Quality improvement in neurology: Parkinson disease update quality measurement set: Executive summary

Lewy Body Dementias

PURPOSE OF REVIEW

This article describes current diagnostic criteria relating to the diagnosis of Lewy body dementia, highlights diagnostic controversies, and reviews treatment approaches.

RECENT FINDINGS

Clinical diagnostic criteria for both Parkinson disease and dementia with Lewy bodies have been recently updated. These criteria result in overlap between individuals diagnosed with Parkinson disease and those with dementia with Lewy bodies. Although clinical features and symptomatic treatment overlap, differences remain in epidemiology and expected progression. The high prevalence of cognitive impairment in Parkinson disease supports regular screening for cognitive changes and counseling patients and families regarding what to expect. Treatment for Lewy body dementia involves avoiding medications that may cause or exacerbate symptoms; prescribing pharmacologic agents to address bothersome cognitive, behavioral, movement, and other nonmotor symptoms; recommending physical exercise and therapy; and providing education, counseling, caregiver support, and palliative care.

SUMMARY

Lewy body dementia includes both dementia with Lewy bodies and Parkinson disease dementia, overlapping clinicopathologic entities with differences relating to diagnosis and expected progression. Treatment is symptomatic and thus largely overlapping for the two conditions.

Recommendations for the Organization of Multidisciplinary Clinical Care Teams in Parkinson's Disease

BACKGROUND

Optimal management in expert centers for Parkinson's disease (PD) usually involves pharmacological and non-pharmacological interventions, delivered by a multidisciplinary approach. However, there is no guideline specifying how this model should be organized. Consequently, the nature of multidisciplinary care varies widely.

OBJECTIVE

To optimize care delivery, we aimed to provide recommendations for the organization of multidisciplinary care in PD.

METHODS

Twenty expert centers in the field of multidisciplinary PD care participated. Their leading neurologists completed a survey covering eight themes: elements for optimal multidisciplinary care; team members; role of patients and care partners; team coordination; team meetings; inpatient versus outpatient care; telehealth; and challenges towards multidisciplinary care. During a consensus meeting, outcomes were incorporated into concept recommendations that were reviewed by each center's multidisciplinary team. Three patient organizations rated the recommendations according to patient priorities. Based on this feedback, a final set of recommendations (essential elements for delivery of multidisciplinary care) and considerations (desirable elements) was developed.

RESULTS

We developed 30 recommendations and 10 considerations. The patient organizations rated the following recommendations as most important: care is organized in a patient-centered way; every newly diagnosed patient has access to a core multidisciplinary team; and each team has a coordinator. A checklist was created to further facilitate its implementation.

CONCLUSION

We provide a practical tool to improve multidisciplinary care for persons with PD at the organizational level. Future studies should focus on implementing these recommendations in clinical practice, evaluating their potential applicability and effectiveness, and comparing alternative models of PD care.

Using Implementation Frameworks to Provide Proactive Physical Therapy for People With Parkinson Disease: Case Report

BACKGROUND AND PURPOSE

European clinical practice guidelines recommend physical therapy for people with Parkinson disease (PD) soon after diagnosis to provide education, physical activity advice, and individualized interventions when needed. However, therapy is frequently not used until after gait and balance problems occur. The purpose of this administrative case study is to present the application of a proactive physical therapy (PAPT) approach at 1 rehabilitation center using implementation frameworks to support the (1) implementation process, (2) determinants of implementation success, and (3) implementation evaluation.

CASE DESCRIPTION

The PAPT program targeted people with PD before the onset of significant mobility dysfunction. It was initiated in 1 outpatient neurological rehabilitation center. The program used shared decision-making to promote long-term maintenance of independent exercise. The Knowledge-to-Action Framework was used by champions to plan implementation processes. Implementation barriers were addressed using the Consolidated Framework for Implementation Research. The program was evaluated using the RE-AIM (Reach, Effectiveness, Adoption, Implementation, Maintenance) framework with mixed methods.

