M.), Wilmington, DE; UT Southwestern Medical Center (J.A.), Dallas, TX; MaxMD (M.E.), Fort Lee, NJ; Washington University School of Medicine (E.R.F.), St. Louis, MO; Bronson Neuroscience Center (K.F.), Kalamazoo, MI; University Hospitals Cleveland Medical Center and Case Western Reserve University (S.A.G.), OH; Veterans Affairs Puget Sound Health Care System (H.K.), Seattle, WA; Rush University Medical Center (A.M.), Chicago, IL; Weill Cornell Medicine (H.S.), New York, NY; Rush University (G.T.S.), Chicago, IL; American Academy of Neurology (E.L.), Minneapolis, MN; and Stanford Health Care (L.Y.), Palo Alto, CA
| | - Justin Martello
- From the University of Michigan Medical School (K.L.C.), Ann Arbor; Christiana Care (J.M.), Wilmington, DE; UT Southwestern Medical Center (J.A.), Dallas, TX; MaxMD (M.E.), Fort Lee, NJ; Washington University School of Medicine (E.R.F.), St. Louis, MO; Bronson Neuroscience Center (K.F.), Kalamazoo, MI; University Hospitals Cleveland Medical Center and Case Western Reserve University (S.A.G.), OH; Veterans Affairs Puget Sound Health Care System (H.K.), Seattle, WA; Rush University Medical Center (A.M.), Chicago, IL; Weill Cornell Medicine (H.S.), New York, NY; Rush University (G.T.S.), Chicago, IL; American Academy of Neurology (E.L.), Minneapolis, MN; and Stanford Health Care (L.Y.), Palo Alto, CA
| | - Juliana Atem
- From the University of Michigan Medical School (K.L.C.), Ann Arbor; Christiana Care (J.M.), Wilmington, DE; UT Southwestern Medical Center (J.A.), Dallas, TX; MaxMD (M.E.), Fort Lee, NJ; Washington University School of Medicine (E.R.F.), St. Louis, MO; Bronson Neuroscience Center (K.F.), Kalamazoo, MI; University Hospitals Cleveland Medical Center and Case Western Reserve University (S.A.G.), OH; Veterans Affairs Puget Sound Health Care System (H.K.), Seattle, WA; Rush University Medical Center (A.M.), Chicago, IL; Weill Cornell Medicine (H.S.), New York, NY; Rush University (G.T.S.), Chicago, IL; American Academy of Neurology (E.L.), Minneapolis, MN; and Stanford Health Care (L.Y.), Palo Alto, CA
| | - Matt Elrod
- From the University of Michigan Medical School (K.L.C.), Ann Arbor; Christiana Care (J.M.), Wilmington, DE; UT Southwestern Medical Center (J.A.), Dallas, TX; MaxMD (M.E.), Fort Lee, NJ; Washington University School of Medicine (E.R.F.), St. Louis, MO; Bronson Neuroscience Center (K.F.), Kalamazoo, MI; University Hospitals Cleveland Medical Center and Case Western Reserve University (S.A.G.), OH; Veterans Affairs Puget Sound Health Care System (H.K.), Seattle, WA; Rush University Medical Center (A.M.), Chicago, IL; Weill Cornell Medicine (H.S.), New York, NY; Rush University (G.T.S.), Chicago, IL; American Academy of Neurology (E.L.), Minneapolis, MN; and Stanford Health Care (L.Y.), Palo Alto, CA
| | - Erin R Foster
- From the University of Michigan Medical School (K.L.C.), Ann Arbor; Christiana Care (J.M.), Wilmington, DE; UT Southwestern Medical Center (J.A.), Dallas, TX; MaxMD (M.E.), Fort Lee, NJ; Washington University School of Medicine (E.R.F.), St. Louis, MO; Bronson Neuroscience Center (K.F.), Kalamazoo, MI; University Hospitals Cleveland Medical Center and Case Western Reserve University (S.A.G.), OH; Veterans Affairs Puget Sound Health Care System (H.K.), Seattle, WA; Rush University Medical Center (A.M.), Chicago, IL; Weill Cornell Medicine (H.S.), New York, NY; Rush University (G.T.S.), Chicago, IL; American Academy of Neurology (E.L.), Minneapolis, MN; and Stanford Health Care (L.Y.), Palo Alto, CA
| | - Karen Freshwater
