Alzheimer Disease Treatment Can Improve Population Health and Health Equity

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Alzheimer disease (AD) disproportionately affects older adults, women, racial and ethnic minority groups, and individual with lower socioeconomic and educational levels. Because these groups are more affected by AD, examining health equity outcomes of treatment is significant. Authors of a study published in JAMA Network Open analyzed how AD treatment benefits and costs might differ across different racial, ethnic, and socially vulnerable subgroups. Additionally, they assessed the potential of targeted policies that can help reduce disparities within health care.

According to the authors, this study was conducted from June 16, 2022, to January 11, 2024, and followed the Consolidated Health Economic Evaluation Reporting Standards. A conceptual equity pathway that depicted the stages of AD management in which inequalities are present in the need, receipt, and outcomes of AD treatment among equity-relevant subgroups. The pathway, according to the authors, reflects the differences in treatment need (eg, higher AD risk among Black, Hispanic, and socially marginalized groups) and treatment receipt. These groups are less likely to receive timely diagnoses with confirmed AD pathology which is necessary for amyloid-targeting therapy.

Additionally, the authors divided the enrolled US population into 25 subgroups based on race and ethnicity (eg, American Indian or Alaska Native, Asian or Pacific Islander, Hispanic, non-Hispanic Black, and non-Hispanic White) as well as social vulnerability. The authors also evaluated a hypothetical disease-modifying AD treatment and compared it with best supportive care. The approach, according to the investigators, allowed for the generalizability of insights across the landscape of AD therapies.

Patients’ transitions were tracked across 5 health states: mild cognitive impairment (MCI) due to AD, mild AD, moderate AD, severe AD, and death. Within each health state, patients could transition from a community setting to long-term care. Cycle lengths were 1 year, and costs were modeled over a lifetime time horizon from a modified societal perspective.

According to the findings, a total of 316,037,100 individuals were included in the analysis, of which 1,730,055 were assumed to receive treatment for AD. The cost-effectiveness analysis revealed there were minor differences in total incremental costs and quality-adjusted life-years (QALY) gains between subgroups, which were associated with variations both in age and AD stage at the time of treatment initiation.

Further, at the population level, treatment generated 222,468 QALYs and about $29.1 trillion in incremental costs. The authors found that applying an opportunity cost benchmark of $150 thousand per QALY, financing AD treatment could produce 194,271 foregone QALYs and have a net health benefit of 28,197 QALYs, with a reduction in health inequalities of 0.009%. In addition, if each subgroup were to sustain an equal share of the total opportunity costs, all non-Hispanic White subgroups—in addition to the 2 most vulnerable Black subgroups—would have a net health improvement; however, subgroups with higher levels of baseline health and those with lowest levels of baseline quality-adjusted life expectancy would have negative net health benefit from treatment. The authors observed an overall population-level net health benefit among groups that represent over two-thirds of the US population. In addition, among those aged 65 years and older, the net health benefit was positive among most subgroups.

Because these results could worsen the overall health of certain subgroups, the authors suggested that decision-makers should focus their efforts to combat existing health disparities present within AD so all subgroups may experience benefits from AD treatment. Analyses demonstrated that health system factors are significant in the potential equity impacts of AD treatment.

Further, the investigators also observed that through the proliferation of diagnostic advancements (eg, blood-based biomarkers), the population health impact of AD treatment could be nearly ten times higher than what was estimated in the base case analysis. These findings suggest that the impact of decisions to fund AD treatments could be strengthened by parallel efforts to expand dementia screening into routine clinical practice to better improve the timeliness of AD diagnosis among older adults.

Limitations of the study include additionally variability between the enrolled subgroups, the lack of clarity when accounting for culturally driven variability in assessing health equity, and the use of geographic-based social disadvantage has not yet been widely adopted within AD research. Additionally, the authors noted their uncertainty regarding the distribution of funding decisions and whether it would remain consistent across coverage determinations.

REFERENCE

Synnott PG, Majda T, Lin P, Ollendorf DA, Zhu Y, Kowal S. Modeling the Population Equity of Alzheimer Disease Treatments in the US. JAMA Netw Open. 2024;7(10):e2442353. doi:10.1001/jamanetworkopen.2024.42353