OUTCOMES

In the program's first year, 38 people were referred, 28 were evaluated, and 20 participated in the 6-month program evaluation. Following PAPT, the number of participants reporting regular participation in aerobic, strengthening, and flexibility exercise approximately doubled, while those engaging in balance activities increased from 1 to 8. They reported a median of 140 minutes of aerobic exercise per week. Implementation barriers included location, insurance coverage, and difficulty scheduling long-term follow-up visits. Participants reported physical and emotional benefits of the program.

DISCUSSION

Implementation frameworks assisted with the implementation and evaluation of a PAPT delivery model that helped people with PD to increase and maintain independent exercise participation.

Advance care planning in Parkinson's disease: ethical challenges and future directions

Recent discoveries support the principle that palliative care may improve the quality of life of patients with Parkinson's disease and those who care for them. Advance care planning, a component of palliative care, provides a vehicle through which patients, families, and clinicians can collaborate to identify values, goals, and preferences early, as well as throughout the disease trajectory, to facilitate care concordant with patient wishes. While research on this topic is abundant in other life-limiting disorders, particularly in oncology, there is a paucity of data in Parkinson's disease and related neurological disorders. We review and critically evaluate current practices on advance care planning through the analyses of three bioethical challenges pertinent to Parkinson's disease and propose recommendations for each.

Physical Activity in Early Parkinson Disease

Background:

Physical activity and exercise improve outcomes in Parkinson disease (PD), however little is known about activity levels in early PD patients.

Objective and Methods:

We examined self-reported activity scores and examined associations with clinical characteristics in 383 PD subjects and 175 healthy controls from the Parkinson Progression Markers Initiative (PPMI).

Results:

Activity scores were 8% lower for PD subjects than HC (162.6±86.2 vs 175.0±78.5, p = 0.10). Higher scores were associated with younger age and male sex. Only 47% of PD subjects and 44% of HC reported activity consistent with standard recommendations for adults.

Conclusions:

Our findings highlight the need to encourage exercise even in early PD.

Assessment of Parkinson disease quality measures on 12-month patient outcomes

Background

Quality measures (QMs) exist to operationalize guidelines by measuring adherence to guidelines through documentation, ultimately leading to improved patient outcomes. Studies are rare looking at the relationship between adherence to Parkinson disease (PD) QMs and patient outcomes.

Methods

We assessed adherence of our movement disorders specialists (MDSs) to the American Academy of Neurology's 2010 PD QM set through chart review using the measure set work group's criteria of documentation. We then evaluated patient outcomes to see whether there was a correlation with adherence to these QMs.

Results

Ninety-seven consecutive patients met the inclusion criteria. The mean disease duration was 9.3 (5.8) years. All patients were assessed by 1 of 4 MDSs. A total of 68% of QMs were documented across all patients. There was a small positive correlation between the number of documented QMs the year before the index visit and the number of calls/emails both the year before and after the index visit (r = 0.20, p = 0.04 and r = 0.26, p = 0.01, respectively.) There was a small negative correlation between the number of documented QMs and the number of PD follow-up visits the year after the index visit (r = -0.19, p = 0.05.) No other outcome showed a statistically significant correlation with the adherence to documented QMs.

Conclusions

We found no clinically important improvement in patient outcomes with higher adherence levels. It is important that QM developers validate QMs to ensure that they fulfill the intended goal of improved patient outcomes.

Framing advance care planning in Parkinson disease: Patient and care partner perspectives

OBJECTIVE

Advance care planning (ACP) is a core quality measure in caring for individuals with Parkinson disease (PD) and there are no best practice standards for how to incorporate ACP into PD care. This study describes patient and care partner perspectives on ACP to inform a patient- and care partner-centered framework for clinical care.

