Rural-Urban Disparities in Diagnosis of Early-Onset Dementia

Abstract

Importance: Limited access to appropriate specialists and testing may be associated with delayed diagnosis and symptom management for patients with early-onset Alzheimer disease and related dementias (ADRDs).

Objectives: To examine rural vs urban differences in diagnostic and symptom management service use among patients with early-onset ADRDs.

Design, setting, and participants: This cross-sectional study was conducted using commercial claims from 2012 to 2017. Included patients were those with early-onset ADRDs aged 40 to 64 years, including new patients, defined as those with no claims of ADRDs for 36 months before the first ADRD diagnosis. The likelihood of receiving diagnostic and symptom management services was estimated, with adjustment for individual-level variables associated with health care use. Data were analyzed from February 2021 to March 2022.

Exposures: Rural residence.

Main outcomes and measures: Among patients with new, early-onset ADRDs, use of psychological assessment and neuropsychological testing performed at the initial diagnosis (index date) or 90 days or less after the index date and use of brain imaging during the 180 days before the index date were collected. Access to different clinicians on the index date or 90 days or less after the index date was also collected, including visits to primary care physicians and nurse practitioners (PCPs) and specialty visits to psychologists, neurologists, and psychiatrists.

Results: Among 71 799 patients with early-onset ADRD (mean [SD] age, 56.34 [6.05] years; 39 231 women [54.64%]), 8430 individuals had new early-onset ADRDs (mean [SD] age, 55.94 [6.30] years; 16 512 women [56.65%]). There were no statistically significant differences between new patients with early-onset ADRDs in rural vs urban areas in the use of psychological assessments, imaging studies, or visits to neurologists or psychiatrists. However, new patients in rural areas were less likely to receive neuropsychological testing (odds ratio [OR], 0.83; 95% CI, 0.70-0.98) or visit a psychologist (OR, 0.72; 95% CI, 0.60-0.85) compared with patients in urban areas. However, new patients in rural areas with early-onset ADRDs were more likely to have only PCP visits for diagnosis and symptom management compared with those in urban areas (OR, 1.40; 95% CI, 1.19-1.66).

Conclusions and relevance: This study found that new patients with early-onset ADRDs in rural areas were less likely to receive neuropsychological testing or visit psychologists but more likely to be diagnosed and treated exclusively by PCPs compared with those in urban areas. These findings suggest that efforts, such as clinician education or teleconsultative guidance to PCPs, may be needed to enhance access to specialist services in rural areas.

Figure 1.. Unadjusted Rural-Urban Differences in Service Use Around Diagnosis

Index date indicates date of the first-observed Alzheimer disease and related dementia (ADRD) diagnosis after 3 consecutive years of no ADRD claim. All differences were statistically significant at 95% CI for unadjusted comparison between new patients in rural vs urban areas.

Figure 2.. Unadjusted Rural-Urban Differences in Clinician Visits Around Diagnosis

Index date indicates the date of first-observed Alzheimer disease and related dementia (ADRD) diagnosis after 3 consecutive years of no ADRD claim. All differences were statistically significant at 95% CI for unadjusted comparison between new patients in rural vs urban areas.