- From the University of Michigan Medical School (K.L.C.), Ann Arbor; Christiana Care (J.M.), Wilmington, DE; UT Southwestern Medical Center (J.A.), Dallas, TX; MaxMD (M.E.), Fort Lee, NJ; Washington University School of Medicine (E.R.F.), St. Louis, MO; Bronson Neuroscience Center (K.F.), Kalamazoo, MI; University Hospitals Cleveland Medical Center and Case Western Reserve University (S.A.G.), OH; Veterans Affairs Puget Sound Health Care System (H.K.), Seattle, WA; Rush University Medical Center (A.M.), Chicago, IL; Weill Cornell Medicine (H.S.), New York, NY; Rush University (G.T.S.), Chicago, IL; American Academy of Neurology (E.L.), Minneapolis, MN; and Stanford Health Care (L.Y.), Palo Alto, CA
| | - Steven A Gunzler
- From the University of Michigan Medical School (K.L.C.), Ann Arbor; Christiana Care (J.M.), Wilmington, DE; UT Southwestern Medical Center (J.A.), Dallas, TX; MaxMD (M.E.), Fort Lee, NJ; Washington University School of Medicine (E.R.F.), St. Louis, MO; Bronson Neuroscience Center (K.F.), Kalamazoo, MI; University Hospitals Cleveland Medical Center and Case Western Reserve University (S.A.G.), OH; Veterans Affairs Puget Sound Health Care System (H.K.), Seattle, WA; Rush University Medical Center (A.M.), Chicago, IL; Weill Cornell Medicine (H.S.), New York, NY; Rush University (G.T.S.), Chicago, IL; American Academy of Neurology (E.L.), Minneapolis, MN; and Stanford Health Care (L.Y.), Palo Alto, CA
| | - Hojoong Kim
- From the University of Michigan Medical School (K.L.C.), Ann Arbor; Christiana Care (J.M.), Wilmington, DE; UT Southwestern Medical Center (J.A.), Dallas, TX; MaxMD (M.E.), Fort Lee, NJ; Washington University School of Medicine (E.R.F.), St. Louis, MO; Bronson Neuroscience Center (K.F.), Kalamazoo, MI; University Hospitals Cleveland Medical Center and Case Western Reserve University (S.A.G.), OH; Veterans Affairs Puget Sound Health Care System (H.K.), Seattle, WA; Rush University Medical Center (A.M.), Chicago, IL; Weill Cornell Medicine (H.S.), New York, NY; Rush University (G.T.S.), Chicago, IL; American Academy of Neurology (E.L.), Minneapolis, MN; and Stanford Health Care (L.Y.), Palo Alto, CA
| | - Abhimanyu Mahajan
- From the University of Michigan Medical School (K.L.C.), Ann Arbor; Christiana Care (J.M.), Wilmington, DE; UT Southwestern Medical Center (J.A.), Dallas, TX; MaxMD (M.E.), Fort Lee, NJ; Washington University School of Medicine (E.R.F.), St. Louis, MO; Bronson Neuroscience Center (K.F.), Kalamazoo, MI; University Hospitals Cleveland Medical Center and Case Western Reserve University (S.A.G.), OH; Veterans Affairs Puget Sound Health Care System (H.K.), Seattle, WA; Rush University Medical Center (A.M.), Chicago, IL; Weill Cornell Medicine (H.S.), New York, NY; Rush University (G.T.S.), Chicago, IL; American Academy of Neurology (E.L.), Minneapolis, MN; and Stanford Health Care (L.Y.), Palo Alto, CA
| | - Harini Sarva
- From the University of Michigan Medical School (K.L.C.), Ann Arbor; Christiana Care (J.M.), Wilmington, DE; UT Southwestern Medical Center (J.A.), Dallas, TX; MaxMD (M.E.), Fort Lee, NJ; Washington University School of Medicine (E.R.F.), St. Louis, MO; Bronson Neuroscience Center (K.F.), Kalamazoo, MI; University Hospitals Cleveland Medical Center and Case Western Reserve University (S.A.G.), OH; Veterans Affairs Puget Sound Health Care System (H.K.), Seattle, WA; Rush University Medical Center (A.M.), Chicago, IL; Weill Cornell Medicine (H.S.), New York, NY; Rush University (G.T.S.), Chicago, IL; American Academy of Neurology (E.L.), Minneapolis, MN; and Stanford Health Care (L.Y.), Palo Alto, CA
| | - Glenn T Stebbins
- From the University of Michigan Medical School (K.L.C.), Ann Arbor; Christiana Care (J.M.), Wilmington, DE; UT Southwestern Medical Center (J.A.), Dallas, TX; MaxMD (M.E.), Fort Lee, NJ; Washington University School of Medicine (E.R.F.), St. Louis, MO; Bronson Neuroscience Center (K.F.), Kalamazoo, MI; University Hospitals Cleveland Medical Center and Case Western Reserve University (S.A.G.), OH; Veterans Affairs Puget Sound Health Care System (H.K.), Seattle, WA; Rush University Medical Center (A.M.), Chicago, IL; Weill Cornell Medicine (H.S.), New York, NY; Rush University (G.T.S.), Chicago, IL; American Academy of Neurology (E.L.), Minneapolis, MN; and Stanford Health Care (L.Y.), Palo Alto, CA