METHODS

This is a qualitative descriptive study of 30 patients with PD and 30 care partners within a multisite, randomized clinical trial of neuropalliative care compared to standard care. Participants were individually interviewed about perspectives on ACP, including prior and current experiences, barriers to ACP, and suggestions for integration into care. Interviews were analyzed using theme analysis to identify key themes.

RESULTS

Four themes illustrate how patients and care partners perceive ACP as part of clinical care: (1) personal definitions of ACP vary in the context of PD; (2) patient, relationship, and health care system barriers exist to engaging in ACP; (3) care partners play an active role in ACP; (4) a palliative care approach positively influences ACP. Taken together, the themes support clinician initiation of ACP discussions and interdisciplinary approaches to help patients and care partners overcome barriers to ACP.

CONCLUSIONS

ACP in PD may be influenced by patient and care partner perceptions and misperceptions, symptoms of PD (e.g., apathy, cognitive dysfunction, disease severity), and models of clinical care. Optimal engagement of patients with PD and care partners in ACP should proactively address misperceptions of ACP and utilize clinic teams and workflow routines to incorporate ACP into regular care.

Does outpatient palliative care improve patient-centered outcomes in Parkinson's disease: Rationale, design, and implementation of a pragmatic comparative effectiveness trial

Patients with Parkinson's disease and related disorders (PDRD) and their families have considerable unmet needs including non-motor symptom management, caregiver support, spiritual wellbeing, advance care planning, and end-of-life care. There is increasing interest in applying palliative care (PC) models to better meet these needs. While PC has been shown to improve care and quality of life (QOL) for people with cancer and heart failure, few studies have evaluated the role of PC for people with PDRD. Well-designed clinical trials are needed to optimize the PC approach for PDRD and to influence policy and implementation efforts. We initiated a randomized multicenter comparative effectiveness trial of team-based outpatient PC versus usual care for people with PDRD and their caregivers. The primary aims of this study are to determine the effects of PC on patient QOL and caregiver burden. Qualitative interviews will be utilized to gain additional insights into the impact of PC on participants, the outcomes that matter most to this population, and to find opportunities to refine future interventions and trials. As a novel application of PC, challenges involved in the design of this study include choosing appropriate inclusion criteria, standardizing the intervention, defining usual care, and choosing outcome measures suitable to our research questions. Challenges involved in implementation include participant recruitment, retention, and management of participant burden. We anticipate the results of this trial will have relevance for both clinical care and future clinical research trial design in evaluating models of PC for people with PDRD and other serious illnesses.

Development of evidence-based quality indicators for deep brain stimulation in patients with Parkinson's disease and first year experience of implementation of a nation-wide registry

INTRODUCTION

Deep Brain Stimulation (DBS) is a complex, invasive and cost-intensive therapy that requires a high level of expertise. To date, data on quality of DBS in clinical routine in the German health care system are lacking.

METHODS

The development of evidence-based QIs for DBS in PD patients was performed following a standardized process by a multidisciplinary board between 2014 and 2016. The process was initiated by the German Parkinson Society and followed international recommendations for developing QIs including: a systematic literature search; an appraisal of the published evidence; a consensus-based selection of the QI set; and a pilot study to assess the feasibility in implementing the QIs in clinical routine.

RESULTS

A set of 28 QIs for determining the quality of DBS in PD was established by the board covering different dimensions of health care quality (structure, process, and outcome) in different treatment phases of DBS care (pre-operative, peri-operative, and post-operative). Implementation in clinical practice was tested in a pilot study comprising three hospitals delivering DBS care. The feasibility of the QI set was evaluated positively by the participating physicians and hospitals. Mean time to document one patient was 25 min. The German-wide implementation of the defined indicator set within a dedicated quality registry (QualiPa) started in June 2016.

CONCLUSION

QIs are a necessary requirement to monitor hospital performance in DBS care. The evidence-based approach to develop the proposed indicator set is expected to assure transparency, acceptance and long-term applicability of the QI set in Germany.

