Browsing by Author "Summanwar, Diana"
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Item Agile Implementation of a Digital Cognitive Assessment for Dementia in Primary Care(Annals of Family Medicine, 2025-05-27) Summanwar, Diana; Fowler, Nicole R.; Hammers, Dustin B.; Perkins, Anthony J.; Brosch, Jared R.; Willis, Deanna R.; Family Medicine, School of MedicinePurpose: This study aimed to assess how agile implementation-driven iterative processes and tailored workflows can facilitate the implementation of a digital cognitive assessment (DCA) tool for patients aged 65 years or older into primary care practices. Methods: We used agile implementation principles to integrate a DCA tool into routine workflows across 7 primary care clinics. The intervention involved a structured selection process for identifying an appropriate DCA tool, stakeholder engagement through iterative sprints (structured, time-bound cycles), and development of tailored workflows to meet clinic-specific needs. A brain health navigator role was established to support patients with positive or borderline screenings, and assist primary care clinicians with follow-up assessment. We used the reach, effectiveness, adoption, implementation, and maintenance (RE-AIM) framework to evaluate the intervention's performance over a 12-month period. Results: The intervention engaged 69 (63.8%) of 108 clinicians across the 7 clinics. DCA screening was completed in 1,808 (10.8%) of 16,708 eligible visits. We selected the Linus Health Core Cognitive Evaluation tool as our DCA tool based on stakeholder evaluations. Screening workflows were tailored to each clinic. The brain health navigator received 447 referrals for further assessment of a positive or borderline screening result. Four clinics fully adopted the intervention, achieving a DCA completion rate of at least 20%, and 5 clinics were still routinely using the DCA tool at 12 months. Conclusions: Agile implementation effectively helped integrate the DCA tool into primary care workflows. Customized workflows, stakeholder engagement, and iterative improvements were crucial for adoption and sustainability. These insights can guide future efforts for early detection and management of cognitive impairment in primary care, ultimately improving patient outcomes and easing the burden on health care professionals.Item Agile implementation of alcohol screening in primary care(Springer Nature, 2024-07-11) Summanwar, Diana; Ropert, Chelan; Barton, James; Hiday, Rachael; Bishop, Dawn; Boustani, Malaz; Willis, Deanna; Medicine, School of MedicineBackground: Despite the United States Preventive Services Task Force recommendation to screen adults for unhealthy alcohol use, the implementation of alcohol screening in primary care remains suboptimal. Methods: A pre and post-implementation study design that used Agile implementation process to increase screening for unhealthy alcohol use in adult patients from October 2021 to June 2022 at a large primary care clinic serving minority and underprivileged adults in Indianapolis. Results: In comparison to a baseline screening rate of 0%, the agile implementation process increased and sustained screening rates above 80% for alcohol use using the Alcohol Use Disorders Identification Test - Consumption tool (AUDIT-C). Conclusions: Using the agile implementation process, we were able to successfully implement evidence-based recommendations to screen for unhealthy alcohol use in primary care.Item Becoming an Agile Change Conductor(Frontiers, 2022) Mehta, Jade; Aalsma, Matthew C.; O'Brien, Andrew; Boyer, Tanna J.; Ahmed, Rami A.; Summanwar, Diana; Boustani, Malaz; Family Medicine, School of MedicineBackground: It takes decades and millions of dollars for a new scientific discovery to become part of clinical practice. In 2015, the Center for Health Innovation & Implementation Science (CHIIS) launched a Professional Certificate Program in Innovation and Implementation Sciences aimed at transforming healthcare professionals into Agile Change Conductors capable of designing, implementing, and diffusing evidence-based healthcare solutions. Method: In 2022, the authors surveyed alumni from the 2016–2021 cohorts of the Certificate Program as part of an educational quality improvement inquiry and to evaluate the effectiveness of the program. Results: Of the 60 alumni contacted, 52 completed the survey (87% response rate) with 