| | - Erin Lee
- From the University of Michigan Medical School (K.L.C.), Ann Arbor; Christiana Care (J.M.), Wilmington, DE; UT Southwestern Medical Center (J.A.), Dallas, TX; MaxMD (M.E.), Fort Lee, NJ; Washington University School of Medicine (E.R.F.), St. Louis, MO; Bronson Neuroscience Center (K.F.), Kalamazoo, MI; University Hospitals Cleveland Medical Center and Case Western Reserve University (S.A.G.), OH; Veterans Affairs Puget Sound Health Care System (H.K.), Seattle, WA; Rush University Medical Center (A.M.), Chicago, IL; Weill Cornell Medicine (H.S.), New York, NY; Rush University (G.T.S.), Chicago, IL; American Academy of Neurology (E.L.), Minneapolis, MN; and Stanford Health Care (L.Y.), Palo Alto, CA.
| | - Laurice Yang
- From the University of Michigan Medical School (K.L.C.), Ann Arbor; Christiana Care (J.M.), Wilmington, DE; UT Southwestern Medical Center (J.A.), Dallas, TX; MaxMD (M.E.), Fort Lee, NJ; Washington University School of Medicine (E.R.F.), St. Louis, MO; Bronson Neuroscience Center (K.F.), Kalamazoo, MI; University Hospitals Cleveland Medical Center and Case Western Reserve University (S.A.G.), OH; Veterans Affairs Puget Sound Health Care System (H.K.), Seattle, WA; Rush University Medical Center (A.M.), Chicago, IL; Weill Cornell Medicine (H.S.), New York, NY; Rush University (G.T.S.), Chicago, IL; American Academy of Neurology (E.L.), Minneapolis, MN; and Stanford Health Care (L.Y.), Palo Alto, CA
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6
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Fullard ME, Thibault DP, Hill A, Fox J, Bhatti DE, Burack MA, Dahodwala N, Haberfeld E, Kern DS, Klepitskava OS, Urrea-Mendoza E, Myers P, Nutt J, Rafferty MR, Schwalb JM, Shulman LM, Willis AW. Utilization of rehabilitation therapy services in Parkinson disease in the United States. Neurology 2017; 89:1162-1169. [PMID: 28835397 PMCID: PMC5595277 DOI: 10.1212/wnl.0000000000004355] [Citation(s) in RCA: 50] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2016] [Accepted: 06/21/2017] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE To examine rehabilitation therapy utilization for Parkinson disease (PD). METHODS We identified 174,643 Medicare beneficiaries with a diagnosis of PD in 2007 and followed them through 2009. The main outcome measures were annual receipt of physical therapy (PT), occupational therapy (OT), or speech therapy (ST). RESULTS Outpatient rehabilitation fee-for-service use was low. In 2007, only 14.2% of individuals with PD had claims for PT or OT, and 14.6% for ST. Asian Americans were the highest users of PT/OT (18.4%) and ST (18.4%), followed by Caucasians (PT/OT 14.4%, ST 14.8%). African Americans had the lowest utilization (PT/OT 7.8%, ST 8.2%). Using logistic regression models that accounted for repeated measures, we found that African American patients (adjusted odds ratio [AOR] 0.63 for PT/OT, AOR 0.63 for ST) and Hispanic patients (AOR 0.97 for PT/OT, AOR 0.91 for ST) were less likely to have received therapies compared to Caucasian patients. Patients with PD with at least one neurologist visit per year were 43% more likely to have a claim for PT evaluation as compared to patients without neurologist care (AOR 1.43, 1.30-1.48), and this relationship was similar for OT evaluation, PT/OT treatment, and ST. Geographically, Western states had the greatest use of rehabilitation therapies, but provider supply did not correlate with utilization. CONCLUSIONS This claims-based analysis suggests that rehabilitation therapy utilization among older patients with PD in the United States is lower than reported for countries with comparable health care infrastructure. Neurologist care is associated with rehabilitation therapy use; provider supply is not.
