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

我们寻求续签我们目前的奖项(UH3NS105562)，作为检测CID联盟的一部分，并进行一项务实的试验，以测试我们的NIH工具箱派生范式的有效性和保真度，以改进初级保健环境中认知障碍/痴呆症的早期检测和管理，为不同的健康人群提供服务。早期识别认知障碍(CI)，包括阿尔茨海默病(AD)和相关痴呆(ADRD)，是公共卫生的首要任务。然而，在管理大多数社区老年人健康的初级保健环境中，只有不到一半的CI患者被发现和/或诊断。在为边缘化患者提供服务的社区卫生中心--由于社会经济地位(SES)低、少数族裔或民族--发现率可能要低得多。这一点非常令人担忧，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到2倍。需要实用、可扩展的战略来帮助初级保健实践更好地检测和管理CI，特别是那些照顾医疗服务不足、低SES社区的人。自2017年以来，我们的团队一直是NINDS检测CID联盟的成员，该联盟是一个致力于改善临床范式，以早期检测CI和ADRD及其在日常临床环境中的后续管理的网络。在开发了NIH神经和行为功能评估工具箱(Co-I：Gershon，MPI：Nowinski)和以患者为中心的医疗系统重新设计方面的专业知识(MPI：WOLF)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)链接的战略，用于在发现问题时评估初级保健就诊期间的CI。作为对RFA-NS-22-009的回应，我们将与国家初级保健提供者(Oak Street Health)合作，进行一项双臂、临床随机、务实的试验，将MyCog与常规护理进行比较。我们将关注经历CI/ADRD差异的人群：黑人、H/L和低SES老年人。我们的具体目标是：1)测试MyCog范式的有效性，以改进低SES、黑人和西班牙裔老年人中CI和痴呆的早期检测；2)调查CI的早期检测、诊断以及按种族和民族转诊率方面存在的差异；3)确定MyCog范式的保真度和可靠性，并找出阻碍其最佳、可持续实施的任何患者、护理人员、临床医生和/或医疗系统障碍；4)从初级保健的角度评估MyCog范式的成本效益。影响：我们的发现将解决已知的差异，并为全面的、支持EHR的、可计费的、可扩展的初级保健方案提供新的证据，用于早期检测CI-通知未来的广泛传播。

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.