Mapping disparities in access to lecanemab in Georgia

Abstract

INTRODUCTION

The approval of lecanemab‐irmb offers potential disease‐modifying treatments for Alzheimer's disease (AD), but geographical access barriers to infusion and amyloid positron emission tomography (PET) imaging sites might prevent timely access to the drug. We examined disparities in access to lecanemab infusion sites and amyloid PET scan facilities in Georgia's 159 counties.

METHODS

Facility location maps were used to examine lecanemab access. We used drive time analysis to identify and map counties by drive time.

RESULTS

No rural county had an amyloid PET scan center and only one had a lecanemab infusion center. Residents in rural counties need to drive > 1 hour on average to reach the nearest facility, which is statistically significantly longer than those in non‐rural counties.

DISCUSSION

Lack of access and long drive times pose health equity issues for those in rural counties, which already have a higher percentage of older residents and a higher prevalence of behavioral AD risk factors.

Highlights

• We mapped amyloid positron emission tomography (PET) scan and lecanemab infusion facilities in Georgia.

• We examined the drive time to the nearest facility in each county.

• One lecanemab infusion facility and no amyloid PET scan facilities were found in rural counties.

• The mean drive time to the nearest facility is significantly longer for rural counties.

• The results call for policies and resources to address this health disparity issue.

1. INTRODUCTION

Alzheimer's disease (AD) affects ≈ 6 million Americans. ¹ AD's cause is unknown, but one hypothesis attributes it to the accumulation of amyloid beta (Aβ) plaques in the brain. ² A disease‐modifying therapy targeting Aβ, lecanemab‐irmb, or leqembi by Eisai, received US Food and Drug Administration approval in 2023, with an annual price of $26,500. ³ Lecanemab is indicated for early‐stage AD patients. To be eligible for lecanemab, one must have clinically diagnosed AD and the existence of excess Aβ in the brain via either an amyloid positron emission tomography (PET) scan or lumbar puncture. ⁴ Both procedures are considered safe; evidence shows lumbar puncture has slightly more adverse events. ⁵ , ⁶ Patients in North America tend to prefer an amyloid PET scan over a lumbar puncture due to fear and anxiety of lumbar puncture, and the perception that an amyloid PET scan is less invasive. ⁷ , ⁸ Compared to lumbar puncture, amyloid PET scans have limited availability and much higher costs. ⁵ Lecanemab is given as an infusion every 2 weeks. It offers potential disease‐modifying treatments for AD, but its regulatory approval requires ongoing discussion of potential harms with patients and close medical safety and surveillance, including side effect monitoring for amyloid‐related imaging abnormalities (ARIAs), which include brain swelling and/or bleeding. ⁹ , ¹⁰

AD incidence is projected to increase from 58 million in 2022 to 82 million by 2050; ¹¹ consequently, growing demand for these medications is expected. AD prevalence and incidence are higher in the southeastern United States, in part because of concomitantly higher AD risk factors, like smoking, high prevalence of hypertension and diabetes, obesity, and poor nutrition. ¹² , ¹³ , ¹⁴ More than 130,000 people in Georgia have AD and related dementias (ADRD). ¹⁵ Georgia ranks among the top 10 states in ADRD prevalence, ¹⁶ and has communities, such as Dougherty County, ranked among the United States’ top 10 AD prevalence counties. ¹⁶ Consequently, in communities like these, demand for these medications may be even higher than in the rest of the United States.