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Affiliation(s)
- Michelle E Fullard
- From the Departments of Neurology (M.E.F., D.P.T., A.H., N.D., A.W.W.) and Biostatistics and Epidemiology (D.P.T., A.H., A.W.W.), University of Pennsylvania School of Medicine; Dan Aaron Parkinson's Rehabilitation Center (J.F.), Leonard Davis Institute of Health Economics (A.W.W.), and Center for Clinical Epidemiology and Biostatistics (A.W.W.), University of Pennsylvania, Philadelphia; Department of Neurobiological Sciences (D.E.B.), University of Nebraska Medical Center, Omaha; Department of Neurology (M.A.B.), University of Rochester, NY; Department of Neurology (E.H.), Temple University, Philadelphia, PA; Department of Neurology (D.S.K., O.S.K.), University of Colorado, Aurora; Greenville Health System (E.-U.M.), SC; Parkinson's Disease Foundation Advocate Group (P.M.), Lakeport, CA; Department of Neurology (J.N.), Oregon Health Sciences University, Portland; Center for Education in Health Sciences (M.R.R.), Northwestern University, Evanston, IL; Department of Neurosurgery (J.M.S.), Henry Ford Medical Group, Detroit, MI; Department of Neurology (L.M.S.), University of Maryland School of Medicine, Baltimore.
| | - Dylan P Thibault
- From the Departments of Neurology (M.E.F., D.P.T., A.H., N.D., A.W.W.) and Biostatistics and Epidemiology (D.P.T., A.H., A.W.W.), University of Pennsylvania School of Medicine; Dan Aaron Parkinson's Rehabilitation Center (J.F.), Leonard Davis Institute of Health Economics (A.W.W.), and Center for Clinical Epidemiology and Biostatistics (A.W.W.), University of Pennsylvania, Philadelphia; Department of Neurobiological Sciences (D.E.B.), University of Nebraska Medical Center, Omaha; Department of Neurology (M.A.B.), University of Rochester, NY; Department of Neurology (E.H.), Temple University, Philadelphia, PA; Department of Neurology (D.S.K., O.S.K.), University of Colorado, Aurora; Greenville Health System (E.-U.M.), SC; Parkinson's Disease Foundation Advocate Group (P.M.), Lakeport, CA; Department of Neurology (J.N.), Oregon Health Sciences University, Portland; Center for Education in Health Sciences (M.R.R.), Northwestern University, Evanston, IL; Department of Neurosurgery (J.M.S.), Henry Ford Medical Group, Detroit, MI; Department of Neurology (L.M.S.), University of Maryland School of Medicine, Baltimore
| | - Andrew Hill
- From the Departments of Neurology (M.E.F., D.P.T., A.H., N.D., A.W.W.) and Biostatistics and Epidemiology (D.P.T., A.H., A.W.W.), University of Pennsylvania School of Medicine; Dan Aaron Parkinson's Rehabilitation Center (J.F.), Leonard Davis Institute of Health Economics (A.W.W.), and Center for Clinical Epidemiology and Biostatistics (A.W.W.), University of Pennsylvania, Philadelphia; Department of Neurobiological Sciences (D.E.B.), University of Nebraska Medical Center, Omaha; Department of Neurology (M.A.B.), University of Rochester, NY; Department of Neurology (E.H.), Temple University, Philadelphia, PA; Department of Neurology (D.S.K., O.S.K.), University of Colorado, Aurora; Greenville Health System (E.-U.M.), SC; Parkinson's Disease Foundation Advocate Group (P.M.), Lakeport, CA; Department of Neurology (J.N.), Oregon Health Sciences University, Portland; Center for Education in Health Sciences (M.R.R.), Northwestern University, Evanston, IL; Department of Neurosurgery (J.M.S.), Henry Ford Medical Group, Detroit, MI; Department of Neurology (L.M.S.), University of Maryland School of Medicine, Baltimore
| | - Joellyn Fox
