Qualitative Assessment of Rapid System Transformation to Primary Care Video Visits at an Academic Medical Center.

BACKGROUND: The coronavirus disease 2019 pandemic spurred health systems across the world to quickly shift from in-person visits to safer video visits. OBJECTIVE: To seek stakeholder perspectives on video visits' acceptability and effect 3 weeks after near-total transition to video visits. DESIGN: Semistructured qualitative interviews. SETTING: 6 Stanford general primary care and express care clinics at 6 northern California sites, with 81 providers, 123 staff, and 97 614 patient visits in 2019. PARTICIPANTS: 53 program participants (overlapping roles as medical providers [n = 20], medical assistants [n = 16], nurses [n = 4], technologists [n = 4], and administrators [n = 13]) were interviewed about video visit transition and challenges. INTERVENTION: In 3 weeks, express care and primary care video visits increased from less than 10% to greater than 80% and from less than 10% to greater than 75%, respectively. New video visit providers received video visit training and care quality feedback. New system workflows were created to accommodate the new visit method. MEASUREMENTS: 9 faculty, trained in qualitative research methods, conducted 53 stakeholder interviews in 4 days using purposeful (administrators and technologists) and convenience (medical assistant, nurses, and providers) sampling. A rapid qualitative analytic approach for thematic analysis was used. RESULTS: The analysis revealed 12 themes, including Pandemic as Catalyst; Joy in Medicine; Safety in Medicine; Slipping Through the Cracks; My Role, Redefined; and The New Normal. Themes were analyzed using the RE-AIM (reach, effectiveness, adoption, implementation, and maintenance) framework to identify critical issues for continued program utilization. LIMITATIONS: Evaluation was done immediately after deployment. Although viewpoints may have evolved later, immediate evaluation allowed for prompt program changes and identified broader issues to address for program sustainability. CONCLUSION: After pandemic-related systems transformation at Stanford, critical issues to sustain video visit long-term viability were identified. Specifically, technology ease of use must improve and support multiparty videoconferencing. Providers should be able to care for their patients, regardless of geography. Providers need decision-making support with virtual examination training and home-based patient diagnostics. Finally, ongoing video visit reimbursement should be commensurate with value to the patients' health and well-being. PRIMARY FUNDING SOURCE: Stanford Department of Medicine and Stanford Health Care.

Frequency of and risk factors for poor cognitive performance in hemodialysis patients.

OBJECTIVE: There are few detailed data on cognition in patients undergoing dialysis. We evaluated the frequency of and risk factors for poor cognitive performance using detailed neurocognitive testing. METHODS: In this cross-sectional cohort study, 314 hemodialysis patients from 6 Boston-area hemodialysis units underwent detailed cognitive assessment. The neuropsychological battery assessed a broad range of functions, with established age-, sex-, and education-matched normative scores. Principal component analysis was used to derive composite scores for memory and executive function domains. Risk factors for each domain were evaluated using linear regression adjusting for age, sex, race, and education status. Analyses were repeated in those with Mini-Mental State Examination (MMSE) score ≥ 24. RESULTS: Compared with population norms, patients on dialysis had significantly poorer executive function but not memory performance, a finding that persisted in the subgroup with MMSE score ≥ 24. In adjusted analyses, vascular risk factors and vascular disease were associated with lower executive function (p < 0.01). CONCLUSIONS: There is a high frequency of poor cognitive performance in hemodialysis patients, primarily affecting executive function. Risk factors for worse executive function include vascular risk factors as well as vascular disease. Normal performance on the MMSE does not preclude impaired cognitive function, because individuals with MMSE score ≥ 24 also have a high frequency of poor cognitive performance.

Association of sleep disturbances with cognitive impairment and depression in maintenance hemodialysis patients.

