Care Ecosystem Collaborative Model and Health Care Costs in Medicare Beneficiaries With Dementia: A Secondary Analysis of a Randomized Clinical Trial

Population Health in Neurology and the Transformative Promise of Artificial Intelligence and Large Language Models

This manuscript examines the expanding role of population health strategies in neurology, emphasizing systemic approaches that address neurological health at a community-wide level. Key themes include interdisciplinary training in public health, policy reform, biomedical informatics, and the transformative potential of artificial intelligence (AI) and large language models (LLMs). In doing so, neurologists increasingly adopt a holistic perspective that targets the social determinants of health, integrates advanced data analytics, and fosters cross-sector collaborations-ensuring that prevention and early intervention are central to their efforts. Innovative applications, such as predictive analytics for identifying high-risk populations, digital twin technologies for simulating patient outcomes, and AI-enhanced diagnostic tools, illustrate the transition in neurology from reactive care to proactive, data-driven interventions. Examples of transformative practices include leveraging wearable health technologies, telemedicine, and mobile clinics to improve early detection and management of neurological conditions, particularly in underserved populations. These emerging methodologies expand access to care while offering nuanced insights into disease progression and community-specific risk factors. The manuscript emphasizes health disparities and ethical considerations in designing inclusive, data-driven interventions. By harnessing emerging technologies within frameworks that prioritize equity, neurologists can reduce the burden of neurological diseases, improve health outcomes, and establish a sustainable, patient-centered model of care benefiting both individuals and entire communities. This integration of technology, interdisciplinary expertise, and community engagement fosters a future where brain health is preventive, accessible, and equitable.

Long-term effects of collaborative dementia care on quality of life and caregiver well-being

INTRODUCTION

Collaborative dementia care models with care navigation, including the Care Ecosystem, improve outcomes for persons living with dementia (PLWDs) and their caregivers. The effects of continuous care over long periods have not been studied.

METHODS

In this randomized clinical trial with 456 PLWD-caregiver dyads with high caregiver burden, we evaluated the cumulative 5-year treatment effect on PLWD quality of life, health care utilization, caregiver depression, self-efficacy, and burden.

RESULTS

Five-year participation was associated with higher quality of life, lower caregiver depression, and higher caregiver self-efficacy (all p's < 0.05) with a trend for lower burden (p = 0.07). Treatment effects were most robust during the first 2 years. The effects on emergency department visits and hospitalizations were not significant.

DISCUSSION

The benefits of collaborative dementia care on PLWD quality of life and caregiver well-being are sustained for 5 years, and the dyads may experience the greatest benefit during the first 2 years.

HIGHLIGHTS

Collaborative dementia care with care navigation was evaluated over 5 years using a randomized clinical trial. The care was associated with better quality of life for the person with dementia and well-being for the caregiver. The most robust treatment effects were in the first 2 years.

Paving the way for Alzheimer's disease blood-based biomarkers in primary care

Blood-based biomarkers (BBBMs) for Alzheimer's disease (AD) have the potential to revolutionize the detection and management of cognitive impairment. AD BBBMs are not currently recommended for use in primary care but may soon be as research demonstrates their clinical utility for differential diagnosis and patient management. To prepare for the incorporation of AD BBBMs into primary care, several practical challenges must be addressed. Here, we describe four immediate challenges: (1) preparing primary care providers to order and disclose AD BBBMs, (2) expanding the dementia-capable workforce, (3) ensuring equitable uptake of AD BBBM testing, and (4) securing access to AD treatment. We conclude by discussing future directions and challenges for use of AD BBBMs in primary care, including screening for preclinical AD and dementia detection algorithms. HIGHLIGHTS: Alzheimer's disease (AD) blood-based biomarkers (BBBMs) may be well suited for primary care. Many changes are needed to prepare the workforce and ensure patient access. Paving the way for AD BBBMs in primary care will require a multi-pronged approach.

Collaborative Dementia Care During the New Therapeutic Era

This Viewpoint advocates for the implementation of collaborative care with care navigation in the diagnosis and treatment of Alzheimer disease.

Clinical Outcomes and Cost-Effectiveness of Collaborative Dementia Care: A Secondary Analysis of a Cluster Randomized Clinical Trial

Importance

Long-term evidence for the effectiveness and cost-effectiveness of collaborative dementia care management (CDCM) is lacking.

Objective

To evaluate whether 6 months of CDCM is associated with improved patient clinical outcomes and caregiver burden and is cost-effective compared with usual care over 36 months.

Design, Setting, and Participants

This was a prespecified secondary analysis of a general practitioner (GP)-based, cluster randomized, 2-arm clinical trial conducted in Germany from January 1, 2012, to December 31, 2014, with follow-up until March 31, 2018. Participants were aged 70 years or older, lived at home, and screened positive for dementia. Data were analyzed from March 2011 to March 2018.

Intervention

The intervention group received CDCM, comprising a comprehensive needs assessment and individualized interventions by nurses specifically qualified for dementia care collaborating with GPs and health care stakeholders over 6 months. The control group received usual care.

Main Outcomes and Measures

Main outcomes were neuropsychiatric symptoms (Neuropsychiatric Inventory [NPI]), caregiver burden (Berlin Inventory of Caregivers' Burden in Dementia [BIZA-D]), health-related quality of life (HRQOL, measured by the Quality of Life in Alzheimer Disease scale and 12-Item Short-Form Health Survey [SF-12]), antidementia drug treatment, potentially inappropriate medication, and cost-effectiveness (incremental cost per quality-adjusted life year [QALY]) over 36 months. Outcomes between groups were compared using multivariate regression models adjusted for baseline scores.