- From the Departments of Neurology (M.E.F., D.P.T., A.H., N.D., A.W.W.) and Biostatistics and Epidemiology (D.P.T., A.H., A.W.W.), University of Pennsylvania School of Medicine; Dan Aaron Parkinson's Rehabilitation Center (J.F.), Leonard Davis Institute of Health Economics (A.W.W.), and Center for Clinical Epidemiology and Biostatistics (A.W.W.), University of Pennsylvania, Philadelphia; Department of Neurobiological Sciences (D.E.B.), University of Nebraska Medical Center, Omaha; Department of Neurology (M.A.B.), University of Rochester, NY; Department of Neurology (E.H.), Temple University, Philadelphia, PA; Department of Neurology (D.S.K., O.S.K.), University of Colorado, Aurora; Greenville Health System (E.-U.M.), SC; Parkinson's Disease Foundation Advocate Group (P.M.), Lakeport, CA; Department of Neurology (J.N.), Oregon Health Sciences University, Portland; Center for Education in Health Sciences (M.R.R.), Northwestern University, Evanston, IL; Department of Neurosurgery (J.M.S.), Henry Ford Medical Group, Detroit, MI; Department of Neurology (L.M.S.), University of Maryland School of Medicine, Baltimore
| | - Danish E Bhatti
- From the Departments of Neurology (M.E.F., D.P.T., A.H., N.D., A.W.W.) and Biostatistics and Epidemiology (D.P.T., A.H., A.W.W.), University of Pennsylvania School of Medicine; Dan Aaron Parkinson's Rehabilitation Center (J.F.), Leonard Davis Institute of Health Economics (A.W.W.), and Center for Clinical Epidemiology and Biostatistics (A.W.W.), University of Pennsylvania, Philadelphia; Department of Neurobiological Sciences (D.E.B.), University of Nebraska Medical Center, Omaha; Department of Neurology (M.A.B.), University of Rochester, NY; Department of Neurology (E.H.), Temple University, Philadelphia, PA; Department of Neurology (D.S.K., O.S.K.), University of Colorado, Aurora; Greenville Health System (E.-U.M.), SC; Parkinson's Disease Foundation Advocate Group (P.M.), Lakeport, CA; Department of Neurology (J.N.), Oregon Health Sciences University, Portland; Center for Education in Health Sciences (M.R.R.), Northwestern University, Evanston, IL; Department of Neurosurgery (J.M.S.), Henry Ford Medical Group, Detroit, MI; Department of Neurology (L.M.S.), University of Maryland School of Medicine, Baltimore
| | - Michelle A Burack
- From the Departments of Neurology (M.E.F., D.P.T., A.H., N.D., A.W.W.) and Biostatistics and Epidemiology (D.P.T., A.H., A.W.W.), University of Pennsylvania School of Medicine; Dan Aaron Parkinson's Rehabilitation Center (J.F.), Leonard Davis Institute of Health Economics (A.W.W.), and Center for Clinical Epidemiology and Biostatistics (A.W.W.), University of Pennsylvania, Philadelphia; Department of Neurobiological Sciences (D.E.B.), University of Nebraska Medical Center, Omaha; Department of Neurology (M.A.B.), University of Rochester, NY; Department of Neurology (E.H.), Temple University, Philadelphia, PA; Department of Neurology (D.S.K., O.S.K.), University of Colorado, Aurora; Greenville Health System (E.-U.M.), SC; Parkinson's Disease Foundation Advocate Group (P.M.), Lakeport, CA; Department of Neurology (J.N.), Oregon Health Sciences University, Portland; Center for Education in Health Sciences (M.R.R.), Northwestern University, Evanston, IL; Department of Neurosurgery (J.M.S.), Henry Ford Medical Group, Detroit, MI; Department of Neurology (L.M.S.), University of Maryland School of Medicine, Baltimore
| | - Nabila Dahodwala
- From the Departments of Neurology (M.E.F., D.P.T., A.H., N.D., A.W.W.) and Biostatistics and Epidemiology (D.P.T., A.H., A.W.W.), University of Pennsylvania School of Medicine; Dan Aaron Parkinson's Rehabilitation Center (J.F.), Leonard Davis Institute of Health Economics (A.W.W.), and Center for Clinical Epidemiology and Biostatistics (A.W.W.), University of Pennsylvania, Philadelphia; Department of Neurobiological Sciences (D.E.B.), University of Nebraska Medical Center, Omaha; Department of Neurology (M.A.B.), University of Rochester, NY; Department of Neurology (E.H.), Temple University, Philadelphia, PA; Department of Neurology (D.S.K., O.S.K.), University of Colorado, Aurora; Greenville Health System (E.-U.M.), SC; Parkinson's Disease Foundation Advocate Group (P.M.), Lakeport, CA; Department of Neurology (J.N.), Oregon Health Sciences University, Portland; Center for Education in Health Sciences (M.R.R.), Northwestern University, Evanston, IL; Department of Neurosurgery (J.M.S.), Henry Ford Medical Group, Detroit, MI; Department of Neurology (L.M.S.), University of Maryland School of Medicine, Baltimore
