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UCSF-Quest Dementia ProjectImproving patient care and outcomes

Innovator Presentation

Joseph J. Higgins, MD, FAAN, Medical Director, Neurology, Quest DiagnosticsMichael Geschwind, MD PhD, Professor of Neurology, UCSFJune Lee, MD, Director, Early Translational Research, UCSF

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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

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Multi-billion Dollar ProblemAD 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

0

2

4

6

8

10

12

14

2000 2010 2020 2030 2040 2050

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

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PartnershipUCSF 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

Quest DiagnosticsWorld’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

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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

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.

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7 Cores to developing dementia algorithm

Dementia diagnosis Strategic integration

Neurobehavior Imaging

RPD Genetics

Education

Economics

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Initial timeline: 2-3 Phases

Lab Tests

Patient

Individual tests, evaluations, & validations

Pubs & Prototype implementation

Refinement of the care delivery value chain

Phase 1A (0-9 mo.) Phase 1B (6-18 mo.) Phase 2

Integration (SIM, Neuropsychology, Neuroimaging,

Neuroimmunology, Genetics, Education/Counseling, Health

Economics)

DoctorIntegrated reports

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Neurobehavior Core

• 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

• Using Tablet-Based Cognitive Assessment Tool (TabCAT) software to create cognitive/behavioral assessment tools

Imaging CorePhase 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

Virtual

Radiology

Interpretation

Test Secondary

Causes

Imaging

CenterPCP Cognitive

Assessment

Lab

Suspected cognitive

impairmentImpaired?

No

Yes

Monitor annually -Assess against collected

longitudinal data

No

Treatable?Treat appropriately

& monitor

Dementia

Protocol

Generalized Business Model Neuroradiology

services

All arrows represent Care360 connections

Certified

imaging centers

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Implementation of Dementia PCP AlgorithmFosters improvements in clinical care and lowering costs

by:• 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

interpretationsImproves 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

Collaboration Beyond DementiaProgram• 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, MDKatherine Rankin, PhDMichael Geschwind, MD, PhDHowie Rosen, MDKatherine Possin, PhDChris Hess, MD

Jennifer Merrilees, RN, PhDJoel Kramer, PsyDJennifer Yokoyama, PhDRosalie Gearhart, RNJeffrey Gelfand, MD, MSCarolyn Fredericks, MD

Suzee Lee, MDJamie Fong, MSChristine Richie, MDMichael SchafferBri Bettcher, PhD

Alistair Martin, PhDJohn Kornak, PhDDavid Marin

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