VMAT2 Inhibitors in Neuropsychiatric Disorders

The basal ganglia and dopaminergic pathways play a central role in hyperkinetic movement disorders. Vesicular monoamine transporter 2 (VMAT2) inhibitors, which deplete dopamine at presynaptic striatal nerve terminals, are a class of drugs that have long been used to treat hyperkinetic movement disorders, but have recently gained more attention following their development for specific indications in the United States. At present, there are three commercially available VMAT2 inhibitors: tetrabenazine, deutetrabenazine, and valbenazine. Pharmacokinetics, metabolism, and dosing vary significantly between the three drugs, and likely underlie the more favorable side effect profile of the newer agents (deutetrabenazine and valbenazine). Tetrabenazine and deutetrabenazine have demonstrated safety and efficacy in the treatment of chorea associated with Huntington's disease, including in randomized controlled trials, although direct comparison studies are limited. Both deutetrabenazine and valbenazine have demonstrated safety and efficacy in the treatment of tardive dyskinesia, with multiple double-blind, placebo-controlled trials, whereas tetrabenazine has been studied less rigorously. There have been no blinded, prospective trials with tetrabenazine in Tourette's syndrome (TS); however, double-blind, placebo-controlled trials in TS are ongoing for both deutetrabenazine and valbenazine. Given the favored side effect profile of newer VMAT2 inhibitors, clinicians should be aware of the distinctions between agents and become familiar with differences in their use, especially as there is potential for their utilization to increase across the range of hyperkinetic movement disorders.

Understanding physical activity in Veterans with Parkinson disease: A mixed-methods approach

INTRODUCTION

Physical activity is critical in Parkinson disease (PD) management, but barriers and motivators of activity in Veterans with PD may be unique. We examined activity habits, including barriers and motivators, in this population.

METHODS

Participants completed the Physical Activity Scale in the Elderly (PASE). Compliance with American Heart Association (AHA) recommendations was assessed. Veterans also completed the Exercise Perceptions Questionnaire (EPQ), assessing knowledge, barriers, and motivators of activity. Free-text barriers/motivators were analyzed by the overlapping clusters method.

RESULTS

Seventy-five Veterans were recruited; mean age (standard deviation [SD]) was 70.5 (8.2) years and mean disease duration (SD) was 5.4 (5.2) years. Raw median PASE was 120.4 (interquartile range [IQR] 68.8-165.7); age-adjusted median PASE was 135.3. Only 9 Veterans (14.3%) were AHA-compliant. There were trends toward negative association between PASE and UPDRS-3 (r = -0.24, p = 0.06) and between PASE and PDQ-8 (r = -0.23, p = 0.08). Sixty-three subjects (84%) completed the EPQ; 27 (42.9%) preferred scheduled exercise, and only 33 (53.2%) reported that they preferred to exercise with others. Common themes of 46 free-text responses included desire to improve PD symptoms (n = 15, 32.6%) and social engagement (n = 12, 26.1%).

CONCLUSIONS

Self-reported activity in Veterans with PD is low, with less than 15% of subjects meeting recommended activity targets. Qualitative analysis of barriers and motivators revealed that although many Veterans enjoy the social aspects of group exercise, they may not feel comfortable in general exercise classes aimed at younger participants without chronic illnesses. These data will be useful in designing Veteran- and/or PD-specific interventions to increase activity levels.

Neuropalliative care: Priorities to move the field forward

Neuropalliative care is an emerging subspecialty in neurology and palliative care. On April 26, 2017, we convened a Neuropalliative Care Summit with national and international experts in the field to develop a clinical, educational, and research agenda to move the field forward. Clinical priorities included the need to develop and implement effective models to integrate palliative care into neurology and to develop and implement informative quality measures to evaluate and compare palliative approaches. Educational priorities included the need to improve the messaging of palliative care and to create standards for palliative care education for neurologists and neurology education for palliative specialists. Research priorities included the need to improve the evidence base across the entire research spectrum from early-stage interventional research to implementation science. Highest priority areas include focusing on outcomes important to patients and families, developing serious conversation triggers, and developing novel approaches to patient and family engagement, including improvements to decision quality. As we continue to make remarkable advances in the prevention, diagnosis, and treatment of neurologic illness, neurologists will face an increasing need to guide and support patients and families through complex choices involving immense uncertainty and intensely important outcomes of mind and body. This article outlines opportunities to improve the quality of care for all patients with neurologic illness and their families through a broad range of clinical, educational, and investigative efforts that include complex symptom management, communication skills, and models of care.

