As more people in the U.S. seek treatment with the anti-amyloid antibody Leqembi, dementia clinics are becoming swamped, and wait times are lengthening (Jan 2024 news). Many clinicians believe that at least some aspects of diagnosis and treatment will have to transition to general neurology clinics and even to primary care—but how much would that help?
A January 30 report from Rand Health Care lays this out. Modeling potential demand for drugs, such as Leqembi, as well as existing healthcare capacity across the U.S., Jodi Liu and colleagues project that shifting the responsibility for Alzheimer’s diagnosis from memory clinics or AD research centers to primary care would ease the burden on dementia specialists sufficiently to halve wait times for treatment. Even so, they foresee waits of two years or more if everyone eligible seeks treatment.
“Our results suggest that engaging the primary-care workforce in the diagnostic process would be vital to accelerate the delivery of AD disease-modifying therapies, which will overwhelm neurology and geriatric practices that often already have wait lists for appointments,” the authors concluded.
Ballooning Wait Times. If treatment remains confined to specialty clinics, then by 2027 patients might have to wait more than four years for Leqembi. Lack of dementia specialists would cause most of the delay (gray); shortage of PET scanners would lead to additional waits of up to 10 months (orange). (Courtesy of Rand Health Care.)
How did Rand arrive at these numbers? Analysts counted the number of dementia specialists, PET scanners, and infusion centers in counties across the country, and used that data to calculate wait times under current conditions, where neurologists or geriatricians diagnose AD. They assumed moderate demand, where 20 percent of people over the age of 50 seek cognitive testing, and 5 percent of those end up taking a disease-modifying treatment. In this scenario, patients would soon be waiting an average of 37 months, or about three years, to start amyloid immunotherapy, the report projects. Most of this is due to the scarcity of dementia specialists, with the remainder caused by a shortage of PET scanners (see image above). Over the next 20 years, a total of 2.5 million Americans would receive the drug in this scenario.
However, if primary care specialists prescreened patients using cognitive tests and referred those testing positive to a specialist, the wait time would drop to 23 months, with a total of 3 million people getting the drug over the next 20 years. The use of blood-based biomarkers for screening would improve the situation even more, dropping the average wait time to 16 months and allowing 4 million people to be treated over the next two decades (see image below). Blood tests could soon become available in primary care (Jan 2024 news). Liu and colleagues did not model how using fluid biomarkers instead of PET for confirmatory screening would change the scenario.
The report also examined geographic differences. Unsurprisingly, because rural areas have few specialized clinics, people there would wait three times longer than those in cities. The states that fared worst due to limited access to specialists and more older people: Alaska, Arkansas, Idaho, Mississippi, Montana, Nevada, Oklahoma, and Wyoming. For them, the Rand report projected wait times of more than seven years under a specialist-only scenario. “Our analysis draws attention to states in which addressing capacity constraints would be most critical,” the report noted.
The Rand Corporation has put their simulator online so researchers can test how changing healthcare capacity would alter treatment scenarios. The report was funded by Genentech, which has an anti-tau antibody in Phase 2 in partnership with AC Immune.—Madolyn Bowman Rogers
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