Identifying and supporting patients with undiagnosed dementia using the EHR Risk of Alzheimer's and Dementia Assessment Rule (eRADAR): a pilot clinical trial

意义：近一半患有阿尔茨海默病和相关痴呆的人没有 诊断出来了。诊断这些患者有许多潜在的好处，例如将他们与他们的 为家庭提供适当的支持和服务。也有潜在的风险，如耻辱、抑郁和 失去独立性。我们提出了一项试点临床试验，以改进和测试一种检测患者的新方法。 通过有针对性的外展，帮助未确诊的阿尔茨海默病或痴呆症患者。我们的目标是最大化 及早发现的好处，同时将危害降至最低。创新：我们开发了电子健康 记录阿尔茨海默氏症和痴呆症风险评估规则(ERADAR)，该规则使用 电子健康记录(EHR)，以确定未诊断痴呆症风险增加的患者。此外, 我们采访了患者、护理人员、临床医生和医疗保健系统领导人，以告知计划 实施。我们目前的提案在很大程度上受到了这项前期工作的影响。我们估计，如果患者 随着eRADAR得分在前15%被作为评估的目标，我们将检测到近一半患有 未确诊的痴呆症。调查人员：私人侦查员在痴呆症流行病学、风险预测方面拥有专业知识 模特和初级保健。他们成功地合作开发了eRADAR。联合调查员带来了 在定性方法、实施科学和卫生系统改革方面的专业知识。方法：我们建议 一项试点临床试验，由Kaiser Permanente内两家诊所的约50名初级保健医生参与 华盛顿(KPWA)将被随机分配到他们的患者(N=~12,000)作为外展基地 根据他们的eRADAR评分或常规护理(对照组)。我们的研究人员将在诊所工作 与初级保健团队接触eRADAR评分较高的患者，进行初步痴呆症 评估，提出后续建议，并在确诊后为患者提供支持。在目标1中，我们将开发 并利用患者、护理人员和初级医生的意见以迭代的方式改进干预流程 护理团队。在目标2中，我们将评估eRADAR的性能，重点是积极的预测价值和 干预组与常规护理组的痴呆症诊断率。在目标3中，我们将使用混合方法来 评估实施eRADAR对医疗保健利用率以及患者和家庭成员的影响 经历。环境：KPWA是一个学习型医疗保健系统，在这里研究塑造实践和 实践塑造研究。KPWA还在利用Epic EMR进行创新方面有着良好的记录，这是 在美国广泛使用，增加了传播的潜力。摘要：拟议的研究将进一步完善 并对未确诊的高风险患者进行了一种独特的定向痴呆症筛查方法的试点试验 痴呆症。它将使用一种基于电子病历的新工具和以患者为中心的外展流程。这项工作将为 为全面临床试验奠定基础，在该试验中，我们将确定eRADAR的实施 改善老年人的护理和结果。

Significance: Nearly half of people living with Alzheimer's disease and related dementias have not been diagnosed. There are many potential benefits of diagnosing these patients, such as connecting them and their families with appropriate support and services. There are also potential risks such as stigma, depression, and loss of independence. We propose a pilot clinical trial to refine and test a novel approach for detecting patients with undiagnosed Alzheimer's disease or dementia through targeted outreach. Our goal is to maximize the benefits of early detection while minimizing harms. Innovation: We have developed the electronic health record Risk of Alzheimer's and Dementia Assessment Rule (eRADAR), which uses information in the electronic health record (EHR) to identify patients with an elevated risk of undiagnosed dementia. In addition, we have interviewed patients, caregivers, clinicians and healthcare system leaders to inform plans for implementation. Our current proposal is heavily informed by this preliminary work. We estimate that, if patients with eRADAR scores in the top 15% were targeted for assessment, we would detect nearly half of patients with undiagnosed dementia. Investigators: The PIs have expertise in dementia epidemiology, risk prediction modeling and primary care. They collaborated successfully to develop eRADAR. Co-investigators bring expertise in qualitative methods, implementation science, and health system change. Approach: We propose a pilot clinical trial in which about 50 primary care physicians at two clinics within Kaiser Permanente Washington (KPWA) will be randomly assigned to have their patients (N=~12,000) targeted for outreach based on their eRADAR scores or to usual care (control group). Our research staff embedded in the clinics will work with the primary care team to reach out to patients with high eRADAR scores, conduct a preliminary dementia assessment, make follow-up recommendations, and support patients after diagnosis. In Aim 1, we will develop and refine intervention processes in an iterative fashion with input from patients, caregivers and primary care teams. In Aim 2, we will assess eRADAR's performance, focusing on positive predictive value and dementia diagnosis rates in the intervention vs. usual care groups. In Aim 3, we will use mixed methods to assess the impact of eRADAR implementation on healthcare utilization and patient and family member experiences. Environment: KPWA is a learning healthcare system, where research shapes practice and practice shapes research. KPWA also has a strong track record of innovation utilizing the Epic EMR, which is widely used in the US, increasing the potential for dissemination. Summary: The proposed study will refine and pilot test a unique approach for targeted dementia screening in patients at high risk of having undiagnosed dementia. It will use a novel EHR-based tool and patient-centered outreach processes. This work will lay the groundwork for a full-scale clinical trial in which we will determine whether implementation of eRADAR improves care and outcomes for older adults.