60% of graduates being female while 30% were an under-represented minority. On a scale from 1 to 5, the graduates agreed that the certificate benefited their careers (4.308 with a standard deviation (SD) of 0.612); expanded their professional network (4.615, SD of 0.530); and had a large impact on the effectiveness of their leadership (4.288, SD of 0.667), their change management (4.365, SD of 0.742), and their communication (4.392, SD of 0.666). Graduates claimed to use Agile Processes (Innovation, Implementation, or Diffusion), storytelling, and nudging weekly. On a scale from 0 to 10 where 10 indicates reaching a mastery, the average score for different Agile competencies ranged from 5.37 (SD of 2.80) for drafting business proposals to 7.77 (SD of 1.96) for self-awareness. For the 2020 and 2021 cohorts with existing pre and post training competency data, 22 of the 26 competencies saw a statistically significant increase. Conclusion: The Graduate Certificate has been able to create a network of Agile Change Conductors competent to design, implement, and diffuse evidence-based care within the healthcare delivery system. Further improvements in building dissemination mastery and program expansion initiatives are advised.Item Feasibility and Acceptability of Implementing a Digital Cognitive Assessment for Alzheimer Disease and Related Dementias in Primary Care(Annals of Family Medicine, 2025-05-27) Fowler, Nicole R.; Hammers, Dustin B.; Perkins, Anthony J.; Summanwar, Diana; Higbie, Anna; Swartzell, Kristen; Brosch, Jared R.; Willis, Deanna R.; Medicine, School of MedicinePurpose: We assessed the feasibility and acceptability of implementing a digital cognitive assessment (DCA) for Alzheimer disease and related dementias (ADRD) screening into primary care. We also assessed the prevalence of positive screens and measured diagnostic and care outcomes after a positive DCA result. Methods: We conducted a single-arm pragmatic clinical demonstration project in 7 diverse primary care clinics to test implementation of the Linus Health Core Cognitive Evaluation and Digital Clock and Recall DCAs (Linus Health, Inc). Eligible patients were aged ≥65 years. Patients were ineligible if unable to see or hear, not English or Spanish speaking, or if they had a DCA in the past 12 months with an unimpaired or impaired result. Results: There were 16,708 eligible encounters during the 12-month study period (June 2022-May 2023). A total of 1,808 DCAs (10.8%) were completed by 1,722 unique patients; 3,727 (22.3%) declined, and at 9,232 encounters (55.3%) the physicians declined to have the patient complete the DCA or the encounter was deemed out of scope. Among those who completed DCAs, results for 762 (44.3%) were categorized as unimpaired, 628 (36.5%) borderline, 236 (13.7%) impaired, and 96 (5.6%) inconclusive. Among the 236 patients who were categorized as impaired, 2.1% received a new diagnosis of ADRD, and 5.1% received a new diagnosis of mild cognitive impairment within 90 days after the DCA. Conclusions: One-half of all patients scored impaired or borderline for cognitive impairment. Digital cognitive assessments can be implemented in primary care, have utility for early detection, and could represent the first step in identification of patients who could benefit from ADRD disease-modifying therapeutics, care management, or other interventions to improve patient and family caregiver outcomes.Item Improving Early Dementia Detection Among Diverse Older Adults With Cognitive Concerns With the 5-Cog Paradigm: Protocol for a Hybrid Effectiveness-Implementation Clinical Trial(JMIR, 2025-04-03) Rosansky Chalmer, Rachel Beth; Ayers, Emmeline; Weiss, Erica F.; Fowler, Nicole R.; Telzak, Andrew; Summanwar, Diana; Zwerling, Jessica; Wang, Cuiling; Xu, Huiping; Holden, Richard J.; Fiori, Kevin; French, Dustin D.; Nsubayi, Celeste; Ansari, Asif; Dexter, Paul; Higbie, Anna; Yadav, Pratibha; Walker, James M.; Congivaram, Harrshavasan; Adhikari, Dristi; Melecio-Vazquez, Mairim; Boustani, Malaz; Verghese, Joe; Medicine, School of MedicineBackground: The 5-Cog paradigm is a 5-minute brief cognitive assessment coupled with a clinical decision support tool designed to improve clinicians' early detection of cognitive impairment, including dementia, in their diverse older primary care patients. The 5-Cog battery uses picture- and symbol-based assessments and a questionnaire. It is low