Many structural barriers prevent timely AD diagnosis nationwide, such as primary care and neurology physician shortages. ¹⁷ , ¹⁸ In Georgia, for example, 120 out of 159 counties are considered rural, as defined by the Georgia Senate as having a population < 50,000. ¹⁹ Only 9% of Georgia physicians practice in rural areas. ²⁰ Nine Georgia counties have no physicians and 18 lack family medicine physicians. ²¹ Georgia is also ranked 18th for having the most Health Professional Shortage Areas (HPSAs), defined as areas with a population‐to‐provider ratio of ≤ 3500 people to 1 provider. ²² Out of 402 neurologists in Georgia, < 20 focus on ADRD, and more than half work at a single center (the Emory Brain Health Center), where new patients often wait many months for an appointment. ²³

RESEARCH IN CONTEXT

1. Systematic review: The research team reviewed the literature using Google Scholar and PubMed. Timely access to disease‐modifying Alzheimer's disease (AD) therapies can be affected by structural barriers such as lack of access to AD specialists, access to a skilled infusion center, and a long travel time to an amyloid positron emission tomography (PET) scan or infusion center. This study aims to map amyloid PET scan and lecanemab infusion facilities in Georgia, and examine disparities in access using drive time to the nearest facility in each county.

2. Interpretation: Rural county residents had significantly longer drive time to the nearest facility than non‐rural county residents. Lack of access and long drive times pose health equity issues for those in rural counties.

3. Future directions: This study provides actionable data to inform research and policy needs, such as subsidizing transportation, telehealth, and providing portable PET scans to patients living in rural and underserved areas.

The same structural barriers that prevent diagnosis, such as living in an HPSA, also prevent access to new AD treatments. Access to health care is defined across five dimensions: availability (the adequacy of supply of health professionals and facilities), accessibility (distance and travel to locations of health‐care services), accommodation (the organization of health professionals and facilities to meet patients’ needs), affordability (costs to patients), and acceptability (patients’ perceptions of provider characteristics such as age, sex, and race). ²⁴ In this study, we focus on the availability and accessibility of amyloid PET scans and lecanemab infusion facilities. To our knowledge, no evidence quantifying access to new AD disease‐modifying therapies exists.

Given the high proportion of rural counties and the AD burden, our study focused on Georgia. This study aims to map the locations of Georgia amyloid PET scan centers and lecanemab infusion sites and quantify access to the nearest amyloid PET scan and infusion sites using drive time data. This study will inform strategies to improve lecanemab access for Georgia communities that can be expanded nationwide.

2. METHODS

We obtained amyloid PET scan center locations from the Georgia Memory Net website. ²⁵ The Georgia Memory Net is a statewide program sponsored by the Georgia Department of Human Services and managed by the Goizueta Alzheimer's Disease Research Center at Emory University, which funds early ADRD diagnosis and treatment via a network of specialty Memory Assessment Clinics in Georgia, based on primary care physician referral. ²⁵ The research team also made two phone calls to each Memory Assessment Clinic in April and June 2024 to confirm the onsite availability of amyloid PET scans. We used the location of amyloid PET scans to show a “worse‐off” scenario because the barriers to accessing amyloid PET scans are likely greater than those to access lumbar puncture.

We obtained the location of lecanemab infusion centers from the LEQEMBI Infusion Site Locator website. ²⁶ This website is maintained by the National Infusion Center Association (NICA). These infusion sites are responsible for adding and updating their information on the locator to ensure accuracy. The last day of data collection on this website was June 23, 2024.

Given the higher portion of rural counties and HPSAs in Georgia, it is critical to put access to lecanemab in the context of rurality and areas with limited access to primary health providers. We identified and mapped the locations of amyloid PET scan and lecanemab infusion facilities in rural and non‐rural counties and counties with and without geographic HPSA designations. Each county was classified as rural or non‐rural based on the Georgia Senate's definition of population < 50,000. ¹⁹ We adopted this definition because it directly impacts state‐level initiatives, funding, programs, and policies on health‐care access. Geographic HPSA designation indicates health‐care provider shortages in primary, maternal, and dental care. ²⁷ For this study, we obtained a list of primary care HPSAs in Georgia.