Results

A total of 308 patients, of whom 221 (71.8%) received CDCM (mean [SD] age, 80.1 [5.3] years; 142 [64.3%] women) and 87 (28.2%) received usual care (mean [SD] age, 79.2 [4.5] years; 50 [57.5%] women), were included in the clinical effectiveness analyses, and 428 (303 [70.8%] CDCM, 125 [29.2%] usual care) were included in the cost-effectiveness analysis (which included 120 patients who had died). Participants receiving CDCM showed significantly fewer behavioral and psychological symptoms (adjusted mean difference [AMD] in NPI score, -10.26 [95% CI, -16.95 to -3.58]; P = .003; Cohen d, -0.78 [95% CI, -1.09 to -0.46]), better mental health (AMD in SF-12 Mental Component Summary score, 2.26 [95% CI, 0.31-4.21]; P = .02; Cohen d, 0.26 [95% CI, -0.11 to 0.51]), and lower caregiver burden (AMD in BIZA-D score, -0.59 [95% CI, -0.81 to -0.37]; P < .001; Cohen d, -0.71 [95% CI, -1.03 to -0.40]). There was no difference between the CDCM group and usual care group in use of antidementia drugs (adjusted odds ratio, 1.91 [95% CI, 0.96-3.77]; P = .07; Cramér V, 0.12) after 36 months. There was no association with overall HRQOL, physical health, or use of potentially inappropriate medication. The CDCM group gained QALYs (0.137 [95% CI, 0.000 to 0.274]; P = .049; Cohen d, 0.20 [95% CI, -0.09 to 0.40]) but had no significant increase in costs (437€ [-5438€ to 6313€] [US $476 (95% CI, -$5927 to $6881)]; P = .87; Cohen d, 0.07 [95% CI, -0.14 to 0.28]), resulting in a cost-effectiveness ratio of 3186€ (US $3472) per QALY. Cost-effectiveness was significantly better for patients living alone (CDCM dominated, with lower costs and more QALYs gained) than for those living with a caregiver (47 538€ [US $51 816] per QALY).

Conclusions and Relevance

In this secondary analysis of a cluster randomized clinical trial, CDCM was associated with improved patient, caregiver, and health system-relevant outcomes over 36 months beyond the intervention period. Therefore, it should become a health policy priority to initiate translation of CDCM into routine care.

Trial Registration

ClinicalTrials.gov Identifier: NCT01401582.

2024 Alzheimer's disease facts and figures

This article describes the public health impact of Alzheimer's disease (AD), including prevalence and incidence, mortality and morbidity, use and costs of care and the ramifications of AD for family caregivers, the dementia workforce and society. The Special Report discusses the larger health care system for older adults with cognitive issues, focusing on the role of caregivers and non-physician health care professionals. An estimated 6.9 million Americans age 65 and older are living with Alzheimer's dementia today. This number could grow to 13.8 million by 2060, barring the development of medical breakthroughs to prevent or cure AD. Official AD death certificates recorded 119,399 deaths from AD in 2021. In 2020 and 2021, when COVID-19 entered the ranks of the top ten causes of death, Alzheimer's was the seventh-leading cause of death in the United States. Official counts for more recent years are still being compiled. Alzheimer's remains the fifth-leading cause of death among Americans age 65 and older. Between 2000 and 2021, deaths from stroke, heart disease and HIV decreased, whereas reported deaths from AD increased more than 140%. More than 11 million family members and other unpaid caregivers provided an estimated 18.4 billion hours of care to people with Alzheimer's or other dementias in 2023. These figures reflect a decline in the number of caregivers compared with a decade earlier, as well as an increase in the amount of care provided by each remaining caregiver. Unpaid dementia caregiving was valued at $346.6 billion in 2023. Its costs, however, extend to unpaid caregivers' increased risk for emotional distress and negative mental and physical health outcomes. Members of the paid health care and broader community-based workforce are involved in diagnosing, treating and caring for people with dementia. However, the United States faces growing shortages across different segments of the dementia care workforce due to a combination of factors, including the absolute increase in the number of people living with dementia. Therefore, targeted programs and care delivery models will be needed to attract, better train and effectively deploy health care and community-based workers to provide dementia care. Average per-person Medicare payments for services to beneficiaries age 65 and older with AD or other dementias are almost three times as great as payments for beneficiaries without these conditions, and Medicaid payments are more than 22 times as great. Total payments in 2024 for health care, long-term care and hospice services for people age 65 and older with dementia are estimated to be $360 billion. The Special Report investigates how caregivers of older adults with cognitive issues interact with the health care system and examines the role non-physician health care professionals play in facilitating clinical care and access to community-based services and supports. It includes surveys of caregivers and health care workers, focusing on their experiences, challenges, awareness and perceptions of dementia care navigation.

Transforming Value-Based Dementia Care-Implications for the GUIDE Model

This Viewpoint reviews the Guiding an Improved Dementia Experience (GUIDE) Model to assess its suitability in providing equitable and cost-effective dementia care and to compare it with previously introduced specialty care payment models to identify opportunities for refining payment innovation in dementia care.