cost, simple, minimizes literacy bias, and is culturally fair. The decision support component of the paradigm helps nudge appropriate care provider response to an abnormal 5-Cog battery. Objective: The objective of our study is to evaluate the effectiveness, implementation, and cost of the 5-Cog paradigm. Methods: We will enroll 6600 older patients with cognitive concerns from 22 primary care clinics in the Bronx, New York, and in multiple locations in Indiana for this hybrid type 1 effectiveness-implementation trial. We will analyze the effectiveness of the 5-Cog paradigm to increase the rate of new diagnoses of mild cognitive impairment syndrome or dementia using a pragmatic, cluster randomized clinical trial design. The secondary outcome is the ordering of new tests, treatments, and referrals for cognitive indications within 90 days after the study visit. The 5-Cog's decision support component will be deployed as an electronic medical record feature. We will analyze the 5-Cog's implementation process, context, and outcomes through the Consolidated Framework for Implementation Research using a mixed methods design (surveys and interviews). The study will also examine cost-effectiveness from societal and payer (Medicare) perspectives by estimating the cost per additional dementia diagnosis. Results: The study is funded by the National Institute of Neurological Disorders and Stroke of the National Institutes of Health (2U01NS105565). The protocol was approved by the Albert Einstein College of Medicine Institutional Review Board in September 2022. A validation study was completed to select cut scores for the 5-Cog battery. Among the 76 patients enrolled, the resulting clinical diagnoses were as follows: dementia in 32 (42%); mild cognitive impairment in 28 (37%); subjective cognitive concerns without objective cognitive impairment in 12 (16%); no cognitive diagnosis assigned in 2 (3%). The mean scores were Picture-Based Memory Impairment Screen 5.8 (SD 2.7), Symbol Match 27.2 (SD 18.2), and Subjective Motoric Cognitive Risk 2.4 (SD 1.7). The cut scores for an abnormal or positive result on the 5-Cog components were as follows: Picture-Based Memory Impairment Screen ≤6 (range 0-8), Symbol Match ≤25 (range 0-65), and Subjective Motoric Cognitive Risk >5 (range 0-7). As of December 2024, a total of 12 clinics had completed the onboarding processes, and 2369 patients had been enrolled. Conclusions: The findings of this study will facilitate the rapid adaptation and dissemination of this effective and practical clinical tool across diverse primary care clinical settings.Item Improving the User Interface and Guiding the Development of Effective Training Material for a Clinical Research Recruitment and Retention Dashboard: Usability Testing Study(JMIR, 2025-02-24) Gardner, Leah Leslie; Parvari, Pezhman Raeisian; Seidman, Mark; Holden, Richard J.; Fowler, Nicole R.; Zarzaur, Ben L.; Summanwar, Diana; Barboi, Cristina; Boustani, Malaz; Medicine, School of MedicineBackground: Participant recruitment and retention are critical to the success of clinical trials, yet challenges such as low enrollment rates and high attrition remain ongoing obstacles. RecruitGPS is a scalable dashboard with integrated control charts to address these issues by providing real-time data monitoring and analysis, enabling researchers to better track and improve recruitment and retention. Objective: This study aims to identify the challenges and inefficiencies users encounter when interacting with the RecruitGPS dashboard. By identifying these issues, the study aims to inform strategies for improving the dashboard's user interface and create targeted, effective instructional materials that address user needs. Methods: Twelve clinical researchers from the Midwest region of the United States provided feedback through a 10-minute, video-recorded usability test session, during which participants were instructed to explore the various tabs of the dashboard, identify challenges, and note features that worked well while thinking aloud. Following the video session, participants took a survey on which they answered System Usability Scale (SUS) questions, ease of navigation questions, and a Net Promoter Score (NPS) question. Results: A quantitative analysis of survey responses revealed an average SUS score of 61.46 (SD 23.80; median 66.25) points, indicating a need for improvement in the user interface. The