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[P1–520]: PRIMARY CARE INITIATIVES FOR COMPLEX NEUROCOGNITIVE DISORDER CARE: PROTOCOL FOR AN INNOVATIVE MIXED‐METHODS DESIGN
Author(s) -
Bronskill Susan E.,
Vedel Isabelle,
McAiney Carrie A.,
Couturier Yves,
ArsenaultLapierre Genevieve,
GodardSebillotte Claire,
Sourial Nadia,
Simmons Rachel,
Rochon Paula A.,
Strumpf Erin,
Pakzad Sarah,
Bergman Howard
Publication year - 2017
Publication title -
alzheimer's and dementia
Language(s) - English
Resource type - Journals
SCImago Journal Rank - 6.713
H-Index - 118
eISSN - 1552-5279
pISSN - 1552-5260
DOI - 10.1016/j.jalz.2017.06.536
Subject(s) - stakeholder , observational study , qualitative property , protocol (science) , checklist , health care , research design , population , process management , baseline (sea) , nursing , medicine , knowledge management , psychology , business , public relations , computer science , environmental health , political science , alternative medicine , social science , pathology , machine learning , sociology , law , cognitive psychology
Background:Early referral to cognitive specialty clinics is recommended in most European practice guidelines. In the US, where most cognitive problems are managed in primary care, the role of cognitive specialty clinics is controversial and referrals are inconsistent and often delayed. Specialists without a dementia focus may not offer family education and support.Methods:We used electronic medical records from 2013 to compare outcomes in 8887 patients age >65 in primary care community clinics and in 290 patients in our transdisciplinary cognitive specialty clinic. We examined patient-centered outcomes a care partner panel identified as important, and health system outcomes a health care leadership panel judged sufficient to change practice. The difference in dichotomous outcomes was tested with Chi-square tests and count outcomes were comparedwith the exact rate ratio test assuming Poisson distribution. Results:Patients with cognitive impairment weremuchmore likely to achieve patient-centered outcomes when seen by the cognitive specialty team than only primary care. Family support from a social worker was documented in 77% vs 4.2%, use of drugs classified as inappropriate on the Beer’s list was 9% vs. 36%, and referral for driving evaluation was 30% vs. 0.8% (all p <0.001). Only documented advanced directives were not significantly different, 27% vs. 24% (p 1⁄4 0.43). Emergency visit rate was lower (0.13 vs. 0.20, p 1⁄4 0.03), and there was a trend toward better diabetes control (p1⁄40.06) with specialty care. Patients with both diabetes and cognitive impairment achieved even lower rates of patient-oriented outcomes in primary care: family support was 0.35% vs. 72% and completion of advanced directives was 12% vs. 23%, (both p <0.001). Conclusions: Cognitive specialty teams are more likely to achieve patient-centered and health system outcomes than primary care. Current strategies in primary care fail to identify as many patients with cognitive impairment as expected, so considerable opportunity for improvement remains. Cognitive impairment may contribute to poor control of diabetes and diabetes may interfere with outcomes in primary care setting because attention is distracted away from cognitive care. A pragmatic, prospective, randomized trial would address limitations of this retrospective, observational study.