Amyloid PET scan and lecanemab infusion facilities were geocoded and then mapped using ArcGISPro 3.3 (Environmental Systems Research Institute). Access to the nearest amyloid PET scan and lecanemab infusion facility was measured using quartiles of drive time in minutes using Google Maps. The drive time analysis estimates the time it takes to drive from one central point (centroid) in each county to the nearest facility. This approach has been used in access‐to‐care research, such as access to community pharmacies, ²⁸ and access to opioid treatment programs. ²⁹ There has been no commonly accepted cutoff in drive time to access health care in previous research, ²⁸ so we used quartiles of drive time. We adopted the drive time analysis instead of the distance analysis because driving is the primary mode of transportation in Georgia. ³⁰ Public transportation is limited outside Atlanta. Another important advantage of drive time analysis is that it takes into account road networks, traffic patterns, and speed limits, reflecting real‐world travel conditions rather than using distance analysis. ²⁸ In addition, given that AD patients are likely to rely on family caregivers for transportation to receive amyloid PET scans and lecanemab treatment, estimating drive time helps calculate the opportunity cost of caregiving. ³¹ We also used left‐leaning hatching in the maps to indicate the 18 counties without family medicine in Georgia, the “entry point” to receiving an AD diagnosis, to better illustrate Georgia's lack of health‐care access.

We identified the number of amyloid PET scan and lecanemab infusion facilities present in a rural county or an HPSA‐designated county, and we reported the number of facilities in counties falling within each quartile of AD prevalence. Because surveillance systems to monitor the development of AD are lacking, we used the county‐level estimates of AD prevalence from Dhana et al. ¹⁶ We also compared the mean drive time (in minutes) to the nearest amyloid PET scan and lecanemab facilities between rural and non‐rural counties and between counties with and without HPSA designation. We used two‐tailed t tests for the comparison. Statistical analyses were conducted using STATA 18 (STATACorp). Statistical significance was set a priori at two tailed p < 0.05.

3. RESULTS

At the time of writing, there are six Memory Assessment Clinics in the Georgia Memory Net, and five provide amyloid PET scans onsite. The Memory Assessment Clinic in Macon refers patients to a medical center in Macon for amyloid PET scans, and we obtained the address of the facility in Macon. Two of the six amyloid PET scan facilities are located in HPSAs, but none are in rural counties, and four PET scan facilities are in counties with the highest AD prevalence quartile (Table S1, Figures S1 and S2 in supporting information).

As of this writing, there are 28 lecanemab infusion centers in Georgia. Only seven are located in HPSAs and one in a rural county, and more than half (53.6%) are in counties with the highest AD prevalence quartile (Table S1). There is a spatial clustering of lecanemab infusion centers near Atlanta, whereas southern Georgia has very few locations. Counties with higher AD prevalence are clustered in southwest and central Georgia, but the distribution of amyloid PET scan and lecanemab infusion centers is scant (Figure 1). The distribution of counties in quartiles of drive time to the nearest amyloid PET scan and lecanemab infusion centers is even (Table 1). The counties falling into the fourth quartile of drive time (between 80 and 149 minutes) to the nearest amyloid PET scan centers are clustered in the northwest and southeast of Georgia (Figure 2). The counties falling into the fourth quartile of drive time (between 108 and 196 minutes) to the nearest lecanemab infusion centers are clustered in the south of Georgia (Figure 3).

FIGURE 1.

Location of amyloid PET scan and lecanemab infusion centers in counties in quartiles of AD prevalence in Georgia. AD, Alzheimer's disease; PET, positron emission tomography.

TABLE 1.

Mean drive time to the nearest amyloid PET scan and lecanemab infusion centers (in minutes), between rural and non‐rural counties, and between counties with and without HPSA designation.

	Rural, mean (SD), minutes	95% CI	Non‐rural, mean (SD), minutes	95% CI	p value *	HPSA, mean (SD), minutes	95% CI	Non‐HPSA, mean (SD), minutes	95% CI	p value **
Drive time to the nearest amyloid PET scan center	69 (27)	65–74	51 (31)	41–60	<0.001	68 (27)	60–75	64 (29)	58–69	0.4
Drive time to the nearest lecanemab infusion center	89 (41)	81–96	45 (36)	34–57	<0.001	89 (43)	77–102	73 (44)	65–82	0.04

Abbreviations: CI, confidence interval; HPSA, health professional shortage area; PET, positron emission tomography; SD, standard deviation.

