Association of Caregiver Depression Risk With Patient Outcomes in Parkinson Disease.

Importance: Caregivers are integral to Parkinson disease (PD) care, but little information exists regarding how caregivers impact patient outcomes. Objective: To assess the association between caregivers reporting depression symptoms and patient quality of life (QOL), emergency department (ED) visits, and hospitalizations. Design, Setting, and Participants: This retrospective cohort study was conducted at 15 Parkinson's Foundation Centers of Excellence within the US. The Parkinson's Foundation Parkinson Outcomes Project registry was used to collect baseline data from January 1, 2016, to December 31, 2018, with subsequent annual study visits through July 31, 2020. Data were analyzed from August 5, 2020, to June 9, 2023. A convenience sample of 454 patients with PD and their caregivers was recruited during routine clinical visits with movement disorder specialists. Patients with a physician diagnosis of idiopathic PD who lived at home and had 1 or more follow-up study visits were included. Exposure: Caregiver depression symptoms using the Center for Epidemiologic Studies Depression Scale. Main Outcomes and Measures: Patient health-related QOL (measured by the 39-item Parkinson Disease Questionnaire), number of annual ED visits, and number of annual hospitalizations were measured. The independent association between caregivers reporting depression symptoms and patient outcomes was assessed using linear mixed-effects and Poisson regression models. The a priori hypotheses were that a greater number of depression symptoms reported via the Center for Epidemiologic Studies Depression Scale would be associated with worse patient QOL and a greater number of ED visits and hospitalizations. Results: Among 454 patient-caregiver dyads (patients: mean [SD] age, 67.3 [8.4] years; 320 men [70.5%]; caregivers: mean [SD] age, 65.9 [8.7] years; 326 women [71.8%]), the mean (SD) follow-up was 2.0 (1.4) study visits. Greater depression symptoms among caregivers were associated with worse patient QOL as measured by the Parkinson Disease Questionnaire (mean [SD] score, 33.78 [17.71], on a scale of 0-100, with higher scores indicating worse QOL, among patients with caregivers who had depression symptoms vs 24.50 [14.19] among patients with caregivers who did not have depression symptoms; ß = 0.43; 95% CI, 0.28-0.58; P < .001) and more annual ED visits (ß = 0.02; 95% CI, 0 to 0.04; P = .03) but not more hospitalizations (ß = 0.02; 95% CI, -0.01 to 0.03; P = .10). Conclusions and Relevance: In this cohort study, patients with PD who had caregivers at higher risk of depression were more likely to have worse QOL and higher ED use than patients who had caregivers not at higher risk of depression. Additional caregiving resources and interventions to reduce caregiver depression symptoms could potentially improve patient outcomes.

"Intersections of Social Systems, Race, and Health in America: A Historical Perspective": A Novel Elective for Medical Students to Increase Antiracism Advocacy.

PROBLEM: There are growing calls for medical education to effectively teach about and explicitly name racism as a driver of inequities in social determinants of health and inspire student action to address health inequities. APPROACH: Using a novel application of the generative co-design approach, in 2020 Perelman School of Medicine students and faculty implemented a student-led, interdisciplinary elective course for preclerkship medical students. The co-design process allowed for an iterative and conversation-based experience emphasizing how social systems and racist policies shape health care access and outcomes. Active student participation was integral to developing discussion questions to elicit how students' positions in power structures can uphold inequities. Community members and nonprofit leaders taught about the current realities of discrimination and how students could best advocate for patients in the future. Enrolled students (n = 17) and a control group of nonenrolled classmates (n = 37) completed the Anti-Racism Behavioral Inventory (ARBI) pre- and post-course to compare changes in antiracist behaviors. OUTCOMES: Course participants demonstrated a significant increase in ARBI scores (mean = 4.29 (7.30); t(16) = 2.42; P = .01), while students from the control group did not (mean = 1.43 (6.98); t(36) = 1.25; P = .11). The "individual advocacy" subdomain of the ARBI largely drove the change in ARBI scores, suggestive of increased antiracism behavior in the enrolled cohort. Students provided feedback offering praise for course elements and suggestions for improvement. NEXT STEPS: Early findings suggest that this course, created with a co-design approach, generated new experiences for medical students, increased their understanding of systemic racism, and increased individual antiracist advocacy. Future work, with larger class sizes and longitudinal measurement of behavior change, should further investigate the transformative effects of applying co-design strategies to medical education courses about race and health.