为澳大利亚参加初级保健的原住民实施认知障碍和痴呆症最佳实践护理模式：一项阶梯式楔形整群随机试验。

Implementation of a best-practice model of care for cognitive impairment and dementia for first nations peoples attending primary care in Australia: a stepped-wedge cluster-randomised trial.

作者信息

Hughson Jo-Anne, Hyde Zoë, Bradley Kate, Malay Roslyn, Douglas Harold, Rind Sadia, Sullivan Kylie, Poulos Lauren, Allen Bridget, Martin-Giles Bonnie, Quigley Rachel, Russell Sarah, Cadet-James Diane, Wallace Valda, Allan Wendy, Bessarab Dawn, Smith Kate, Radford Kylie, Strivens Edward, Flicker Leon, Atkinson David, Thompson Sandra, Ciaccia Juliette, Lavrencic Louise, Ducker Belinda, Humphry Tina, Wenitong Mark, Belfrage Mary, Blackberry Irene, Fulford Kate, Wall Sharon, Smith Robyn, LoGiudice Dina

机构信息

Department of Medicine - Royal Melbourne Hospital, The University of Melbourne, Royal Park Campus, Administration Building 21, 34-54 Poplar Road, Melbourne, Victoria 3052, Australia.

Western Australian Centre for Heath and Ageing, Medical School, The University of Western Australia, 35 Stirling Highway, Perth, WA 6009, Australia.

出版信息

Lancet Reg Health West Pac. 2025 Apr 3;57:101529. doi: 10.1016/j.lanwpc.2025.101529. eCollection 2025 Apr.

DOI:10.1016/j.lanwpc.2025.101529

PMID:40242462

原文链接:https://pmc.ncbi.nlm.nih.gov/articles/PMC12002872/

Abstract

BACKGROUND

Dementia and cognitive impairment not dementia (CIND) are under-detected amongst First Nations peoples attending primary care. This trial implemented a culturally adapted best-practice model of care to increase detection and optimise management of CIND/dementia.

METHODS

This closed cohort open-label, stepped-wedge, cluster-randomised trial recruited 12 Aboriginal community-controlled primary health care services (ACCHSs) across urban, regional and remote settings in Australia. ACCHSs were eligible to participate if they conducted annual health checks, engaged in continuous quality improvement processes and had ≥55 clients aged ≥50 years. After a baseline control period, four ACCHSs were scheduled to enter the intervention phase every six months. During the intervention phase, ACCHSs were supported to embed best-practice dementia care through staff education and practice change initiatives. Co-primary outcomes were: (i) documented detection of CIND/dementia and, (ii) evidence of uptake of the diagnostic pathway measured as presence of ≥2 of: use of cognitive assessment tools, relevant pathology investigations, neuroimaging, and/or referral of clients with cognitive concerns to specialist services. Data were analysed with mixed effects complementary log-log regression. This study was registered with the Australia and New Zealand Clinical Trials Registry, ACTRN12618001485224.

FINDINGS

Between September 2018 and January 2019, 12 ACCHSs were recruited, comprising a sample of 1655 ACCHS clients aged ≥50 years (mean 60.3 ± 8.2 years), of whom 935 (56.5%) were female. One ACCHS withdrew during the study. After adjustment for time, the intervention did not show evidence of an effect for the first co-primary outcome (detection of CIND/dementia): HR = 1.53 (95% CI 0.64, 3.65). However, the intervention improved the second co-primary outcome (uptake of diagnostic pathway): HR = 2.34 (95% CI 1.05, 5.25). Intention-to-treat analyses yielded similar results.

INTERPRETATION

The co-developed best-practice model of care for cognitive impairment and dementia for Aboriginal and Torres Strait Islander people attending primary care improved the diagnostic CIND/dementia management process.

FUNDING

National Health and Medical Research Council (Australia) and Dementia Training Australia.

摘要

背景

在接受初级保健的原住民中，痴呆症和非痴呆性认知障碍（CIND）的检出率较低。本试验实施了一种经过文化调整的最佳实践护理模式，以提高对CIND/痴呆症的检测并优化管理。

方法

这项封闭队列开放标签、阶梯式楔形、整群随机试验在澳大利亚城市、地区和偏远地区招募了12家原住民社区控制的初级卫生保健服务机构（ACCHS）。如果ACCHS进行年度健康检查、参与持续质量改进过程且有≥55名年龄≥50岁的客户，则有资格参与。在基线对照期后，每六个月安排4家ACCHS进入干预阶段。在干预阶段，通过员工教育和实践变革举措，支持ACCHS采用最佳实践痴呆症护理。共同主要结局为：（i）记录在案的CIND/痴呆症检测情况，以及（ii）通过以下至少两项的存在来衡量的诊断途径采用证据：使用认知评估工具、相关病理检查、神经影像学检查，和/或将有认知问题的客户转诊至专科服务机构。数据采用混合效应互补对数-对数回归分析。本研究已在澳大利亚和新西兰临床试验注册中心注册，注册号为ACTRN12618001485224。

结果

2018年9月至2019年1月期间，招募了12家ACCHS，包括1655名年龄≥50岁的ACCHS客户样本（平均60.3±8.2岁），其中935名（56.5%）为女性。一家ACCHS在研究期间退出。在对时间进行调整后，干预措施对第一个共同主要结局（CIND/痴呆症检测）未显示出效果：风险比（HR）=1.53（95%置信区间0.64，3.65）。然而，干预措施改善了第二个共同主要结局（诊断途径的采用）：HR=2.34（95%置信区间1.05，5.25）。意向性分析得出了类似结果。