Management of Alzheimer's disease has entered a new phase with the advent of disease-modifying therapies (DMTs). Anti-amyloid beta antibodies used in DMTs—such as aducanumab, lecanemab, and donanemab—differ from earlier medications in that they slow cognitive decline by reducing amyloid plaque accumulation in the brain [1]. As Belder noted, the introduction of DMTs is expected to increase the demand for clinical services, necessitating systems that ensure timely and equitable access to these therapies [2].
Despite the demonstrated efficacy of DMTs, there are concerns remain regarding their cost-effectiveness. Their adoption has been limited in the United States, and they have not yet been approved in the European Union. In contrast, the Japanese government has taken a proactive stance toward promoting the use of DMTs. Japan's universal health insurance system allows patients to access treatment with minimal out-of-pocket costs if they meet specified criteria [3]. However, implementing DMTs within this system requires careful planning to avoid disruptions and ensure equitable delivery.
Our institution was tasked with advising the Tokyo Metropolitan Government to establish a delivery system for DMTs. We initially anticipated that expanding therapeutic options would lead to earlier diagnoses, thereby increasing the number of patients requiring post-diagnostic support. However, we have encountered an unintended consequence: the implementation of DMTs is, in some cases, impeding the provision of post-diagnostic support. We share this experience with the global scientific community.
The philosophy underlying Tokyo's DMT delivery system is based on the following principles [4]: diagnosis and treatment require confirmation of amyloid pathology and the capacity to monitor and manage amyloid-related imaging abnormalities (ARIA) throughout an 18-month treatment course. Therefore, only hospitals equipped with PET and MRI scanners and staffed by certified neurologists were designated as DMT-initiating hospitals. When primary care physicians (typically based in clinics) suspect that a patient is eligible for DMT, they refer the patient to an initiating hospital. In Tokyo, medical centers for dementia (MCDs), government-certified hubs for dementia care, serves as either DMT-initiating hospitals or as collaborating hospitals that support DMT-initiating institutions.
With the increasing number of patients starting DMTs, hospitals have exceeded their capacity. Consequently, patients are transferred after 6 months to less-equipped “DMT-continuing clinics,” usually smaller institutions or clinics. These continuing clinics take over day-to-day care while DMT-initiating hospitals remain responsible for periodic MRIs, cognitive assessments, and managing serious side effects, such as ARIA. Thus, a two-tiered system (Figure 1) was established to balance the need for specialized care with unive
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