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

初级保健需要有效和用户友好的范例来检测包括痴呆症在内的认知障碍。加州大学旧金山分校的大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。利用第一轮资金，我们在英语和西班牙语使用者中验证了该范式，开发了基于回归的规范，根据患者受损的可能性准确地对患者进行分类，确定了种族和民族差异以及脑保健的障碍，在加州大学旧金山分校的初级保健中，该范式将诊断率提高了40%。这项拟议工作的主要目标是通过一项大型务实试验来评估改善脑保健的范例的有效性，解决实施中的挑战，并开创参考群体调整的精确医学方法。在目标1中，我们将在26家凯撒南加州初级保健诊所进行一项务实的整群随机试验，以确定该范式对发现率和其他脑健康结果的有效性。在目标2中，我们将确定和应对执行和可持续性方面的挑战。在目标3中，我们将进一步使我们特征良好的参照组多样化，并改进我们的检测算法，以适应大脑健康(而不是种族)的社会决定因素，这是新颖的，也是一个适用于日益多样化的美国老年人口的所有成员的范例的关键。如果成功，这项工作将产生一个有效的范例，可用于解决在初级保健中看到的大量和多样化的人群中检测包括痴呆症在内的认知障碍的未得到满足的需求，并提供有关广泛实施该范例以缓解医疗保健差距和改善大脑健康保健的有用信息。

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.