Departments of Geriatrics and Pediatrics Win First Place in Quality Improvement Program

By Karmen Robinson

They presented their findings during the third annual QIALP Conference in April.

Project leaders from the UAMS Donald W. Reynolds Institute on Aging and Department of Geriatrics included institute director Jeanne Wei, M.D., Ph.D.; Gohar Azhar, M.D., (lead facilitator); Regina Gibson, Ph.D., RN; Priya Mendiratta, M.D.; and Jasmine Crane. Rosemary Nabaweesi, Dr.P.H., from the Department of Pediatrics, and UAMS Chief Quality Officer Troy Schmit, MHA, also served as project co-facilitator and mentor, respectively.

During their presentation titled “Health care Disparity in the Assessment of Dementia in the Outpatient Setting,” UAMS faculty members discussed prevalent research that indicates Black people age 65 and above are twice as likely as their white counterparts to be diagnosed with Alzheimer’s disease or dementia. Despite this, outpatient clinical data demonstrated that Black patients were less likely to be screened for dementia at UAMS.

As a result of this research, the team’s assessment aimed to determine if screening methods differed among the two populations, which could result in the disproportional outcome, in addition to the over or underestimation of a dementia diagnosis.

“A wrong diagnosis or label of dementia can have tremendous negative psychological, medical and social consequences for the patient and their family,” said Azhar, a professor in the Department of Geriatrics and director of the Pat Walker Memory Center, a component of the UAMS Thomas and Lyon Longevity Clinic.

“Conversely, a missed diagnosis of dementia in someone who actually has dementia will also have a negative impact by delaying treatment. It is important to have the correct diagnosis to prepare for the future.”

Azhar, who conceptualized, designed and oversaw the project, explained that many times, it takes more than two visits with lab tests and brain imaging to have a definitive diagnosis and treatment plan.

The UAMS researchers analyzed screening methods at the Thomas and Lyon Longevity Clinic, where they surveyed 15 providers and reviewed 150 medical records from patients age 60 and older in order to identify and document racial disparity.

“What we hoped to accomplish was to improve comparable dementia screening using standardized cognitive tests for both Black and white patients,” said Gibson, an assistant professor in the Department of Geriatrics in the College of Medicine and the institute’s senior nurse educator.

The team of faculty members used two “Plan-Do-Study-Acts” (PDSA) to identify and implement interventions focused on improving dementia screening rates to ensure comparable testing across the board and thus reduce racial disparity.

To first determine if racial disparity in screening methods was actually present in the clinic, they randomly selected 78 of the medical records to see if a diagnosis of dementia was given and to evaluate the use of appropriate standardized cognitive assessments such as the Montreal Cognitive Assessment, the Saint Louis University Mental Status Examination and the Mini-Mental State Exam.

“The review of the 78 charts indicated that Black patients were screened using standardized tests at a much lower rate compared to their white counterparts,” said Gibson, who led the presentation.

They discovered Black patients were screened at a 43.4% rate while white patients were screened at a 68.5% rate, meaning less than half of the Black patients were diagnosed with dementia using appropriate standardized screenings while more than half were diagnosed with dementia without using appropriate screening methods.

“The clinicians were not aware of the implicit bias that was taking place during the screening of their patients,” said Nabaweesi, an assistant professor in the Department of Pediatrics and senior research and evaluation director for the UAMS Division of Diversity, Equity and Inclusion.

The team pinpointed potential root causes of poor screening methods by evaluating contributing factors from patients, caregivers and providers that could influence implicit racial bias and ultimately impact the quality of health care provided to patients.

“As you can imagine, it is a challenge to clinically manage cognitively impaired patients and to support their caregivers who are under stress because of the care they have to provide their loved ones,” said Nabaweesi.

Trust, bias, fear and lack of knowledge regarding dementia were primary factors in low screening rates for patients and caregivers. The researchers noted the cognitive decline of the patients was a component as well.

For providers, the team suggested implicit bias, experience, knowledge and training as the main causes of poor screenings, in addition to time constraints, staff support, resources and the knowledge deficit between the provider and the patient.

Nabaweesi noted that the team observed more challenges in the outpatient setting, including “the burnout providers faced given the emotional toll of taking care of cognitively impaired patients as well as providing support to their caregivers. On multiple occasions, the providers have to explain the care for the patients to the caregivers several times.”

The team implemented various strategies for all three groups in an effort to reduce implicit bias.

The faculty members conducted geriatric grand rounds, held a special discussion for providers and coordinated one-on-one instruction on dementia screening and proper approach on how to communicate the diagnosis of dementia in difficult situations and make the patient and caregiver feel comfortable. Patients and caregivers received brochures and booklets on understanding memory loss.

After implementing the interventions, the team of researchers analyzed the impact of the interventions on screening disparity by reviewing 72 patient records with a dementia diagnosis between November 2020 and March 2021.

In the fourth month span, they surveyed patients and caregivers about care they received when they underwent cognitive testing, in addition to surveying clinicians about providing care for dementia patients in the clinic.

Dementia screening rates for both Black and white patients at the clinic showed significant improvement due to the interventions. Screenings for white patients increased from 68.5% to almost 90%, and rates for Black patients nearly doubled, jumping from 43.4% to 82.3%.

The outcome of their study also resulted in 95% of providers feeling more comfortable with evaluating memory patients.

“Our educational interventions significantly reduced the screening disparity gap between white and Black patients,” said Nabaweesi. “We also found that patients and their caregivers valued the care they received from the Longevity Clinic, and they appreciated having compassionate providers who took their time to listen to them and address all patient and caregiver concerns.”

The team discussed next steps for continuous improvement of screening rates, including provider education and training using a variety of convenient methods and presentations, implicit bias training to improve cultural sensitivity and funding for patient and caregiver support groups to enhance the understanding of memory disorders.

In addition to UAMS, health care professionals from Arkansas Children’s, Baptist Health and UT Health Tyler also presented various research topics at the virtual conference.