^*Mean drive time from rural versus non‐rural counties to the nearest facilities was compared using two‐tailed t tests.

^**Mean drive time from HPSA versus non‐HPSA counties to the nearest facilities was compared using two‐tailed t tests.

FIGURE 2.

Drive time analysis (in minutes) for access to the nearest amyloid PET scan center in Georgia. PET, positron emission tomography.

FIGURE 3.

Drive time analysis (in minutes) for access to the nearest lecanemab infusion centers in Georgia.

The drive time analysis in Table 1 showed that the mean drive time for residents in rural counties to reach the nearest PET scan facility is slightly > 1 hour (69 minutes, 95% confidence interval [CI]: 65–74), which is statistically significantly higher than residents in non‐rural counties whose mean drive time is 51 minutes (95% CI: 41–60, p < 0.001). The mean drive time for residents in rural counties to reach the nearest lecanemab infusion facility is close to 1.5 hour (89 minutes, 95% CI: 81–96), which is also statistically significantly higher than residents in non‐rural counties whose mean drive time is 45 minutes (95% CI: 34–57, p < 0.001). There was no statistically significant difference between the mean drive time to the nearest amyloid PET scan facility in HPSA‐designated counties (68 minutes, 95% CI: 60–75) versus non–HPSA‐designated counties (64 minutes, 95% CI: 58–69, p = 0.4). However, both groups showed a drive time of slightly > 1 hour. The mean drive time for residents in HPSA‐designated counties to reach the nearest lecanemab infusion facility is close to 1.5 hour (89 minutes, 95% CI: 77–102), which is statistically significantly higher than residents in non–HPSA‐designated counties whose mean drive time is 73 minutes (95% CI: 65–82, p = 0.04). As drive time increases, the counties falling in higher drive time are increasingly rural, from 13.8% to 20.8% to the nearest amyloid PET scan facilities, and from 10.1% to 24.5% to the nearest lecanemab infusion centers. Regarding HPSA counties, a larger proportion of counties were in the third quartile drive time to the nearest amyloid PET scan (10.7%) and lecanemab infusion facilities (10.1%; Table S1).

4. DISCUSSION

This study showed a longer drive time for rural than non‐rural residents to reach the nearest amyloid PET scan and lecanemab infusion centers. Yet, it should be noted that no residents have a “short” drive time. Our results echo a previous Washington State study showing that ADRD decedents in rural areas traveled four times farther to the nearest neurologists and three times farther to reach primary care providers than those in metropolitan areas. ³² Long drive times may add anxiety and cause agitation for people living with AD. ³³ The current discussion on the side effects of lecanemab mostly centers on ARIAs and infusion reactions, ³⁴ but little attention is devoted to the consequences of frequent long time travel to infusion sites for patients, as lecanemab is given bi‐weekly.

As Figure 1 suggests, lecanemab sites are concentrated around Atlanta, where health‐care resources are more plentiful. In contrast, amyloid PET scan facilities are dispersed. Figure 1 also suggests areas with the highest AD prevalence lack access to both amyloid PET scans and infusion facilities. Providing a reason for this unequal distribution is outside the scope of this paper. However, we speculate that PET scanners are needed for many diagnostics, particularly cancer, affecting all age ranges, and therefore have broader geographical dispersion than lecanemab infusion centers.

