UCSF-Quest Dementia Project Improving patient care and outcomes Joseph J. Higgins, MD, FAAN, Medical Director, Neurology, Quest Diagnostics Michael Geschwind, MD PhD, Professor of Neurology, UCSF June Lee, MD, Director, Early Translational Research, UCSF

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Innovator Presentation

Problem:

• Dementia diagnosed too late! • AD treatment trial failures show need to diagnosis and treat earlier • Earlier intervention could delay NH placement and other costly medical care • Diagnosing dementia can be difficult • Need to begin diagnostic & management process at PCP office #P4C2014

Multi-billion Dollar Problem

AD and related dementia in USA • 2012 - 5.4 million • 2025 - 6.7 million • 2050 - 13.8 million

Key figures

• $200 billion est. health care costs (2012) • $1.2 trillion est. health care costs (2050) • Businesses: $61 billion health care/loss of productivity

Clinical needs

• Only condition among top 10 causes of death • Earlier diagnosis of disease - Preclinical, Mild Cognitive Impairment (MCI). • Biomarkers • Comprehensive diagnostic solutions and effective patient management decisions across the continuum of care

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Projected Number of Americans Aged 65 and Over with AD (in Millions) 14 12 10

8 6 4

2 0 2000

2010

2020

2030

2040

2050

Partnership UCSF Memory and Aging Center (MAC)

 Neurology Dept ranked #1 in NIH Funding  UCSF ranked 2nd in world in clinical medicine by Academic Ranking of World Universities Leading dementia research & clinical center  Multi-disciplinary approach  Basic and clinical research/trials on novel biomarkers and therapies #P4C2014

Quest Diagnostics  World’s largest and leading diagnostic service provider  30% of patients and 50% of providers in USA  Menu of thousands of tests  2,200 patient service centers

Leading medical innovator in diagnostics Rapidly validate & deliver diagnostic testing around world

Dementia Care Pathway Project Goals  Develop, implement, and demonstrate value (clinical and health economic) of a integrated care pathway for dementia evaluation and care – “Dementia Care Pathway”  Generate clinical validation data on prevalence and care for all causes of dementia including treatable and non-treatable causes  Integrate primary and specialty care in an optimal dementia workup and treatment  Generate research / developmental data for emerging lab and imaging biomarkers #P4C2014

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7 Cores

Strategic integration and management (SIM): Project oversight/budgeting/mangement; integrating with community PCPs/care partners; Building the overall Dementia Care Pathway Model/Decision tree Neurobehavioral Core: Develop standardized brief, PCP accessible screening tool to enable PCPs to identify patients requiring further dementia evaluation Rapidly Progressive Dementia (RPD) Core: Develop a diagnostic algorithm; identifying spectrum of antibody-mediated dementias Neuroimaging Core: Establish standardized MRI acquisitions and interpretation templates for dementia-specific visual reads and create an automated diagnostic classification system Genetics Core: Standardize genetic diagnostic elements of the CDVC to establish clinical practice parameters for testing and counseling. Education and Counseling Core: Design and provide patient and family education materials for the CDVC that integrates the finding of all core projects. Economics and Outcomes Core: Use Kaplan and Porter modeling to enhance the CDVC and provide tools to measure economic value based on outcome and provider/family satisfaction/preferences.

7 Cores to developing dementia algorithm

Neurobehavior

Imaging

Dementia diagnosis Strategic integration RPD

Genetics Education

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Economics

Initial timeline: 2-3 Phases Integration (SIM, Neuropsychology, Neuroimaging, Neuroimmunology, Genetics, Education/Counseling, Health Economics)

Phase 1A (0-9 mo.) Individual tests, evaluations, & validations

Phase 1B (6-18 mo.) Pubs & Prototype implementation

Phase 2 Refinement of the care delivery value chain

Integrated reports Doctor

Patient Lab Tests

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Neurobehavior Core • Using Tablet-Based Cognitive Assessment Tool (TabCAT) software to create cognitive/behavioral assessment tools • Phase 1a: 5-minute Brief Cognitive Screen (memory, exec), neurobehavioral screen (eCog, NDG screeners) • Phase 1b: piloting Brief Screen at UCSF primary care and other sites; prototype 1-hour Comprehensive Screen #P4C2014

Imaging Core

Phase 1a: • Develop unified structural MRI acquisition protocols (standard/enhanced) • Develop automated MRI interpretation algorithms for diagnostic classification • Write protocol for dementia-specific clinical reads Phase 1b: validate/test these tools/interpretive report system with UCSF Primary Care and other care partners Finalize enhanced (RPD-specific) protocol

Dementia Collaboration Concepts All arrows represent Care360 connections

Generalized Business Model Suspected cognitive impairment

PCP

Dementia No Monitor annually -Protocol Assess against collected longitudinal data

Impaired?

Cognitive Assessment

Certified imaging centers

Test Secondary Imaging Center Causes Yes

Neuroradiology services

Virtual Radiology Interpretation

No Lab Treatable?

Treat appropriately & monitor

Implementation of Dementia PCP Algorithm Fosters improvements in clinical care and lowering costs by: • •

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Closing gaps in guidelines supported care through facilitating ordering of the recommended workup Enabling primary care and specialists to utilize complex / expert care pathways involving lab and imaging Delivering clinical value through integrated laboratory, imaging, and clinical data interpretations

Improves resource utilization through: • • • •

Coordinated serial imaging, lab testing, and therapeutic interventions Appropriate esoteric lab and imaging procedures on the populations most likely to benefit Reduction in the duplication of imaging exams by PCPs and specialists Reduction in healthcare expenditure by shifting imaging studies routinely performed in a high cost hospital setting to lower cost free standing imaging centers

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Collaboration Beyond Dementia Program • • • •

Five year collaboration agreement to enable development of new diagnostic solutions Quest and UCSF partners of choice for diagnostic development Quest evaluation of UCSF discoveries for development Collaborative studies to deliver precision medicine with a focus on integrated diagnostics

Governance •

Joint Oversight Committee made up of at least 2 members from each party, plus up to 2 ad hoc members from each party

Project plans • • • • •

Initiated projects in Autism using Quest data and brain disease molecular and imaging integration. Major Project: Dementia Integrated Pathway Additional priority areas: integrated diagnostics, digital health, gynecology, infectious disease Option for Commercializing Agreement pursuant to the right of first negotiation Intent and rights to publish results in peer reviewed literature

Bruce Miller, MD Katherine Rankin, PhD Michael Geschwind, MD, PhD Howie Rosen, MD Katherine Possin, PhD Chris Hess, MD

Jennifer Merrilees, RN, PhD Joel Kramer, PsyD Jennifer Yokoyama, PhD Rosalie Gearhart, RN Jeffrey Gelfand, MD, MS Carolyn Fredericks, MD

Suzee Lee, MD Jamie Fong, MS Christine Richie, MD Michael Schaffer Bri Bettcher, PhD

Alistair Martin, PhD John Kornak, PhD David Marin

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