Exposure to clinical decision support and training increases primary care clinician confidence in managing cognitive impairment care but not confidence to diagnose

JaKa et al. BMC Primary Care (2025) 26:360 https://doi.org/10.1186/s12875-025-03053-z BMC Primary Care Open Access RESEARCH Exposure to clinical decision support and training increases primary care clinician confidence in managing cognitive impairment care but not confidence to diagnose Meghan M. JaKa1*, Rebecca C. Rossom2, Bethany Crouse2, A Lauren Crain2, Sally K. Gustafson2, Heidi L. Ekstrom2, Laura J. Zibley1, Soo Borson3, Patrick J. O’Connor2, Ann M. Werner2, Deepa Appana2, Thomas L. von Sternberg4 and Leah R. Hanson2 Abstract Background Cognitive impairment (CI) is projected to significantly increase as the population ages. While primary care clinicians are often the first point of contact for patients with cognitive decline, many clinicians report significant barriers to addressing CI in primary care, including lack of time, lack of established workflow, and low confidence in diagnosing and managing CI. Methods To address these barriers, a CI clinician decision support system (CI-CDSS) was developed and is being tested in a cluster randomized, controlled clinical trial in 38 primary care clinics. A secondary aim of the study was to assess whether the CI-CDSS increased clinician confidence in CI diagnosis and management, as measured by surveys administered before and 8-months after CI-CDSS implementation. Primary outcome results of CI diagnosis are awaiting the end of the follow-up period; however, clinician surveys are complete and reported here. The odds ratio (OR) for the interaction between survey time and study arm, estimated in a generalized linear mixed model, tested the significance of change in clinician confidence across study arms. The average marginal effect (AME), estimated in a generalized estimating equation, provided a treatment effect estimate. Results While self-reported use of the CI-CDSS was modest (32% remembered the tool and 65% of those used it), those who used it reported high satisfaction (97% said the tool helped provide better CI care). Clinicians in CI-CDSS clinics reported increased confidence in managing CI care relative to usual care (UC) clinicians (AME = 16.8, OR = 2.24 [1.05, 4.80]). Trending, but not significant, increases in clinician confidence in diagnosing CI were observed in CI-CDSS clinics when compared to usual care (e.g., distinguishing types of dementia AME = 9.8, OR = 2.08[0.84, 5.14]). Conclusions The results of this study demonstrate the potential value of a CI-CDSS in promoting primary care clinician confidence in caring for and diagnosing patients with CI. Trial registration This trial is registered on clinicaltrials.gov, NCT05723523 on 02/02/2023. *Correspondence: Meghan M. JaKa Full list of author information is available at the end of the article © The Author(s) 2025. 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To view a copy of this licence, visit http://creati vecommons.org/licenses/by-nc-nd/4.0/. JaKa et al. BMC Primary Care (2025) 26:360 Page 2 of 9 Keywords Dementia, Cognitive impairment, Screening, detection, and diagnosis, Primary care, Healthy aging, Clinical decision support Background As the U.S. population ages, the prevalence of cognitive impairment (CI) is projected to continue increasing, posing significant challenges for primary care clinicians [1, 2]. Among individuals 70 years old and older, 14% have dementia and another 14% have mild cognitive impairment [3]. Primary care clinicians are routinely tasked with diagnosing and managing care for CI due to their frequent role as the first and trusted point of contact for patients exhibiting symptoms of cognitive decline [4]. Similarly, detection of CI is a required part of the Medicare Annual Wellness Visit in the United States, a prevention-oriented visit that primarily occurs in primary care [5]. However, there are still many barriers preventing primary care clinicians from implementing systematic processes for detection, diagnosis, and post-diagnosis management of individuals with CI. These include persistent reports of low confidence in CI diagnosis and management among primary care clinicians [6–9]. Clinician confidence is an important and necessary mechanism of increasing clinician diagnosis and treatment of clinical conditions, although notably not the only factor impacting these behaviors [10, 11]. Confidence is also highly interconnected with other mechanisms of clinical action like skills and ability, fear of negative consequences, and patient characteristics [12, 13]. One result of lack of clinician confidence is that both patients and families feel less support and more uncertainty about their situations. CI carries with it emotional stress about its implication and future prognosis [14]. Primary care clinicians also frequently cite system barriers as major obstacles to providing effective CI care, including insufficient time and lack of available resources [7], compounded by existing electronic health records systems (EHRs) that lack appropriate support for diagnosing and managing care for CI [15]. The complexity of this care, including the need for a nuanced approach to diagnosis and the involvement of families in care planning, adds to the challenge. Clinical decision support systems (CDSS) paired with detection algorithms and targeted training have been proposed to address these issues [16, 17]. CDSS can enhance primary care clinicians’ confidence – one possible predictor of clinician actions – in some contexts, but not in others [18, 19]. For example, in a recent systematic review describing clinician-reported barriers and facilitators to CDSS implementation, improvement of clinician confidence was noted as a facilitator in 7 of 45 systems across various areas of primary care. In one study, a CDSS designed for pulmonary embolism diagnosis did not improve clinician confidence, but confidence was relatively high at baseline [20]. In cancer care, primary care clinician confidence in assessing cancer risk and managing care improved following CDSS access and training [21]. Our team has developed a CI-focused CDSS with an accompanying clinician training (...truncated)