Division of Health Services Management and Policy, College of Public Health, the Ohio State University, Columbus.
Department of Health Administration and Policy, George Mason University, Fairfax, Virginia.
JAMA Netw Open. 2022 Aug 1;5(8):e2225805. doi: 10.1001/jamanetworkopen.2022.25805.
Limited access to appropriate specialists and testing may be associated with delayed diagnosis and symptom management for patients with early-onset Alzheimer disease and related dementias (ADRDs).
To examine rural vs urban differences in diagnostic and symptom management service use among patients with early-onset ADRDs.
DESIGN, SETTING, AND PARTICIPANTS: This cross-sectional study was conducted using commercial claims from 2012 to 2017. Included patients were those with early-onset ADRDs aged 40 to 64 years, including new patients, defined as those with no claims of ADRDs for 36 months before the first ADRD diagnosis. The likelihood of receiving diagnostic and symptom management services was estimated, with adjustment for individual-level variables associated with health care use. Data were analyzed from February 2021 to March 2022.
Rural residence.
Among patients with new, early-onset ADRDs, use of psychological assessment and neuropsychological testing performed at the initial diagnosis (index date) or 90 days or less after the index date and use of brain imaging during the 180 days before the index date were collected. Access to different clinicians on the index date or 90 days or less after the index date was also collected, including visits to primary care physicians and nurse practitioners (PCPs) and specialty visits to psychologists, neurologists, and psychiatrists.
Among 71 799 patients with early-onset ADRD (mean [SD] age, 56.34 [6.05] years; 39 231 women [54.64%]), 8430 individuals had new early-onset ADRDs (mean [SD] age, 55.94 [6.30] years; 16 512 women [56.65%]). There were no statistically significant differences between new patients with early-onset ADRDs in rural vs urban areas in the use of psychological assessments, imaging studies, or visits to neurologists or psychiatrists. However, new patients in rural areas were less likely to receive neuropsychological testing (odds ratio [OR], 0.83; 95% CI, 0.70-0.98) or visit a psychologist (OR, 0.72; 95% CI, 0.60-0.85) compared with patients in urban areas. However, new patients in rural areas with early-onset ADRDs were more likely to have only PCP visits for diagnosis and symptom management compared with those in urban areas (OR, 1.40; 95% CI, 1.19-1.66).
This study found that new patients with early-onset ADRDs in rural areas were less likely to receive neuropsychological testing or visit psychologists but more likely to be diagnosed and treated exclusively by PCPs compared with those in urban areas. These findings suggest that efforts, such as clinician education or teleconsultative guidance to PCPs, may be needed to enhance access to specialist services in rural areas.
对于早发性阿尔茨海默病和相关痴呆症（ADRD）患者，获得适当专家和检测的机会有限可能与诊断延迟和症状管理有关。
检查农村与城市之间早发性 ADRD 患者在诊断和症状管理服务使用方面的差异。
设计、地点和参与者：本横断面研究使用了 2012 年至 2017 年的商业索赔数据。纳入的患者为年龄在 40 至 64 岁之间的早发性 ADRD 新患者，包括无 ADRD 索赔记录至少 36 个月的新患者。使用个体水平与医疗保健使用相关的变量来估计接受诊断和症状管理服务的可能性。数据于 2021 年 2 月至 2022 年 3 月进行分析。
农村居住。
在新的早发性 ADRD 患者中，收集了在初始诊断（索引日期）或索引日期后 90 天或更短时间内进行的心理评估和神经心理测试的使用情况，以及在索引日期前 180 天内进行的脑部成像的使用情况。还收集了索引日期或索引日期后 90 天内不同临床医生的就诊情况，包括初级保健医生和执业护士（PCP）就诊和心理学家、神经病学家和精神科医生的专科就诊情况。
在 71799 名患有早发性 ADRD 的患者中（平均[标准差]年龄为 56.34[6.05]岁；39231 名女性[54.64%]），有 8430 名新患有早发性 ADRD 的患者（平均[标准差]年龄为 55.94[6.30]岁；16512 名女性[56.65%]）。在农村地区和城市地区，新患有早发性 ADRD 的患者在使用心理评估、影像学研究或就诊于神经病学家或精神科医生方面没有统计学上的显著差异。然而，与城市地区的患者相比，农村地区的新患者接受神经心理测试（比值比[OR]，0.83；95%置信区间[CI]，0.70-0.98）或看心理学家（OR，0.72；95%CI，0.60-0.85）的可能性较低。然而，与城市地区的患者相比，农村地区新患有早发性 ADRD 的患者更有可能仅由 PCP 进行诊断和症状管理（OR，1.40；95%CI，1.19-1.66）。
本研究发现，与城市地区的患者相比，农村地区新患有早发性 ADRD 的患者更有可能不接受神经心理测试或看心理学家，但更有可能仅由 PCP 进行诊断和治疗。这些发现表明，可能需要进行临床医生教育或向 PCP 提供远程咨询指导等努力，以加强农村地区获得专家服务的机会。
