A Shortage of Neurologists - We Must Act Now: A Report From the AAN 2019 Transforming Leaders Program

Aducanumab Use in Symptomatic Alzheimer Disease Evidence in Focus: A Report of the AAN Guidelines Subcommittee

OBJECTIVE

To identify the class of evidence for aducanumab use for the treatment of Alzheimer disease and present clinical considerations regarding use.

METHODS

The author panel systematically reviewed available clinical trial data detailing aducanumab use in individuals with early symptomatic Alzheimer disease. Level of evidence statements were assigned in accordance with the American Academy of Neurology's 2017 therapeutic classification of evidence scheme. Safety information, regulatory decisions, and clinical context were also reviewed.

RESULTS

Data were identified from 4 clinical trials, 1 rated Class I and 3 rated Class II. The Class I study showed that single doses of aducanumab up to 30 mg/kg were safe and well tolerated. All 3 Class II studies provided evidence that aducanumab (3-10 mg/kg) decreased amyloid deposition on brain PET at 1 year vs placebo. Efficacy data in the Class II studies varied by dose and outcome, but aducanumab either had no effect on mean change on the Clinical Dementia Rating Sum of Boxes scores or resulted in less worsening (vs placebo) that was of uncertain clinical importance. Adverse amyloid-related imaging abnormalities occurred in approximately 40% of individuals treated with aducanumab vs 10% receiving placebo.

CLINICAL CONTEXT

Administration of aducanumab will require expanded clinical infrastructure. Evidence-based guidance is needed to address key questions (e.g., safety in populations not enrolled in phase 3 studies, expected benefits on daily function, treatment duration) and critical issues relating to access to aducanumab (e.g., coverage, costs, burden of monthly infusions) that will inform shared decision making between patients and providers.

Predictors of No-Show in Neurology Clinics

In this study, we aim to identify predictors of a no-show in neurology clinics at our institution. We conducted a retrospective review of neurology clinics from July 2013 through September 2018. We compared odds ratio of patients who missed appointments (no-show) to those who were present at appointments (show) in terms of age, lead-time, subspecialty, race, gender, quarter of the year, insurance type, and distance from hospital. There were 60,012 (84%) show and 11,166 (16%) no-show patients. With each day increase in lead time, odds of no-show increased by a factor of 1.0019 (p < 0.0001). Odds of no-show were higher in younger (p ≤ 0.0001, OR = 0.49) compared to older (age ≥ 60) patients and in women (p < 0.001, OR = 1.1352) compared to men. They were higher in Black/African American (p < 0.0001, OR = 1.4712) and lower in Asian (p = 0.03, OR = 0.6871) and American Indian/Alaskan Native (p = 0.055, OR = 0.6318) as compared to White/Caucasian. Patients with Medicare (p < 0.0001, OR = 1.5127) and Medicaid (p < 0.0001, OR = 1.3354) had higher odds of no-show compared to other insurance. Young age, female, Black/African American, long lead time to clinic appointments, Medicaid/Medicare insurance, and certain subspecialties (resident and stroke clinics) are associated with high odds of no show. Possible suggested interventions include better communication and flexible appointments for the high-risk groups as well as utilizing telemedicine.

Pediatric Critical Care Neurologists in the United States and Canada: A Survey of Clinical Practice Experience

OBJECTIVE

To describe the characteristics of pediatric intensive care neurologists and their practice in the United States and Canada.

METHODS

We performed a survey-based study of child neurologists who self-identify as 'intensive care neurologists'. The survey included questions about demographics, training, pediatric neurocritical care service and job structure, teaching, academics, challenges, and views on the future of pediatric neurocritical care.

RESULTS

We analyzed 55 surveys. Most respondents were 31-50 years of age with ≤10 years of practice experience. Fifty-four percent identified as female. Most completed subspecialty training after child neurology residency. The majority practice at highly resourced centers with >45 intensive care unit beds. Respondents cover a variety of inpatient (critical and noncritical care) services, at times simultaneously, for a median of 19.5 weeks/y and work >70 hours/wk when on service for pediatric neurocritical care. The top 3 challenges reported were competing demands for time, excess volume, and communication with critical care medicine. Top priorities for the "ideal pediatric neurocritical care service" were attendings with training in pediatric neurocritical care or a related field and joint rounding with critical care medicine.

CONCLUSION

We report a survey-based analysis of the demographics and scope of practice of pediatric critical care neurologists. We highlight challenges faced and provide a framework for the further development of this rapidly growing field.

The Neurology Access Clinic: A Model to Improve Access to Neurologic Care in an Academic Medical Center

Background:

Delays in access to neurologic care is a major problem. In this pilot program, we aimed to evaluate the effectiveness of a novel staffing model for neurology outpatient clinic within an academic neurology center to increase access to neurological care, while incorporating such a model into a growing academic neurology department.

Methods:

We created a new model for provision of access to neurological care that could be introduced in an academic neurological department, the “access clinic”. One attending was assigned to staff the access clinic for one week at a time. This was introduced as rotation equal to conventional on-service inpatient rotations. Descriptive analyses were performed to characterize the access clinic’s performance characteristics. Comparisons were made to the previously established traditional faculty clinic model.

Results:

5,917 access clinic visits were compared to 6,000 traditional clinic visits. Lead time dropped from 142 to 18 days for new patients, and from 64 to 0 days for return visits. While total readmission rates were similar during both clinic periods, readmission through the emergency room was less for access clinic patients. Access clinic resulted in significant improvement in patient satisfaction ratings. The access clinic model was financially profitable.

Conclusions:

Our findings suggest that introducing an access clinic as service rotation for neurology faculty is both effective in offering enhanced access for patients to neurological care and for patient satisfaction. Future studies may test this model in other centers, and should address effect on provider satisfaction.

Site Readiness Framework to Improve Health System Preparedness for a Potential New Alzheimer's Disease Treatment Paradigm

New therapies that address the underlying pathophysiology of Alzheimer's Disease (AD), coupled with the growth of the AD population, will transform the AD care pathway and present significant challenges to health systems. We explored real-world challenges health systems may face in delivering potential new AD therapies with diverse stakeholders. Key challenges in care included integrating primary care providers into assessment and management, availability of memory care specialists, understanding payment and coverage issues and training mid-level providers to help coordinate care and serve as a shared resource across the system. This input informed a novel Site Readiness Framework for AD, comprising self-assessment exercises to identify health system capabilities and gaps and a framework of core strategies and responsive tools to help prepare to integrate new AD therapies. These resources may help health systems improve readiness to modify care pathways to integrate new therapies for AD.

What neurologists wish palliative care physicians knew

As the incidence of neurologic (particularly neurodegenerative) diseases continues to rise, so too will the palliative needs in this patient population. To appropriately care for these patients and families, neurologists and palliative care providers will need to strengthen collaboration. Palliative care providers not formally trained in neurology may feel ill-equipped to manage some of the distinct neuropalliative care needs of these patients. Here, we provide insights into the unique characteristics of patients with neurologic disease and emphasize the relevance of the palliative care skillset in this population to aid the collaboration between palliative care providers and neurologists.