A Mixed-Methods Approach to Understanding the Palliative Needs of Parkinson’s Patients

Parkinson’s disease (PD) is the second-most common age-related neurodegenerative disorder. Despite recommendations for a palliative approach, little is known about what palliative needs are unmet by standard care. This study aims to (a) identify palliative needs of PD patients, (b) determine the relationship between palliative needs and health-related quality of life (HRQoL), and (c) probe into factors affecting HRQoL. PD patients and neurologists were recruited for a survey on palliative need; a subset of patients was interviewed. Significant differences between physicians and patients were found in Physical, Psychological, Social, Financial, and Spiritual domains. Physical and Psychological needs predicted HRQoL. Primary themes across interviews included (a) lack of healthcare education and (b) need for care coordination. Secondary themes included (a) the importance of support groups, (b) the role of spirituality/religion, and (c) the narrow perceived role of the neurologist. Findings highlight the importance of coordinated individualized care.

Neurologic provider views on patient-reported outcomes including depression screening

Background

We sought to assess neurologic provider satisfaction with the systematic electronic collection of patient-reported outcome measures (PROMs) for both disease-specific measures and depression screening (Patient Health Questionnaire [PHQ-9]).

Methods

A web-based survey was sent to 299 staff physicians and advanced practice providers on the staff email list of a large group neurologic practice, of whom 206 used the PROM system. The survey consisted of 11 questions with Likert response options regarding perceived usefulness of PROM collection; usefulness of PROM data for clinical care, quality, and research activities according to provider age group and type; and perceived usefulness between disease-specific information and the PHQ-9 depression screen.

Results

Of those who use the PROM system, 73.3% (151/206) responded. PROM collection was useful for patient care (strongly agree or agree 59.6%), research (strongly agree or agree 68.5%), and to a lesser extent, quality improvement (strongly agree or agree 48.6%). Providers aged 66-75 years believed PROM data were less useful for research (p < 0.01). PROM collection affected patient interactions or clinical management (always or usually 34.6% for disease-specific information and 31.3% for the PHQ-9). Responses were similar concerning perceived clinical usefulness (strongly agree or agree 67.3%) for center-selected disease-specific PROMs and the mandated PHQ-9 (69.8%).

Conclusions

Providers favorably viewed systematic electronic collection of PROMs in neurologic patients. A mandated depression screening was perceived as favorably as center-selected disease-specific information and should be considered when implementing PROMs in neurologic practice.

Increased odds of bladder and bowel symptoms in early Parkinson's disease

AIMS

To compare the prevalence of urinary and bowel symptoms in a sample of adults with early Parkinson's disease (PD) and healthy controls (HC).

METHODS

Data were obtained from the Michael J. Fox Parkinson's Progression Markers Initiative (PPMI). Prevalent bladder (urinary incontinence (UI) and nighttime voiding) and bowel (constipation and fecal incontinence (FI)) symptoms were defined as occurring at least sometimes when queried using the Scale for Outcomes in PD for Autonomic Symptoms.

