Primary Care Detection of Cognitive Impairment Leveraging Health and Consumer Technologies in Underserved Communities: The MyCog Trial

作为Detect CID联盟的一部分，我们寻求更新我们目前的奖项（UH3NS105562），并进行一项实用试验，以测试我们的NIH工具箱衍生范例的有效性和保真度，以改善初级保健机构中为不同健康患者群体服务的认知障碍/痴呆的早期检测和管理。早期识别认知障碍（CI），包括阿尔茨海默病（AD）和相关痴呆（ADRD），是公共卫生的重中之重。然而，在管理大多数社区居住老年人健康的初级保健机构中，只有不到一半的CI患者被发现和/或诊断。在为社会经济地位低（SES）、少数种族或民族的边缘化患者服务的社区卫生中心中，检出率可能要低得多。这是一个非常值得关注的问题，因为西班牙裔/拉丁裔（H/L）和黑人老年人患ADRD的可能性是非H/L白人的1.5至2倍，并且未被发现/诊断。需要实用的、可扩展的战略来帮助初级保健实践更好地发现和管理CI，特别是那些医疗服务不足的低SES社区。自2017年以来，我们的团队一直是NINDS检测CID联盟的成员；该网络致力于改善CI和ADRD的早期发现及其在日常临床环境中的后续管理的临床范例。在开发了美国国立卫生研究院神经和行为功能评估工具箱（Co-I: Gershon, MPI: Nowinski）以及在以患者为中心的护理的卫生系统重新设计方面的专业知识（MPI: Wolf）之后，我们验证了我们自己的临床范例，即MyCog。这包括一个简短的、基于ipad的、自我管理的、与电子健康记录（EHR）相关的策略，用于在初级保健就诊时评估CI。为响应RFA-NS-22-009，我们将与一家国家初级保健提供者（Oak Street Health）合作，开展一项两组临床随机实用试验，比较MyCog与常规护理。我们将重点关注经历CI/ADRD差异的人群：黑人、H/L和低社会经济地位的老年人。我们的具体目标是：1)检验MyCog模式在低社会经济地位、黑人和西班牙裔老年人中提高CI和痴呆早期检测的有效性；2)调查不同种族和民族在CI早期发现、诊断和转诊率方面存在的差异；3)确定MyCog的保真度和可靠性，并确定患者、护理人员、临床医生和/或卫生系统对其最佳、持续实施的任何障碍；4)从初级保健角度评估结核分枝杆菌治疗模式的成本效益。影响：我们的研究结果将解决已知的差异，并为早期发现CI的全面、电子病历支持、可计费、可扩展的初级保健方案提供新的证据，为未来的广泛传播提供信息。

We seek to renew our current award (UH3NS105562) as part of the Detect CID consortium and conduct a pragmatic trial to test the effectiveness + fidelity of our NIH Toolbox-derived paradigm to improve early detection and management of cognitive impairment/dementia in primary care settings serving health disparate patient populations. Early identification of cognitive impairment (CI), including Alzheimer’s disease (AD) and related dementias (ADRD), is a top public health priority. Yet in primary care settings that manage the health of the majority of community-dwelling older adults, less than half of patients with any CI are detected and/or diagnosed. Among community health centers that serve marginalized patients - by low socioeconomic status (SES), minority race or ethnicity - rates of detection may be far lower. This is of great concern, as Hispanic/Latino (H/L) and Black older adults are 1.5 to 2 times more likely to develop ADRD and to go undetected/undiagnosed compared to non-H/L Whites. Practical, scalable strategies are needed to help primary care practices better detect and manage CI, especially those caring for medically underserved, low SES communities. Since 2017, our team has been a member of the NINDS Detect CID Consortium; a network dedicated to improving clinical paradigms for early detection of CI and ADRD and its subsequent management in everyday clinical settings. Having developed the NIH Toolbox for Assessment of Neurological and Behavioral Function (Co-I: Gershon, MPI: Nowinski) and with expertise in health system re-design for patient-centered care (MPI: Wolf), we validated our own clinical paradigm, known as MyCog. This includes a brief, iPad-based, self- administered, electronic health record (EHR)-linked strategy to assess for CI during primary care visits when concerns are identified. In response to RFA-NS-22-009, we will partner with a national primary care provider (Oak Street Health) and conduct a 2-arm, clinic-randomized, pragmatic trial comparing MyCog to usual care. We will focus on populations experiencing CI/ADRD disparities: Black, H/L, and low SES older adults. Our specific aims are to: 1) test the effectiveness of the MyCog paradigm to improve early detection of CI and dementias among low SES, Black and Hispanic older adults; 2) investigate the presence of disparities in early detection of CI, its diagnosis, and rate of referrals by race and ethnicity; 3) determine the fidelity and reliability of MyCog and identify any patient, caregiver, clinician, and/or health system barriers to its optimal, sustained implementation; 4) assess the cost-effectiveness of the MyCog paradigm from a primary care perspective. Impact: Our findings will address known disparities and offer new evidence on a comprehensive, EHR-enabled, billable, scalable, primary care protocol for early detection of CI - informing future widespread dissemination.