A Pragmatic Trial of the UCSF Brain Health Assessment for the Detection of Cognitive Impairment in Primary Care

初级保健需要有效且用户友好的范式来检测认知障碍，包括痴呆症。UCSF脑健康评估通过具有自动评分和EMR集成的吸引人的平板电脑界面准确检测认知障碍。在第一轮资金中，我们验证了英语和西班牙语使用者的范例，开发了基于回归的规范，可以根据患者受损的可能性对患者进行准确分类，确定了种族和民族差异以及大脑健康护理的障碍，并且在UCSF初级保健中，该范例将诊断率提高了40%。拟议工作的主要目标是通过大型务实试验评估改善大脑健康护理的范例的有效性，以解决实施挑战，并开拓精确医学方法来调整参考组。在目标1中，我们将在26个凯撒南加州初级保健诊所进行一项实用的集群随机试验，以确定该范式对检测率和其他脑健康结果的有效性。在目标2中，我们将确定和应对实施和可持续性方面的挑战。在目标3中，我们将进一步使我们的特征良好的参考组多样化，并改进我们的检测算法，以适应大脑健康的社会决定因素（而不是种族），这是新颖的，也是适用于日益多样化的美国所有成员的范式的关键。如果成功，这项工作将产生一个有效的范例，可用于解决未满足的需求，以检测认知障碍，包括痴呆症，在初级保健中看到的大量和多样化的人群，并提供有关范例的大规模实施的有用信息，以减轻医疗差距和改善大脑健康护理。

Efficient and user-friendly paradigms to detect cognitive impairment, including dementia are needed in primary care. The UCSF Brain Health Assessment accurately detects cognitive impairment via an appealing tablet interface with automated scoring and EMR integration. With the first round of funding, we validated the paradigm in English and Spanish speakers, developed regression-based norms that accurately classify patients by their likelihood of impairment, identified racial and ethnic disparities and barriers to brain health care, and at UCSF primary care the paradigm increased diagnosis rates by 40%. The primary goals of the proposed work are to evaluate the effectiveness of the paradigm for improving brain health care via a large pragmatic trial, to address challenges to implementation, and to pioneer precision medicine approaches to reference group adjustments. In Aim 1, we will conduct a pragmatic cluster randomized trial in 26 Kaiser Southern California primary care clinics to determine the effectiveness of the paradigm on detection rates and other brain health outcomes. In Aim 2, we will identify and address challenges to implementation and sustainability. In Aim 3, we will further diversify our well-characterized reference group and refine our detection algorithms to adjust for social determinants of brain health (not race), which is novel and also critical for a paradigm to be appropriate for all members of the increasingly diverse U.S. older adult population. If successful, this work will produce a validated paradigm that is available to address the unmet need to detect cognitive impairment, including dementia, in large and diverse populations seen in primary care, and provide useful information about wide scale implementation of the paradigm to mitigate healthcare disparities and improve brain health care.