| | - Elizabeth Haberfeld
- From the Departments of Neurology (M.E.F., D.P.T., A.H., N.D., A.W.W.) and Biostatistics and Epidemiology (D.P.T., A.H., A.W.W.), University of Pennsylvania School of Medicine; Dan Aaron Parkinson's Rehabilitation Center (J.F.), Leonard Davis Institute of Health Economics (A.W.W.), and Center for Clinical Epidemiology and Biostatistics (A.W.W.), University of Pennsylvania, Philadelphia; Department of Neurobiological Sciences (D.E.B.), University of Nebraska Medical Center, Omaha; Department of Neurology (M.A.B.), University of Rochester, NY; Department of Neurology (E.H.), Temple University, Philadelphia, PA; Department of Neurology (D.S.K., O.S.K.), University of Colorado, Aurora; Greenville Health System (E.-U.M.), SC; Parkinson's Disease Foundation Advocate Group (P.M.), Lakeport, CA; Department of Neurology (J.N.), Oregon Health Sciences University, Portland; Center for Education in Health Sciences (M.R.R.), Northwestern University, Evanston, IL; Department of Neurosurgery (J.M.S.), Henry Ford Medical Group, Detroit, MI; Department of Neurology (L.M.S.), University of Maryland School of Medicine, Baltimore
| | - Drew S Kern
- From the Departments of Neurology (M.E.F., D.P.T., A.H., N.D., A.W.W.) and Biostatistics and Epidemiology (D.P.T., A.H., A.W.W.), University of Pennsylvania School of Medicine; Dan Aaron Parkinson's Rehabilitation Center (J.F.), Leonard Davis Institute of Health Economics (A.W.W.), and Center for Clinical Epidemiology and Biostatistics (A.W.W.), University of Pennsylvania, Philadelphia; Department of Neurobiological Sciences (D.E.B.), University of Nebraska Medical Center, Omaha; Department of Neurology (M.A.B.), University of Rochester, NY; Department of Neurology (E.H.), Temple University, Philadelphia, PA; Department of Neurology (D.S.K., O.S.K.), University of Colorado, Aurora; Greenville Health System (E.-U.M.), SC; Parkinson's Disease Foundation Advocate Group (P.M.), Lakeport, CA; Department of Neurology (J.N.), Oregon Health Sciences University, Portland; Center for Education in Health Sciences (M.R.R.), Northwestern University, Evanston, IL; Department of Neurosurgery (J.M.S.), Henry Ford Medical Group, Detroit, MI; Department of Neurology (L.M.S.), University of Maryland School of Medicine, Baltimore
| | - Olga S Klepitskava
- From the Departments of Neurology (M.E.F., D.P.T., A.H., N.D., A.W.W.) and Biostatistics and Epidemiology (D.P.T., A.H., A.W.W.), University of Pennsylvania School of Medicine; Dan Aaron Parkinson's Rehabilitation Center (J.F.), Leonard Davis Institute of Health Economics (A.W.W.), and Center for Clinical Epidemiology and Biostatistics (A.W.W.), University of Pennsylvania, Philadelphia; Department of Neurobiological Sciences (D.E.B.), University of Nebraska Medical Center, Omaha; Department of Neurology (M.A.B.), University of Rochester, NY; Department of Neurology (E.H.), Temple University, Philadelphia, PA; Department of Neurology (D.S.K., O.S.K.), University of Colorado, Aurora; Greenville Health System (E.-U.M.), SC; Parkinson's Disease Foundation Advocate Group (P.M.), Lakeport, CA; Department of Neurology (J.N.), Oregon Health Sciences University, Portland; Center for Education in Health Sciences (M.R.R.), Northwestern University, Evanston, IL; Department of Neurosurgery (J.M.S.), Henry Ford Medical Group, Detroit, MI; Department of Neurology (L.M.S.), University of Maryland School of Medicine, Baltimore
| | - Enrique Urrea-Mendoza