NPS was 8, with 4 of 12 (33%) respondents classified as promoters and 3 of 12 (25%) as detractors, indicating a slightly positive satisfaction. When participants compared RecruitGPS to other recruitment and study management tools they had used, 8 of 12 (67%) of participants rated RecruitGPS as better or much better. Only 1 of 12 (8%) participants rated RecruitGPS as worse but not much worse. A qualitative analysis of participants' interactions with the dashboard diagnosed a confusing part of the dashboard that could be eliminated or made optional and provided valuable insight for the development of instructional videos and documentation. Participants liked the dashboard's data visualization capabilities, including intuitive graphs and trend tracking; progress indicators, such as color-coded status indicators and comparison metrics; and the overall dashboard's layout and design, which consolidated relevant data on a single page. Users also valued the accuracy and real-time updates of data, especially the integration with external sources like Research Electronic Data Capture (REDCap). Conclusions: RecruitGPS demonstrates significant potential to improve the efficiency of clinical trials by providing researchers with real-time insights into participant recruitment and retention. This study offers valuable recommendations for targeted refinements to enhance the user experience and maximize the dashboard's effectiveness. Additionally, it highlights navigation challenges that can be addressed through the development of clear and focused instructional videos.Item Optimizing primary care for cognitive impairment screening using agile implementation(Wiley, 2025-01-09) Summanwar, Diana; Brosch, Jared R.; Hammers, Dustin B.; Fowler, Nicole R.; Willis, Deanna R.; Medicine, School of MedicineBackground: Screening for cognitive impairment in primary care faces challenges, including time constraints, provider apprehension, and limited diagnostic confidence. An effective initiative for improving screening must include strategies to foster behavioral change, and active provider engagement. Agile implementation science integrates findings from behavioral economics, complexity science, and network science, to address these challenges by confirming the demand to solve the problem; local solution adaptation; and the iterative ‘sprints’, or tests of change, that are focused on execution. This study, which is part of the Davos Alzheimer’s Collaborative (DAC) Early Detection Health System Preparedness Flagship program, explored workflows to support Digital Cognitive Assessment (DCA) in primary care, enhancing early detection of mild cognitive impairment (MCI) and dementia. Methods: Between June 1, 2022, and May 31, 2023, seven diverse primary care clinics participated in the DAC program. The initiative’s core was the integration of offering and performing Linus Health Core Cognitive Evaluation Digital Cognitive Assessment (DCA) for patients aged 65 and above. The selection of the digital screening tool, process workflows, and improvement cycles were co‐designed by the primary care providers, clinic staff, the Patient Advisory Council, and the implementation team using Agile Implementation. A Brain Health Navigator (BHN) role was designed to fill workflow gaps in primary care evaluation of abnormal screening and facilitate specialty care transition for patients needing referral. Results: Among the seven sites, five sites engaged in agile implementation and had similar performances, with an increase in DCA completion observed. A total of 1808 DCA screenings were performed on 1722 unique patients. The agile implementation process facilitated clinic‐specific adaptations, which resulted in an increase in the overall number of eligible patients completing the DCA screening. Conclusions: The adoption of an agile implementation process increased DCA screening uptake in primary care settings. The integration of a BHN and streamlined workflows proved crucial in enhancing the screening, diagnosis, and referral journey. This integration aligns with the principles of person‐centered care and facilitates service coordination. It also supports workforce initiatives and advances the field of health services research, ensuring that each step in the patient’s journey is both effective and efficient.Item Prevalence of Unrecognized Cognitive Impairment in Federally Qualified Health