O'Brien Kyra S, Harkins Kristin, Peifer MaryAnne, Kleid Melanie, Coykendall Cameron, Shea Judy, Karlawish Jason, Burke Robert E
Department of Neurology, University of Pennsylvania Perelman School of Medicine, 3400 Spruce Street, 3W Gates, Philadelphia, PA, 19104, USA. kyra.o'
Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA. kyra.o'
Implement Sci Commun. 2025 Jan 16;6(1):9. doi: 10.1186/s43058-025-00693-1.
Early diagnosis is crucial to the optimal management of patients with cognitive impairment due to Alzheimer's disease (AD) or AD-related dementias. For some patients, early detection of cognitive impairment enables access to disease-modifying therapies. For all patients, it allows access to psychosocial supports. Patients typically first present their concerns about their cognition to a primary care provider, but in this setting, cognitive impairment is commonly underdiagnosed. There is also high variability in how cognitive evaluations are performed. We sought to understand barriers to and facilitators of cognitive evaluations in primary care, map barriers to implementation strategies, and gain consensus from stakeholders on possible strategies to improve dementia diagnosis in primary care.
Semi-structured interviews conducted with primary care providers (PCPs). We used the Consolidated Framework for Implementation Research to inform our question guide and analysis, and incorporated chart-stimulated recall - using actual patients who had cognitive complaints who had presented to these providers - to understand clinicians' medical decision-making processes. These data were used to map identified barriers and facilitators to targeted implementation strategies. Then, this candidate list of strategies was presented to an expert stakeholder panel including clinicians and clinical operations specialists. Through a modified Delphi process, the list was narrowed to select the most promising strategies to incorporate in an intervention to improve cognitive evaluations in primary care.
Twenty PCPs were interviewed and mentioned barriers included lack of expertise to perform or interpret an assessment, time pressures, lack of incentives, competing priorities, lack of decision-making supports, and limited access to dementia specialists. Facilitators included the presence of an informant or caregiver and having additional staff to conduct cognitive testing. Implementation mapping resulted in a list of 15 candidate strategies. Using the modified Delphi process, these were narrowed to six.
We used a rigorous process to identify barriers to and facilitators of cognitive assessments in primary care, identify promising implementation strategies to address these barriers, and obtain the feedback of front-line users on these strategies. This holds substantial promise for improving cognitive assessments in primary care in future implementation trials.
早期诊断对于阿尔茨海默病（AD）或AD相关痴呆所致认知障碍患者的最佳管理至关重要。对于一些患者而言，认知障碍的早期检测能够使其获得疾病修正治疗。对于所有患者来说，这能让他们获得心理社会支持。患者通常首先会向初级保健提供者表达他们对自身认知的担忧，但在此情况下，认知障碍常常未被充分诊断。认知评估的实施方式也存在很大差异。我们试图了解初级保健中认知评估的障碍和促进因素，将障碍映射到实施策略，并就改善初级保健中痴呆症诊断的可能策略获得利益相关者的共识。
对初级保健提供者（PCP）进行半结构化访谈。我们使用实施研究综合框架来指导我们的问题指南和分析，并纳入图表刺激回忆法——使用曾向这些提供者提出认知主诉的实际患者——以了解临床医生的医疗决策过程。这些数据被用于将已确定的障碍和促进因素映射到有针对性的实施策略。然后，将该策略候选清单提交给一个包括临床医生和临床运营专家在内的专家利益相关者小组。通过改进的德尔菲法，该清单被缩小范围，以选择最有前景的策略纳入一项干预措施，以改善初级保健中的认知评估。
对20名初级保健提供者进行了访谈，提及的障碍包括缺乏进行或解释评估的专业知识、时间压力、缺乏激励措施、相互竞争的优先事项、缺乏决策支持以及难以接触到痴呆症专家。促进因素包括有告知者或护理人员在场以及有额外工作人员进行认知测试。实施映射产生了一份包含15项候选策略的清单。通过改进的德尔菲法，这些策略被缩小到6项。
我们采用了严格的流程来确定初级保健中认知评估的障碍和促进因素，确定有前景的实施策略以解决这些障碍，并获得一线用户对这些策略的反馈。这对于在未来的实施试验中改善初级保健中的认知评估具有很大的前景。
