Dementia assessment and management in primary care settings: a survey of current provider practices in the United States

Alissa Bernstein,Joel H Kramer,Natasha Z.R Steele,Katherine P Rankin,Christine S Ritchie,Jay Wohlgemuth,Kirsten M Rogers,Katherine L Possin,Bruce L Miller,Rick Pesano,Joseph J Higgins,Michael Geschwind

doi:10.1186/s12913-019-4603-2

Abstract

BackgroundPrimary care providers (PCPs) are typically the first to screen and evaluate patients for neurocognitive disorders (NCDs), including mild cognitive impairment and dementia. However, data on PCP attitudes and evaluation and management practices are sparse. Our objective was to quantify perspectives and behaviors of PCPs and neurologists with respect to NCD evaluation and management.MethodsA cross-sectional survey with 150 PCPs and 50 neurologists in the United States who evaluated more than 10 patients over age 55 per month. The 51-item survey assessed clinical practice characteristics, and confidence, perceived barriers, and typical practices when diagnosing and managing patients with NCDs.ResultsPCPs and neurologists reported similar confidence and approaches to general medical care and laboratory testing. Though over half of PCPs performed cognitive screening or referred patients for cognitive testing in over 50% of their patients, only 20% reported high confidence in interpreting results of cognitive tests. PCPs were more likely to order CT scans than MRIs, and only 14% of PCPs reported high confidence interpreting brain imaging findings, compared to 70% of specialists. Only 21% of PCPs were highly confident that they correctly recognized when a patient had an NCD, and only 13% were highly confident in making a specific NCD diagnosis (compared to 72 and 44% for neurologists, both p < 0.001). A quarter of all providers identified lack of familiarity with diagnostic criteria for NCD syndromes as a barrier to clinical practice.ConclusionsThis study demonstrates how PCPs approach diagnosis and management of patients with NCDs, and identified areas for improvement in regards to cognitive testing and neuroimaging. This study also identified all providers’ lack of familiarity with published diagnostic criteria for NCD syndromes. These findings may inform the development of new policies and interventions to help providers improve the efficacy of their decision processes and deliver better quality care to patients with NCDs.

Highlights

Primary care providers (PCPs) are typically the first to screen and evaluate patients for neurocognitive disorders (NCDs), including mild cognitive impairment and dementia
We found that 50% of PCPs used cognitive screens or tests in only half of their patients with suspected NCDs, and only 20% reported they had high confidence in their ability to interpret cognitive testing results compared to 68% of specialists
As of 2017, newly created Medicare billing codes in the United States have been established to allow providers more time with patients, and to provide better reimbursement when providers engage in comprehensive neurocognitive evaluation and management practices [50, 51]. This is a step toward remediation of systemslevel practice barriers to improve quality of care, our results suggest that both PCPs and neurology specialists need more training and support in neurocognitive assessment methods and the choice of neuroimaging modalities in the evaluation of NCD patients

Summary

Introduction

Primary care providers (PCPs) are typically the first to screen and evaluate patients for neurocognitive disorders (NCDs), including mild cognitive impairment and dementia. In the United States, primary care providers (PCPs) are typically the first to screen and evaluate patients with neurocognitive disorders (NCDs) such as mild cognitive impairment and dementia. In the primary care setting, as many as two-thirds of people with dementia may be misdiagnosed (i.e., the NCD syndrome and neurologic etiology are misidentified), and there is often a significant delay between symptom onset and diagnosis [1,2,3,4,5]. PCPs, not specialists, carry the principal responsibility of diagnosing and caring for the majority of patients with NCDs, yet experience major barriers to managing patients [17, 18] there is disagreement about what constitutes an appropriate evaluation and which screening tools best fit a patient’s characteristics and presenting symptoms. While there is broad support among neurologists for using MRI rather than CT for brain imaging, the field has never formalized this standard of care

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