Engaging Primary Care Workers in Alzheimer’s Diagnosis Would Speed Treatment

WASHINGTON — Engaging the primary care workforce in the diagnosis process of Alzheimer’s disease would accelerate the delivery of disease-modifying therapies, while easing the pressures already being experienced by overwhelmed neurology and geriatric practices, a new Rand report says.

The analysis comes in the wake of the Food and Drug Administration’s approval last summer of lecanemab, which is marketed as Leqembi, for the treatment of Alzheimer’s disease.

The drug is the first disease-modifying therapy for Alzheimer’s disease ever approved by the agency, but more are on the horizon.

While the widespread availability of these therapies would be a breakthrough in slowing the progression of early stage Alzheimer’s disease to later stages of dementia, they would also dramatically increase the caseloads of neurology and geriatric practices that often already have wait lists for appointments.

The researchers at Rand set out to find a solution.

To do so, they used a simulation model to assess patient demand and provider supply for the delivery of disease-modifying therapies. 

They expanded on previous modeling in two ways: First, they included the capacity of primary care practitioners who perform brief cognitive assessments. Prior models focused only on the capacity of specialists and assumed that primary care practitioners were unconstrained.

The problem with that assumption is that  primary care practitioners serve an important role in early detection and may be a potential bottleneck as well as a potential resource in the diagnostic pathway.

For the purpose of this study, the researchers investigated the impact of changes in primary care practitioner capacity and patient uptake of brief cognitive assessments in primary care settings on the delivery of therapies.

Second, their model utilizes county-level data, taking into account the geographic variations in patient populations and health system capacities. This approach allowed them to capture local variation and provide a more accurate assessment of capacity constraints and wait times. 

Under the base case assumptions, the states with the longest wait times are Alaska, Arkansas, Idaho, Mississippi, Montana, Nevada, Oklahoma and Wyoming.

Primary care models and telehealth models could help improve access to care in these areas, the researchers said.

Key findings of the report include:

• There is substantial variation in health care system capacity across the United States to detect, diagnose and treat early stage AD with DMTs.
• The estimated wait times and the number of patients treated are sensitive to patient uptake of brief cognitive assessments.
• Estimated average wait times vary by state and can be three times longer in rural areas than in urban areas.
• Care models that enable PCPs to diagnose and evaluate patients for treatment eligibility would make the biggest impact on reducing wait times for specialists and increasing the number of people treated from 2025 through 2044 in the analysis. Improved triage of patients using blood-based biomarker tests could further reduce caseloads for specialists.
• Widespread delivery of AD-modifying therapies will require a combination of strategies to communicate the value of detection and treatment to patients, integrate PCPs into the detection and diagnosis pathway, and address capacity disparities across the United States.

Further work is needed to evaluate how primary care-led models of care can widely and effectively evaluate and manage treatment for people with early stage AD, as well as how technological advancements, such as improved biomarkers and computerized testing, can be integrated into workflows.

Alzheimer’s disease is an irreversible, progressive brain disorder affecting more than 6.5 million Americans that slowly destroys memory and thinking skills and, eventually, the ability to carry out simple tasks. 

While the specific causes of Alzheimer’s are not fully known, it is characterized by changes in the brain — including amyloid beta plaques and neurofibrillary, or tau, tangles — that result in loss of neurons and their connections. These changes affect a person’s ability to remember and think.

Dan can be reached at [email protected] and @DanMcCue