More than 5.7 million Americans are living with Alzheimer's disease and related dementias (AD/ADRD); this number is expected to double by 2030 and triple by 2050. Racial and ethnic minorities disproportionality suffer. Minority Persons With Dementia (PWD), particularly community-dwelling, lack high quality continuous primary care and have poor outcomes such as high rates of hospitalizations and emergency department (ED) use. Policymakers caution that health disparities will widen as we face a shortage of primary care physicians. Nurse practitioners (NPs), the fastest growing primary care workforce, could mitigate these challenges. NPs disproportionality deliver care to minorities and practice in underserved areas where many minorities live. Yet little is known about how to optimize primary care practices employing NPs, which often lack the organizational and structural attributes needed to ensure continuity of care and better outcomes for minority PWD. Little is also known about how to enhance community resources to eliminate health disparities for PWD. Our mixed- method national study will fill this gap. We will achieve three specific aims:
Aim 1. Assess the effect of NP practice attributes (i.e., care environment and structural capabilities) on racial and ethnic disparities in ED visits and hospitalizations among PWD and the extent to which the effect is mediated by continuity of care.
Aim 2. Assess the effect of community socioeconomic factors and primary care availability on disparities in ED visits and hospitalizations among PWD.
Aim 3. Identify practice and community barriers and facilitators of caring for PWD in high- and low-performing NP practices. We will use data on community-dwelling Medicare beneficiary PWD cared for by NPs in 2017-2018 and will collect survey data from NPs (n= 4,414) about care environments and structural capabilities using both mail and online survey methods. All data about patients, NPs, practices, and communities will be merged and analyzed in multilevel models. We will also identify practices with low rates of hospitalizations and ED visits (i.e., high-performing practices) and high rates for hospitalizations and ED visits (i.e., low-performing practices) among PWD and collect qualitative interview data from NPs using a positive deviance approach. We will conduct individual telephone or online interviews with ~40 NPs from high- performing and ~20 NPs from low-performing practices. Interviews will be recorded and transcribed. Data will undergo content analysis. Quantitative and qualitative findings will be triangulated to inform administrators and policymakers seeking ways to reduce racial and ethnic disparities in acute care use among PWD through practice, policy, and community interventions. We will identify modifiable factors of high-performing practices that could be introduced in low-performing practices to enhance care to PWD and practices and communities that can most benefit from such interventions and future investments. This innovative study has the potential to make clinical and policy contributions by promoting continuous primary care to millions of minority community- dwelling PWD and is in response to High-Priority Research Topic NOT-AG-18-056 and NOT-MD-19-016.
Eliminating racial and ethnic disparities in costly acute care utilization among Persons With Dementia (PWD) is a national priority. By studying these patients' communities and primary care practices where they receive care from nurse practitioners in a large national study, we will produce evidence to help design future systems and community interventions to ensure optimal care for minority elderly PWD.