Centers(American Medical Association, 2024-10-01) Kulshreshtha, Ambar; Parker, Erik S.; Fowler, Nicole R.; Summanwar, Diana; Ben Miled, Zina; Owora, Arthur H.; Galvin, James E.; Boustani, Malaz A.; Epidemiology, Richard M. Fairbanks School of Public HealthImportance: There is a need for early and equitable detection of cognitive impairment among older adults. Objective: To examine the prevalence of unrecognized cognitive impairment among older adults receiving primary care from federally qualified health centers (FQHCs). Design, setting, and participants: This cross-sectional study was conducted at 5 FQHCs providing primary care in Indianapolis, Indiana, between 2021 and 2023. Participants were adults aged 65 years and older, without a diagnosis of mild cognitive impairment (MCI), dementia, or severe mental illness. Data analysis was performed from September 2023 to April 2024. Main outcomes and measures: The primary outcome was a diagnosis of dementia or MCI, as determined by an interdisciplinary clinical team using data from structured patient and study partner interviews, medical record reviews, and a detailed cognitive assessment, including neuropsychological testing. Differences between participants determined to have normal cognition, MCI, and dementia were assessed statistically using analysis of variance for continuous variables, χ2 or Fisher exact tests for categorical variables, or Fisher exact test alone when expected cell counts were 5 or less. Results: A total of 844 eligible individuals were consecutively approached, 294 consented to participate, and 204 completed the study (mean [SD] age, 70.0 [5.1] years; 127 women [62.3%]). One hundred eight participants (52.9%) were African American, 5 (2.5%) were Hispanic, 199 (97.5%) were not Hispanic, and 90 (44.1%) were White. The mean (SD) duration of education was 13.1 (2.6) years, and the mean (SD) Area Deprivation Index score was 78.3 (19.9), indicating a high level of neighborhood disadvantage. In total, 127 patients (62.3%) met the diagnostic criteria for MCI, 25 (12.3%) had dementia, and 52 (25.5%) had no cognitive impairment. Compared with non-Hispanic White individuals and after adjusting for age, sex, and education level, African American individuals were more than twice as likely to have MCI or dementia (odds ratio, 2.73; 95% CI, 1.38-5.53; P = .02). Conclusions and relevance: This cross-sectional study found that unrecognized cognitive impairment is ubiquitous among older adults from underrepresented, minoritized racial and ethnic groups and those who are socially vulnerable receiving primary care from FQHCs. To overcome the disparity in early detection of cognitive impairment, timely, equitable, scalable, and sustainable detection approaches need to be developed.Item Real world implementation of blood biomarkers in primary care(Wiley, 2025-01-09) Willis, Deanna R.; Brosch, Jared R.; Fowler, Nicole R.; Hammers, Dustin B.; Summanwar, Diana; Medicine, School of MedicinePrimary Care (PC) clinicians are faced with numerous competing demands and priorities for maximizing patient care. These challenges make the implementation of strategies for early detection of Alzheimer’s Disease (AD) complex. Few real‐world implementation projects about early detection of AD in PC exist. From 2022‐2023 the Davos Alzheimer’s Collaborative (DAC) Health System Preparedness Flagship project included seven United States academic affiliated PC clinics. We implemented digital cognitive assessments using the Linus Health Core Cognitive Evaluation at routine PC encounters. Patients who failed the cognitive assessment were offered, as part of a research pilot, C2N Diagnostics’ blood biomarker (BBM) test, PrecivityAD, with results disclosure. PCPs were approached to receive education about BBM for AD and to consent to deliver results themselves or defer delivery to the research team. Of the patients approached for BBM, more than half declined. Providers were split on their willingness to deliver results. For patients whose provider did not elect to deliver results or who was unable to deliver results in the timeframe needed, a trained Registered Nurse was trained and observed to disclose results. This session will share perspectives on these real‐life facilitators and barriers to implementing cognitive screening and BBM in PC and how more fully engaging the whole primary care team may help mitigate some of these barriers.