- From the Departments of Neurology (M.E.F., D.P.T., A.H., N.D., A.W.W.) and Biostatistics and Epidemiology (D.P.T., A.H., A.W.W.), University of Pennsylvania School of Medicine; Dan Aaron Parkinson's Rehabilitation Center (J.F.), Leonard Davis Institute of Health Economics (A.W.W.), and Center for Clinical Epidemiology and Biostatistics (A.W.W.), University of Pennsylvania, Philadelphia; Department of Neurobiological Sciences (D.E.B.), University of Nebraska Medical Center, Omaha; Department of Neurology (M.A.B.), University of Rochester, NY; Department of Neurology (E.H.), Temple University, Philadelphia, PA; Department of Neurology (D.S.K., O.S.K.), University of Colorado, Aurora; Greenville Health System (E.-U.M.), SC; Parkinson's Disease Foundation Advocate Group (P.M.), Lakeport, CA; Department of Neurology (J.N.), Oregon Health Sciences University, Portland; Center for Education in Health Sciences (M.R.R.), Northwestern University, Evanston, IL; Department of Neurosurgery (J.M.S.), Henry Ford Medical Group, Detroit, MI; Department of Neurology (L.M.S.), University of Maryland School of Medicine, Baltimore
| | - Phillip Myers
- From the Departments of Neurology (M.E.F., D.P.T., A.H., N.D., A.W.W.) and Biostatistics and Epidemiology (D.P.T., A.H., A.W.W.), University of Pennsylvania School of Medicine; Dan Aaron Parkinson's Rehabilitation Center (J.F.), Leonard Davis Institute of Health Economics (A.W.W.), and Center for Clinical Epidemiology and Biostatistics (A.W.W.), University of Pennsylvania, Philadelphia; Department of Neurobiological Sciences (D.E.B.), University of Nebraska Medical Center, Omaha; Department of Neurology (M.A.B.), University of Rochester, NY; Department of Neurology (E.H.), Temple University, Philadelphia, PA; Department of Neurology (D.S.K., O.S.K.), University of Colorado, Aurora; Greenville Health System (E.-U.M.), SC; Parkinson's Disease Foundation Advocate Group (P.M.), Lakeport, CA; Department of Neurology (J.N.), Oregon Health Sciences University, Portland; Center for Education in Health Sciences (M.R.R.), Northwestern University, Evanston, IL; Department of Neurosurgery (J.M.S.), Henry Ford Medical Group, Detroit, MI; Department of Neurology (L.M.S.), University of Maryland School of Medicine, Baltimore
| | - Jay Nutt
- From the Departments of Neurology (M.E.F., D.P.T., A.H., N.D., A.W.W.) and Biostatistics and Epidemiology (D.P.T., A.H., A.W.W.), University of Pennsylvania School of Medicine; Dan Aaron Parkinson's Rehabilitation Center (J.F.), Leonard Davis Institute of Health Economics (A.W.W.), and Center for Clinical Epidemiology and Biostatistics (A.W.W.), University of Pennsylvania, Philadelphia; Department of Neurobiological Sciences (D.E.B.), University of Nebraska Medical Center, Omaha; Department of Neurology (M.A.B.), University of Rochester, NY; Department of Neurology (E.H.), Temple University, Philadelphia, PA; Department of Neurology (D.S.K., O.S.K.), University of Colorado, Aurora; Greenville Health System (E.-U.M.), SC; Parkinson's Disease Foundation Advocate Group (P.M.), Lakeport, CA; Department of Neurology (J.N.), Oregon Health Sciences University, Portland; Center for Education in Health Sciences (M.R.R.), Northwestern University, Evanston, IL; Department of Neurosurgery (J.M.S.), Henry Ford Medical Group, Detroit, MI; Department of Neurology (L.M.S.), University of Maryland School of Medicine, Baltimore
| | - Miriam R Rafferty
- From the Departments of Neurology (M.E.F., D.P.T., A.H., N.D., A.W.W.) and Biostatistics and Epidemiology (D.P.T., A.H., A.W.W.), University of Pennsylvania School of Medicine; Dan Aaron Parkinson's Rehabilitation Center (J.F.), Leonard Davis Institute of Health Economics (A.W.W.), and Center for Clinical Epidemiology and Biostatistics (A.W.W.), University of Pennsylvania, Philadelphia; Department of Neurobiological Sciences (D.E.B.), University of Nebraska Medical Center, Omaha; Department of Neurology (M.A.B.), University of Rochester, NY; Department of Neurology (E.H.), Temple University, Philadelphia, PA; Department of Neurology (D.S.K., O.S.K.), University of Colorado, Aurora; Greenville Health System (E.-U.M.), SC; Parkinson's Disease Foundation Advocate Group (P.M.), Lakeport, CA; Department of Neurology (J.N.), Oregon Health Sciences University, Portland; Center for Education in Health Sciences (M.R.R.), Northwestern University, Evanston, IL; Department of Neurosurgery (J.M.S.), Henry Ford Medical Group, Detroit, MI; Department of Neurology (L.M.S.), University of Maryland School of Medicine, Baltimore