RESULTS

The proportion of men (65% vs 64%) and the mean age (61.0 ± 9.7 vs 60.2 ± 11.2 years) was similar between early PD (n = 423) and HC (n = 195). UI and constipation were more prevalent among early PD versus HC (UI: 26.7% vs 8.2%, constipation: 32.4% vs 11.8%; P's < 0.0001). Prevalent nighttime voiding was high among both groups, but not significantly different (82.5% vs 84.1%, P = 0.62). FI was infrequent in both. The odds of UI and constipation were significantly higher in early PD even after adjustment for age, sex, cognition, and overactive bladder (UI model only), constipation (UI and constipation models only), depression, and anxiety medication usage (UI: OR: 4.39 [95% CI: 2.92, 5.87]; constipation: 3.34 [2.20, 4.42]; P's < 0.0001).

CONCLUSIONS

While constipation is known to precede PD diagnosis, these data suggest that the occurrence of UI is elevated in early PD compared to a well-matched HC population.

A Comprehensive Approach to Care in Parkinson's Disease Adds Quality to the Current Gold Standard

BACKGROUND

Providing high-quality care for patients with Parkinson's disease (PD) involves addressing both motor and nonmotor features. We describe the implementation and evaluation of a 2-day, interdisciplinary Comprehensive Care Clinic (CCC) for patients with PD.

METHODS

Patients who attended the CCC between January 2010 and July 2013 were matched by sex and age with patients who were evaluated in specialist care during the same time frame. Provider documentation of the American Academy of Neurology (AAN) quality measures for PD and Unified Parkinson's Disease Rating Scale (UPDRS) motor scores were compared between specialist and CCC visits at baseline and at 12 months.

RESULTS

Ninety-five patients participated in the CCC (60% men; 75% white; mean age, 68 years; age range, 38-97 years). Of these, 29 patients were matched to specialist care patients based on the availability of 12-month follow-up data. Both groups were similar with respect to race, marital status, years with PD, and baseline UPDRS motor scores. On average, patients who received CCC care met 10 of 10 AAN quality measures, whereas those who received specialist care met only 5 of 10 quality measures (P < 0.001) over 12 months. At 12-months, there were no significant differences in UPDRS motor scores between the groups (P = 0.5).

CONCLUSIONS

According to the AAN quality measures, the CCC provided higher quality care than the gold standard of specialty care. A randomized controlled trial of the CCC model is warranted to determine its impact on patient-centered outcomes and to assess whether the standard model of care should be altered.

Regular Exercise, Quality of Life, and Mobility in Parkinson's Disease: A Longitudinal Analysis of National Parkinson Foundation Quality Improvement Initiative Data

BACKGROUND

Research-based exercise interventions improve health-related quality of life (HRQL) and mobility in people with Parkinson's disease (PD).

OBJECTIVE

To examine whether exercise habits were associated with changes in HRQL and mobility over two years.

METHODS

We identified a cohort of National Parkinson Foundation Quality Improvement Initiative (NPF-QII) participants with three visits. HRQL and mobility were measured with the Parkinson's Disease Questionnaire (PDQ-39) and Timed Up and Go (TUG). We compared self-reported regular exercisers (≥2.5 hours/week) with people who did not exercise 2.5 hours/week. Then we quantified changes in HRQL and mobility associated with 30-minute increases in exercise, across PD severity, using mixed effects regression models.

RESULTS

Participants with three observational study visits (n = 3408) were younger, with milder PD, than participants with fewer visits. After 2 years, consistent exercisers and people who started to exercise regularly after their baseline visit had smaller declines in HRQL and mobility than non-exercisers (p < 0.05). Non-exercisers worsened by 1.37 points on the PDQ-39 and a 0.47 seconds on the TUG per year. Increasing exercise by 30 minutes/week was associated with slower declines in HRQL (-0.16 points) and mobility (-0.04 sec). The benefit of exercise on HRQL was greater in advanced PD (-0.41 points) than mild PD (-0.14 points; p < 0.02).

CONCLUSIONS

Consistently exercising and starting regular exercise after baseline were associated with small but significant positive effects on HRQL and mobility changes over two years. The greater association of exercise with HRQL in advanced PD supports improving encouragement and facilitation of exercise in advanced PD.