BACKGROUND: There are few data on the relationship of sleep with measures of cognitive function and symptoms of depression in dialysis patients. METHODS: We evaluated the relationship of sleep with cognitive function and symptoms of depression in 168 hemodialysis patients, using multivariable linear and logistic regression. Sleep disturbances were assessed using the sleep subscale battery of the Choices for Healthy Outcomes in Caring for ESRD (CHOICE) Health Experience Questionnaire. The cognitive battery assessed a broad range of functioning including global ability, verbal intelligence, supraspan learning, auditory retention, visual retention, attention/mental processing speed, visual construction/fluid reasoning and motor speed. Depressive symptoms were assessed using the Center for Epidemiological Studies of Depression (CESD) Scale, with depression indicated by a CESD score >16. RESULTS: Mean (SD) age of participants was 62 (17) years, 49% were women, 30% were African American and 33% had diabetes. There was no significant relationship between sleep score and performance on any neurocognitive test (p>0.13, for all multivariable analyses). The prevalence of depression increased from 16% in the highest quartile (best) of sleep score, to 31% in the lowest quartile (worst) of sleep score. In multivariable analyses, each 1 SD increase in sleep score was associated with a 2.18 (95% confidence interval, 1.07-3.29, p<0.001) lower CESD score. Results were consistent when considering individual components of both the CESD and sleep score. CONCLUSIONS: Disturbances in sleep are associated with symptoms of depression but not measures of cognitive function. Dialysis patients with disturbances in sleep should be screened for depression.

Measures of blood pressure and cognition in dialysis patients.

There are few reports on the relationship of blood pressure with cognitive function in maintenance dialysis patients. The Cognition and Dialysis Study is an ongoing investigation of cognitive function and its risk factors in six Boston area hemodialysis units. In this analysis, we evaluated the relationship between different domains of cognitive function with systolic and diastolic blood pressure, pulse pressure, and intradialytic changes in systolic blood pressure, using univariate and multivariable linear regression models adjusted for age, sex, race, education, and primary cause of end-stage renal disease. Among 314 participants, mean age was 63 years; 47% were female, 22% were African American, and 48% had diabetes. The mean (SD) of systolic blood pressure, diastolic blood pressure, pulse pressure, and intradialytic change in systolic blood pressure were 141 (21), 73 (12), 68 (15), and -10 (24) mmHg, respectively. In univariate analyses, the performance on cognitive tests primarily assessing executive function and processing speeds was worse among participants with lower diastolic blood pressure and higher pulse pressure. These relationships were not statistically significant, however, in multivariable analyses. There was no association between cognitive function and systolic blood pressure or intradialytic change in systolic blood pressure in either univariate or multivariable analyses. We found no association between different measures of blood pressure and cognitive function in cross-sectional analysis. Longitudinal studies are needed to confirm these results.

The kidney disease quality of life cognitive function subscale and cognitive performance in maintenance hemodialysis patients.

BACKGROUND: Cognitive impairment is common but often undiagnosed in patients with end-stage renal disease, in part reflecting limited validated and easily administered tools to assess cognitive function in dialysis patients. Accordingly, we assessed the utility of the Kidney Disease Quality of Life Cognitive Function (KDQOL-CF) scale in comparison to an extensive neuropsychological battery, building on a prior assessment of this potential cognitive screen. STUDY DESIGN: Cross-sectional cohort. SETTING & PARTICIPANTS: Maintenance hemodialysis patients at 6 Boston area dialysis units were administered an extensive neurocognitive battery and the KDQOL-CF at the beginning of a hemodialysis session. PREDICTORS: KDQOL-CF score, depression symptom burden, and demographic and clinical characteristics. OUTCOMES: Neurocognitive performance classified into executive function and memory domains, determined using principal components analysis. MEASUREMENTS: Univariate and multivariable linear regression models adjusting for age, sex, race, and end-stage renal disease cause were used to evaluate the association between KDQOL-CF score and cognitive performance, and test metrics were determined for a KDQOL-CF cutoff score of 60 or less from a maximum score of 100. RESULTS: For 168 prevalent hemodialysis patients, KDQOL-CF score was 76 ± 19 and 40 (24%) had scores of 60 or less, consistent with self-identified worse cognitive performance. There was no significant correlation between KDQOL-CF score and either memory (P = 0.2 and P = 0.3) or executive function (P = 0.1 and P = 0.4) in univariate and multivariable models, respectively. There was a strong correlation between higher KDQOL-CF score and fewer depression symptoms (P < 0.001). Sensitivity of the KDQOL-CF was poor (range, 0.28-0.36), with modest specificity (range, 0.77-0.81) for identifying worse executive function and memory. LIMITATIONS: Cross-sectional study, modest population size, and abbreviated gold-standard cognitive battery. CONCLUSIONS: The KDQOL-CF is a poor determinant of neurocognitive performance in hemodialysis patients, with limited sensitivity. To assess cognitive impairment in hemodialysis patients, better screening tests are essential.

Cardiovascular disease and cognitive function in maintenance hemodialysis patients.