| | - Jason M Schwalb
- From the Departments of Neurology (M.E.F., D.P.T., A.H., N.D., A.W.W.) and Biostatistics and Epidemiology (D.P.T., A.H., A.W.W.), University of Pennsylvania School of Medicine; Dan Aaron Parkinson's Rehabilitation Center (J.F.), Leonard Davis Institute of Health Economics (A.W.W.), and Center for Clinical Epidemiology and Biostatistics (A.W.W.), University of Pennsylvania, Philadelphia; Department of Neurobiological Sciences (D.E.B.), University of Nebraska Medical Center, Omaha; Department of Neurology (M.A.B.), University of Rochester, NY; Department of Neurology (E.H.), Temple University, Philadelphia, PA; Department of Neurology (D.S.K., O.S.K.), University of Colorado, Aurora; Greenville Health System (E.-U.M.), SC; Parkinson's Disease Foundation Advocate Group (P.M.), Lakeport, CA; Department of Neurology (J.N.), Oregon Health Sciences University, Portland; Center for Education in Health Sciences (M.R.R.), Northwestern University, Evanston, IL; Department of Neurosurgery (J.M.S.), Henry Ford Medical Group, Detroit, MI; Department of Neurology (L.M.S.), University of Maryland School of Medicine, Baltimore
| | - Lisa M Shulman
- From the Departments of Neurology (M.E.F., D.P.T., A.H., N.D., A.W.W.) and Biostatistics and Epidemiology (D.P.T., A.H., A.W.W.), University of Pennsylvania School of Medicine; Dan Aaron Parkinson's Rehabilitation Center (J.F.), Leonard Davis Institute of Health Economics (A.W.W.), and Center for Clinical Epidemiology and Biostatistics (A.W.W.), University of Pennsylvania, Philadelphia; Department of Neurobiological Sciences (D.E.B.), University of Nebraska Medical Center, Omaha; Department of Neurology (M.A.B.), University of Rochester, NY; Department of Neurology (E.H.), Temple University, Philadelphia, PA; Department of Neurology (D.S.K., O.S.K.), University of Colorado, Aurora; Greenville Health System (E.-U.M.), SC; Parkinson's Disease Foundation Advocate Group (P.M.), Lakeport, CA; Department of Neurology (J.N.), Oregon Health Sciences University, Portland; Center for Education in Health Sciences (M.R.R.), Northwestern University, Evanston, IL; Department of Neurosurgery (J.M.S.), Henry Ford Medical Group, Detroit, MI; Department of Neurology (L.M.S.), University of Maryland School of Medicine, Baltimore
| | - Allison W Willis
- From the Departments of Neurology (M.E.F., D.P.T., A.H., N.D., A.W.W.) and Biostatistics and Epidemiology (D.P.T., A.H., A.W.W.), University of Pennsylvania School of Medicine; Dan Aaron Parkinson's Rehabilitation Center (J.F.), Leonard Davis Institute of Health Economics (A.W.W.), and Center for Clinical Epidemiology and Biostatistics (A.W.W.), University of Pennsylvania, Philadelphia; Department of Neurobiological Sciences (D.E.B.), University of Nebraska Medical Center, Omaha; Department of Neurology (M.A.B.), University of Rochester, NY; Department of Neurology (E.H.), Temple University, Philadelphia, PA; Department of Neurology (D.S.K., O.S.K.), University of Colorado, Aurora; Greenville Health System (E.-U.M.), SC; Parkinson's Disease Foundation Advocate Group (P.M.), Lakeport, CA; Department of Neurology (J.N.), Oregon Health Sciences University, Portland; Center for Education in Health Sciences (M.R.R.), Northwestern University, Evanston, IL; Department of Neurosurgery (J.M.S.), Henry Ford Medical Group, Detroit, MI; Department of Neurology (L.M.S.), University of Maryland School of Medicine, Baltimore
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