Assessing the Preparedness of the Health Care System Infrastructure in Six European Countries for an Alzheimer’s Treatment

The burden of Alzheimer’s dementia in industrialized countries is projected to approximately double between 2015 and 2050. Early-stage clinical trials of Alzheimer’s disease-modifying therapies have suggested that Alzheimer’s dementia must be prevented rather than cured, which means a large number of patients with early-stage Alzheimer’s disease would need to be screened, diagnosed, and then treated in order to prevent progression to dementia. We assess the preparedness of health care systems in six European countries – France, Germany, Italy, Spain, Sweden, and the United Kingdom – to handle the potential caseload. Our objective is to demonstrate the magnitude of the mismatch between patients and capacity.

We use a simulation model to quantify the expected patient demand and health care system capacity at key steps in evaluation, diagnosis, and treatment delivery. The conceptual framework is a patient journey through screening for mild cognitive impairment, evaluation by a dementia specialist, biomarker testing to determine the presence of Alzheimer’s pathology, and delivery of an infusion treatment, if eligible. The model consists of a Markov model to simulate transitions between disease states and a systems dynamic model to simulate capacity constraints during evaluation and treatment. We draw on transition probabilities from literature and country-specific population and infrastructure data. In addition, we relied on patient uptake assumptions based on expert consultation in our prior US study, and consult ten subject matter experts from the European countries to inform assumptions related to clinical practice. We estimate the number of people who would have to be screened, diagnosed, and then potentially treated if a therapy comes to market in 2020, and the effects of capacity constraints on waiting times and Alzheimer’s dementia cases.

We find substantial variation in preparedness across the countries: patients in all six systems may encounter wait times due to the caseload exceeding capacity, but some systems have less infrastructure than others to diagnose and treat early-stage Alzheimer’s patients. Projected peak wait times range from five months for treatment in Germany to 19 months for evaluation in France. Longer wait times and thus higher shares of potentially avoidable dementia cases are expected for France, the United Kingdom, and Spain. The first year without wait times would be 2030 in Germany, 2033 in France, 2036 in Sweden, 2040 in Italy, 2042 in the United Kingdom and 2044 in Spain. If a therapy becomes available in 2020, we estimate that lack of capacity means that over 1 million patients with mild cognitive impairment due to Alzheimer’s disease could develop dementia while waiting for evaluation and treatment in the six countries between 2020 and 2050.

The most pressing constraint is limited capacity of dementia specialists to evaluate and diagnose patients, but access to biomarker testing to confirm Alzheimer’s disease and to infusion centers to deliver the treatment could also contribute to waiting times. Addressing existing capacity constraints will require a combination of payment, regulatory, and workforce planning policies, combined with broad education campaigns to increase patient awareness of the importance of timely detection of early-stage disease.