Getting a diagnosis and confirming drug eligibility is an upstream issue, whereas getting a lecanemab infusion is a downstream issue. Other dimensions of access and how they relate to each other should be discussed in future work, but perhaps the biggest barrier to providing both scans and infusions in rural Georgia is the shortage of health professionals at both primary and specialty care levels. Diagnosing AD is a complex, costly, and time‐consuming pathway, and lecanemab is currently only recommended for early‐stage AD. As many as 60% of people living with ADRD are not able to get a diagnosis. ³⁵ The number of neurologists capable of diagnosing and treating AD is low, ³⁶ and the wait time for an appointment is usually several months. ³⁷ After getting the amyloid PET scan in a facility, finding a neurologist trained and qualified to read the scan images is also likely a barrier. We speculate that not every AD patient determined “drug eligible” would be prescribed or willing to receive the infusion. This is the downstream issue: the patient needs health‐care providers who know how to treat AD using lecanemab, and manage side effects. The patient also needs to talk to a provider about benefits and risks, and understand the need for frequent travel and side effect monitoring. In Georgia, the lack of rural health primary and specialty care professionals is alarming; we posit that the health professional shortage is a bigger barrier than unequal facility distribution. This study focused on the availability and accessibility of amyloid PET scan and lecanemab infusion facilities using drive time. However, provider availability is another critical aspect of access that warrants future research. A greater number and broader geographical distribution of providers across the state could reduce travel distances for patients seeking care.

Access is “the degree of ‘fit’ between the clients and the system” (p. 128). ²⁴ An important issue in the case of lecanemab is access for patients, who, after discussion with their care partners and health‐care providers, determine that the potential disease‐modifying benefits outweigh the risks. Despite the benefits shown in the clinical trial, ³⁸ a systematic review and meta‐analysis of AD‐modifying therapy clinical trial data concluded that monoclonal anti‐amyloid antibodies are accompanied by potential harms. ³⁹ The Centers for Medicare & Medicaid Services (CMS) covered lecanemab under National Coverage Determination, requiring the providers to participate in a CMS‐facilitated registry to collect real‐world data. ⁴⁰ It is crucial for patients to discuss with their providers the benefits and risks of lecanemab and engage in shared decision making. Our study lays the groundwork for future research on access to lecanemab for patients who are considered likely to benefit from the drug and willing to receive the drug in the United States, with the other aspects of access discussed above serving as a potential springboard for further investigation.

The limitations of this study include the following: First, the results depend upon the completeness of amyloid PET scan facilities and lecanemab infusion centers in Georgia. Despite using the best available information, omission is an important limitation of this analysis. Second, our travel time maps to the nearest facilities indicate potential rather than actual travel time because individuals could choose to go to a facility farther from home. ⁴¹ Additionally, people living in southern Georgia often travel to nearer large cities in Florida for health care. This analysis did not include facilities in neighboring states due to potential insurance coverage barriers to out‐of‐state care, such as Medicare Advantage. Third, the drive time analysis produced projected travel time, which could not consider severe weather and road construction, ²⁸ so the actual patient‐level drive time may differ. Future research is needed to determine the percentage of the patient population able to access amyloid PET scans and lecanemab infusion centers and examine patient‐level drive time. Fourth, Georgia may not be generalizable to the entire United States. However, among Southeastern states (which have disproportionate AD burden), Georgia's AD prevalence ranked fourth highest, ¹⁶ and second highest in the number of primary care HPSAs. ²² Therefore, we conclude AD disease burden and lack of health‐care access in Georgia reflects other Southeastern states.

Disease‐modifying therapies for AD are likely to transform the AD care paradigm. ³⁷ The long drive time to reach the nearest PET scan and infusion centers to access lecanemab, particularly for those living in rural areas, is an alarming issue in health equity and calls for policies and resources. The results of this study provide actionable data to inform research and policy needs, such as subsidizing transportation, telehealth, and providing portable PET scans. As the uptake of disease‐modifying therapies for AD increases, all stakeholders need to consider and support AD patients in rural and underserved areas.

CONFLICT OF INTEREST STATEMENT

We declare no conflicts of interest. Author disclosures are available in the supporting information.

CONSENT STATEMENT

This study did not involve human subjects, so informed consent provided by human subjects is not needed.

Supporting information

Supporting Information

Supporting Information

Li N, Borate SN, Zhang K, et al. Mapping disparities in access to lecanemab in Georgia. Alzheimer's Dement. 2025;21:e70100. 10.1002/alz.70100