Identification of cognitive impairment, depression, and fatigue among multiple sclerosis patients in a large comprehensive care center: A mixed-methods, qualitative study

Abstract

BackgroundDespite studies suggesting a high prevalence of cognitive impairment, depression, and fatigue (CDF) among patients with multiple sclerosis (MS), standardized CDF tools are used infrequently in clinical practice, potentially resulting in underdiagnosis. We documented the use of standardized tools to identify CDF in MS and sought to understand provider attitudes toward the tools and their use. MethodsThis mixed-methods study analyzed electronic health records (EHRs) from a large US urban MS center to determine the frequency and types of CDF screenings and numbers of MS treatment encounters (January 2018–December 2019). Participants included neurologists and nurse practitioners with ≥30 eligible patients and a convenience sample of adult MS patients (≥18 years) with at least outpatient encounters during the study period. Semistructured provider interviews (n = 6; the principal investigator and 1 provider were excluded) were conducted, transcribed, coded, and analyzed to characterize screening patterns. Assessments included proportions of encounters and patients who had standardized CDF screenings, positive screening results, and documentation of a treatment recommendation, as well as provider attitudes toward tools and reported barriers and facilitators for use. Bivariate analysis was used to evaluate the relationship between screening rates and patient and provider covariates for groups with sufficient sample size (n = 30). ResultsThe final population included 260 unique patients, 489 outpatient encounters, and 8 providers. Of 260 patients (75% female, 83% aged <65 years), 24% (n = 63) were screened with a depression tool. Only 2% (n = 4) were screened with a tool measuring cognitive impairment, and none were screened with a tool measuring fatigue. Screening rates varied little by provider type. Higher depression screening rates were associated with white race (difference: 13.2%; 95% CI: 2.8−23.5%; P = .01), ≤2 visits during the study period (difference: 7.6%; 95% CI: 0.6−14.5%; P = .03), and provider experience >10 years (difference: 14.6%; 95% CI: 3.5−25.8%; P = .01). Lack of support staff and perception of limited treatment options were commonly cited barriers to standardized screening in provider interviews. The higher rate of depression screening is likely driven by institutional culture and priorities. ConclusionProviders recognize the importance of CDF to patients, despite infrequent use of standardized screening. Integrating screening into institutional practices may enable ongoing tracking of assessment scores and provide a more comprehensive and longitudinal picture of symptom progression.