Alzheimer's treatment roadblocks can be eased by engaging primary care providers in screenings

There is substantial geographic variation across the U.S. health care system to diagnose and treat early-stage Alzheimer's disease with disease-modifying therapies, and engaging primary care providers in the effort may be a key to accelerating delivery of emerging new treatments, according to a new RAND report.

Enabling primary care practitioners to diagnose and evaluate patients for treatment eligibility would make the biggest impact on reducing wait times for specialists and increase the number of people treated with disease-modifying therapies from 2025 through 2044.

While primary care providers are technically capable of performing cognitive assessments, most do not do them regularly because of time constraints with competing demands, according to the report. Creating new training for primary care providers, improving reimbursement rates, and developing guidelines to streamline workflows would all be key to making such a change.

Additionally, improved triage of patients using blood-based biomarker tests could further reduce caseloads for specialists, according to researchers.

The recommendations are part of a report that assesses the regional capability of the U.S. health care system to deliver disease-modifying therapies for Alzheimer's that have begun to be approved.

The report finds that the states with the longest expected wait times for diagnosis are Alaska, Arkansas, Idaho, Mississippi, Montana, Nevada, Oklahoma and Wyoming—largely the result of low levels of dementia specialists as compared to the number of residents aged 50 and older. Estimated average wait times can be three times longer in rural areas as compared with urban areas.

"System-level barriers may mean that people with early-stage Alzheimer's would not benefit from the therapies that could delay disease progression," said Jodi Liu, the report's lead author and a senior policy researcher at RAND, a nonprofit research organization. "Our analysis suggests that strategies are needed to ease the demand on specialists for evaluation and diagnosis of cognitive impairment."

An estimated 12.1 million people in the U.S. have mild cognitive impairment, which could be signs of Alzheimer's or other illnesses.

The widespread availability of effective disease-modifying therapies would be a breakthrough in slowing the progression of early-stage Alzheimer's disease but would create large challenges to the health care system to screen, diagnose, and treat patients.

Two disease-modifying Alzheimer's therapies have received approval from the U.S. Food and Drug Administration (one with traditional approval and one with accelerated approval), and more candidates are in late-stage clinical trials. But questions remain about how these therapies will be priced, covered by insurance, and delivered.

RAND researchers used a simulation model to assess patient demand and provider supply for the delivery of Alzheimer's disease-modifying therapies, expanding on earlier RAND work that looked at the preparedness of the health care system before any such therapies were in clinical use. The model assessed items such as the number of medical specialists, availability of PET scanners used to confirm a diagnosis of Alzheimer's, and the workforce needed to deliver the intravenous infusion treatments.

The new analysis includes an assessment of the capacity of primary care practitioners to perform brief cognitive assessments, analyzing the impact that patient use of those assessments in primary care settings would have on the delivery of therapies. Such a move would help curb the demand on neurology and geriatric practices, which often already have wait lists for appointments, from the expected surge in people seeking new treatments.

In addition, the new modeling uses county-level information to illustrate the geographic variations in patient populations and health care system capacities. Using this information, the research team created an interactive tool that allows users to vary patient demand and provider capacity assumptions and to view the county-level capacity for key resources such as medical specialists and PET scanners.

"Our estimates are not meant to predict exactly what treatment delivery will look like, but to provide feasible scenarios that can help inform where bottlenecks may occur and identify areas where attention may be needed to prepare the health care system." Liu said.

Researchers say that further work is still needed to evaluate how primary care-led models of care can widely and effectively evaluate and manage treatment for people with early-stage Alzheimer's. Other work should evaluate how technological advancements, such as improved biomarkers and computerized testing, can be integrated into workflows to better serve patients.

Reimbursement levels for disease-modifying therapies will have a critical influence on patient uptake of therapies and on provider decisions to allocate resources to detect, diagnose, and treat eligible patients.

"Widespread delivery of disease-modifying therapies for Alzheimer's will require a combination of strategies to communicate the value of detection and treatment to patients, integrate primary care providers into the detection and diagnosis system, and address geographic disparities in the health care system capacity across the nation," Liu said.