Using the PROMIS Cognition Item Bank for Early Detection of Cognitive Decline in Primary Care

通过检测认知障碍(CI)，特别是在轻度阶段，及早诊断阿尔茨海默病和阿尔茨海默病相关痴呆(AD/ADRD)，将支持及时的临床干预，在疾病轨迹的早期招募患者参加临床试验，并提供重要信息，以启动和指导与患者及其家人的护理规划对话。有效早期识别AD/ADRD的一个障碍是缺乏一种简短、可靠和有效的筛查工具，该工具可以由患者管理并容易地集成到EHR中。CI的简短筛查器提供了增加早期发现的机会，但在繁忙的初级保健环境中，筛查工具必须完全集成EHR，并且最好是可以由患者管理的形式(例如，通过患者门户)。我们建议验证现有的CI评估，该评估将支持在初级保健就诊期间对老年人进行AD/ADRD的普遍筛查，使用EHR集成的简要筛查，其中患者自我报告他们的认知能力。使用患者报告的结果(PRO)用于早期检测AD/ADRD的特定目的是理想的，既以患者为中心，又最大限度地减少负担，同时还提供有用的持续数据点，可以提醒提供者认知功能的细微变化可能表明需要随访。患者报告结果测量信息系统(PROIS)认知功能(PCF)题库包含63个评估认知功能的项目。PROMIS题库方法的好处是灵活、高效、准确，并且非常适合集成到电子管理平台，如EHR。识字率低的人可以获得PCF项目，有几种语言版本，并根据包括种族/族裔和年龄在内的多种人口特征进行了偏见测试。这些特性使PCF题库成为开发筛查工具的理想来源，以在临床环境中检测不同人群中的AD/ADRD。在这个为期五年的项目中，兰德及其合作伙伴(UPMC和NU)将进行定性和二级数据分析，以确定来自PCF题库的分数的有效性；使用产生的数据来得出适用于临床实践的有意义的评分标准和解释指南；最终确定筛查内容；并与至少两个大型地区卫生系统合作，在其EHR中实施筛查，并评估通过EHR在临床会诊期间提供这些数据对初级保健提供者行为的可行性和影响。

Early diagnosis of Alzheimer’s disease and Alzheimer’s disease-related dementias (AD/ADRD) through detection of cognitive impairment (CI), especially at the mild stage, would support timely clinical intervention, recruitment of patients into clinical trials earlier in the disease trajectory and provide important information to initiate and guide care planning conversations with patients and their family members. One barrier to effective early identification of AD/ADRD is the lack of a brief, reliable, and validated screening tool that can be patient administered and is easily integrated into the EHR. Brief screeners for CI present an opportunity to increase early detection, but within the busy primary care setting, a screening tool must be fully EHR-integrated and preferably in a form that can be patient-administered (e.g., through a patient portal). We propose to validate an existing assessment of CI that would support universal screenings for AD/ADRD in older adults during primary care visits using an EHR-integrated brief screener in which patients self-report their cognitive abilities. The use of a patient-reported outcome (PRO) for the specific purpose of early detection of AD/ADRD is ideal in being both patient-centered and minimally burdensome while also providing useful ongoing data points that can alert the provider to subtle changes in cognitive function that may indicate a need for follow-up. The Patient Reported Outcome Measurement Information System (PROMIS) Cognitive Function (PCF) item bank contains 63 items that assess cognitive function. The PROMIS item banking approach has the benefits of being flexible, efficient, precise, and highly suitable for integration into electronic administration platforms, such as EHRs. The PCF items are accessible to those with low literacy, available in several languages, and have been tested for bias according to multiple demographic characteristics including race/ethnicity and age. These properties make the PCF item bank an ideal source for development of a screening tool to detect AD/ADRD among diverse populations in clinical settings. In the course of this five-year project, RAND and its partners (UPMC and NU) will conduct both qualitative and secondary data analysis to establish the validity of scores from the PCF item bank; use the resulting data to derive meaningful scoring criteria and interpretation guidance suitable for use in clinical practice; finalize the screener content; and work with at least two large regional health systems to implement the screener in their EHR and evaluate the feasibility and impact of having these data available during the clinical encounter via the EHR on primary care providers’ behaviors.