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Research Question

  1. Should a disease-modifying therapy become available, how prepared is the Canadian health care system to treat people with early-stage AD?

Alzheimer's disease (AD) is a chronic neurodegenerative disorder that leads to cognitive and functional decline, dementia, and premature death. Similar to other aging societies, Canada faces an increasing burden of this disease on patients and their caregivers, as well as on health care and long-term care resources.

The majority of disease-modifying therapies being studied in current trials target early stages of the disease — when there are symptoms of memory loss and cognitive but not functional decline, also described as mild cognitive impairment (MCI) — or even earlier, before symptoms manifest. The aim of these therapies is to delay or prevent progression of early-stage AD to Alzheimer's dementia.

The possibility of a future AD–modifying therapy for early stages of the disease has significant implications for health care delivery systems in terms of diagnosing and treating a large population. Following the authors' earlier work in the United States and Europe, they draw on publicly available data and expert insights to refine a simulation model that quantifies the capacity of the Canadian health care system to diagnose and treat people with early-stage AD.

The report presents the authors' conceptual framework, simulation model, and projections. They discuss the design of the model and show historical and projected capacity trends that affect diagnosis and treatment and show the impact of capacity constraints on wait lists, waiting times, and the number of people progressing from MCI due to AD to Alzheimer's dementia.

Key Findings

  • Potential disease-modifying therapies could prevent or delay early-stage AD from progressing to dementia but raise challenges for health care systems in diagnosing and treating a large population.
  • The authors use a simulation model to assess the preparedness of the Canadian health care system infrastructure to diagnose and treat people with MCI due to AD if a future therapy becomes available.
  • If a therapy becomes available in 2021, the authors estimate that average annual wait times for diagnosis and treatment in Canada could peak at 28 months and persist for decades if there are not policies and practices to alleviate the burden on dementia specialists and increase capacity for biomarker testing and treatment delivery. Depending on policies, the authors estimate that 166,000 to 485,000 Canadians could progress from MCI due to AD to Alzheimer's dementia while on wait lists.
  • The most pressing constraint is the capacity of dementia specialists to evaluate and diagnose early-stage patients. The use of both neuroimaging and cerebrospinal fluid biomarkers for diagnostic testing could decrease wait times.
  • Canada faces the challenge of large geographic areas with sparse populations and limited access to specialty care, as well as potentially long lead times to add neuroimaging equipment to public facilities.
  • Expanding capacity would require coordinated efforts among multiple stakeholders to increase awareness and investment, and to implement policies that ensure adequate capacity to deliver a future Alzheimer's therapy.

Recommendations

  • The historical challenge of servicing remote areas has led to creative delivery models that use telemedicine and preceptorship approaches to enable primary care–led memory clinics; these models could serve as a blueprint to reduce wait times for specialty appointments in both rural areas and urban centers.
  • Given the long lead time for adding PET scanners in public facilities, two options to reduce wait times are to contract scans out to private facilities and to increase capacity for cerebrospinal fluid testing. A robust network of infusion clinics provides a solid base for expansion of infusion delivery services.
  • The expansion of capacity requires a concerted and coordinated effort of multiple stakeholders, given the need for increased awareness, capital investment, care model innovation, and changes to regulation and reimbursement.

Research conducted by

This research was sponsored by Biogen and conducted by the Access and Delivery Program within RAND Health Care.

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