BACKGROUND: Cardiovascular disease (CVD) and cognitive impairment are common in dialysis patients. Given the proposed role of microvascular disease on cognitive function, particularly cognitive domains that incorporate executive functions, we hypothesized that prevalent systemic CVD would be associated with worse cognitive performance in hemodialysis patients. DESIGN: Cross-sectional cohort. SETTING & PARTICIPANTS: 200 maintenance hemodialysis patients without prior stroke from 5 Boston-area hemodialysis units. PREDICTOR: CVD, defined as history of coronary disease or peripheral vascular disease. OUTCOME: Performance on a detailed neurocognitive battery. Primary analyses quantified cognitive performance using principal components analysis to reduce cognitive tests to a processing speed/executive function domain and a memory domain. Multivariable linear regression models adjusted for age, sex, education, race, and other clinical and demographic characteristics. RESULTS: Mean age of participants was 62 ± 18 (standard deviation) years and 75 (38%) had CVD. Individuals with CVD were older and more likely to be men, have diabetes, and be current or former smokers. In adjusted models, individuals with CVD performed 0.50 standard deviation worse (P < 0.001) on tests assessing processing speed/executive function, whereas there was no difference in performance on tests of memory. Similar results were seen assessing individual tests, with performance on the Block Design, Digit Symbol Coding, and Trail Making Tests A and B significantly associated with CVD in age-, sex-, education-, and race-adjusted analyses and approaching significance in fully adjusted models. LIMITATIONS: CVD ascertainment dependent on patient recall and dialysis unit documentation. No brain imaging. CONCLUSIONS: The presence of CVD is associated with worse cognitive performance on tests of processing speed and executive functioning in hemodialysis patients and identifies a high-risk population for greater difficulty with complex tasks.

Cognitive function and dialysis adequacy: no clear relationship.

BACKGROUND/AIMS: Cognitive impairment is common in hemodialysis patients and may be impacted by multiple patient and treatment characteristics. The impact of dialysis dose on cognitive function remains uncertain, particularly in the current era of increased dialysis dose and flux. METHODS: We explored the cross-sectional relationship between dialysis adequacy and cognitive function in a cohort of maintenance hemodialysis patients. Adequacy was defined as the average of the 3 most proximate single pool Kt/V assessments. A detailed neurocognitive battery was administered during the 1st hour of dialysis. Multivariable linear regression models were adjusted for age, sex, education, race and other clinical and demographic characteristics. RESULTS: Among 273 patients who underwent cognitive testing, the mean (SD) age was 63 (17) years and the median dialysis duration was 13 months, 47% were woman, 22% were African American, and 48% had diabetes. The mean (SD) Kt/V was 1.51 (0.24). In univariate, parsimonious and multivariable models, there were no significant relationships between decreased cognitive function and lower Kt/V. CONCLUSION: In contrast to several older studies, there is no association between lower Kt/V and worse cognitive performance in the current era of increased dialysis dose. Future studies should address the longitudinal relationship between adequacy of dialysis and cognitive function to confirm these findings.

Depression and cognitive function in maintenance hemodialysis patients.

BACKGROUND: Both depression and cognitive impairment are common in hemodialysis patients, are associated with adverse clinical outcomes, and place an increased burden on health care resources. STUDY DESIGN: Cross-sectional cohort. SETTING & PARTICIPANTS: 241 maintenance hemodialysis patients in the Boston, MA, area. PREDICTOR: Depressive symptoms, defined as a Center for Epidemiological Studies Depression Scale (CES-D) score ≥16. OUTCOME: Performance on a detailed neurocognitive battery. RESULTS: Mean age was 63.8 years, 49.0% were women, 21.6% were African American, and median dialysis therapy duration was 13.8 months. There were 57 (23.7%) participants with significant depressive symptoms. In multivariable analysis adjusting for age, sex, education, and other comorbid conditions, participants with and without depressive symptoms performed similarly on the Mini-Mental State Examination (P = 0.4) and tests of memory. However, participants with greater depressive symptoms performed significantly worse on tests assessing processing speed, attention, and executive function, including Trail Making Test B (P = 0.02) and Digit-Symbol Coding (P = 0.01). Defining depression using a CES-D score ≥18 did not substantially change results. LIMITATIONS: Cross-sectional design, absence of brain imaging. CONCLUSIONS: Hemodialysis patients with a greater burden of depressive symptoms perform worse on tests of cognition related to processing speed and executive function. Further research is needed to assess the effects of treating depressive symptoms on cognitive performance in dialysis patients.