Low Reimbursement Research Articles

Requesting That Delirium Achieve Parity With Acute Encephalopathy in the MS-DRG System

Since 2007, the Medicare Severity Diagnosis Related Groups (MS-DRG) classification system has favored billing codes for acute encephalopathy over delirium codes in determining hospital reimbursement and several quality-of-care value metrics, despite broad overlap between these sets of diagnostic codes. Toxic and metabolic encephalopathy codes are designated as major complication or comorbidity (MCC) whereas causally specified delirium codes are designated as complication or comorbidity (CC) and thus associated with lower reimbursement and lesser impact on value metrics.

GJ Express: an improvement initiative to decrease sedation and anesthesia for gastrojejunostomy tube exchanges.

Overuse of sedation and anesthesia causes delays in gastrojejunostomy tube (GJ) exchanges, increased risk of complications, unnecessary use of resources, preventable hospital admissions, and an adverse impact on patient and family experience. Our hospital was over-utilizing sedation and anesthesia, and we aimed to decrease this use from 78% to 20% within two years. An interdisciplinary quality improvement team comprehensively evaluated current processes for GJ tube exchanges through a retrospective chart review for baseline data with prospective time series analysis after improvement implementation. The primary outcome measure was the percentage of pediatric patients that utilized sedation or anesthesia for routine GJ tube exchanges. A statistical process control p-chart was used to calculate and show changes over time for patients (n = 45 patients average). The median percent of pediatric GJ tube exchanges performed with sedation or anesthesia decreased from 77.8% to 11.3%. Most patients (76%) were covered by Medicaid programs; with low reimbursement rates, decreased anesthesiologist billing revenue does not have a negative financial impact. An interprofessional improvement initiative that engaged patients and families, incorporated pediatric-specific staff services, and developed systematic weaning was associated with a significant decrease in the overuse of sedation and anesthesia for GJ tube exchanges. We believe that this work is highly relevant and impactful for medical centers caring for children who require gastrojejunostomy tubes, an increasingly common approach to management of children with feeding issues. There is very little literature available on the use of sedation or anesthesia for changing these tubes. While large children's medical centers in the USA usually do not utilize sedation or anesthesia, there are likely many serious outliers, especially when children receive care outside of a pediatric specific institution. This paper brings awareness to this serious issue and provides information about how we changed care to achieve higher patient safety and lower medical costs.

Geographic Trends for Medicare Reimbursement Rates in Pain Management Anesthesia from 2000 to 2022

Over the past few decades, the reimbursement rates for Medicare have been decreasing steadily. Although some studies have previously evaluated trends in reimbursements in other fields, a comprehensive evaluation of geographic monetary reimbursement trends in pain management anesthesia has not yet been conducted. Because these trends have not been evaluated previously, we aimed to evaluate national and geographic trends of Medicare reimbursement rates in pain management anesthesia from 2000 to 2022. We selected 155 frequently billed codes to determine trends of reimbursement rates specific to pain management anesthesia. Our study shows that over the last 23 years, the inflation-adjusted Medicare reimbursement for the selected pain management procedures decreased annually by 2.81%. The findings raise concerns for anesthesiologists providing pain management care to Medicare-insured patients, because lower reimbursement rates may limit procedure availability and decrease the number of providers accepting Medicare.

Implementation of Point of Care Sexually Transmitted Infections Testing in a Community Clinic Setting.

The rates of sexually transmitted infections (STIs) in the United States, including chlamydia and gonorrhea, are rising. Point-of-care (POC) testing could increase access to testing and treatment. This evaluation found POC STI testing to be concordant with the results of traditional laboratory testing for 100% of patients who were tested. Ninety-five percent of the patients reported being satisfied with the experience, and 66% preferred it to traditional laboratory testing. The most commonly reported reason for preferring the test was the short amount of time it took to receive results. However, insurance reimbursed less than 30% of what was billed for the POC tests. Low insurance reimbursement rates could be a barrier to implementation long-term financial sustainability of POC STI testing.

Financial (dis)incentives to surgical management of head and neck cancer care.

Patients with head and neck cancer (HNC) often require complex surgical reconstruction. This retrospective, cross-sectional study compares financial factors influencing HNC and breast cancer (BC) care to examine care disparities. Pricing data from 2012 to 2021 was abstracted from the CMS Physician Fee Schedule Look-Up Tool. Nonprofit and research support was quantified by searching the NIH, IRS, and GuideStar databases. New York State Department of Health data from 2015 to 2019 was analyzed to compare costs, charges, and payer mix. HNC reconstructive procedures reimburse lower than comparable breast procedures (p < 0.05). Nonprofit and research support for HNC is disproportionately low relative to disease burden. Patients hospitalized for HNC surgical procedures generated higher costs and lower charges than patients with BC (p < 0.05). Comparatively low procedure reimbursement, low nonprofit support, and high cost of care for patients with HNC relative to patients with BC may contribute to care disparities for patients with HNC.

State-to-State Variation in Medicaid Reimbursement for Neurosurgical Procedures: Implications for Healthcare Access in Vulnerable Populations.

Medicaid payment for healthcare services traditionally reimburses less than Medicare and commercial insurance. This disparity in reimbursement seems to be an important driver of limited access to care among Medicaid beneficiaries. This study seeks to examine the degree of variation in Medicaid and Medicare reimbursement for the most common neurosurgical current procedural terminology codes and determine its potential impact on provider accessibility. In this cross-sectional study, maximum allowed physician reimbursement fees for 20 common neurosurgical codes reported in the literature were obtained from the 2022 Medicare Physician Fee Schedule and individual state Medicaid Fee-for-Service Schedules. The Medicaid-Medicare Index (MMI), which measures Medicaid reimbursement as a fraction of Medicare allowed amounts, was calculated for each procedure across 49 states and the District of Columbia. Lower MMI indicates a greater disparity, or "discount," between Medicaid and Medicare reimbursement. The proportion of providers accepting new Medicaid patients and total Medicaid enrollment were compared across states as a function of MMI. The average national MMI was 0.79, with a range of 0.37 in NY/NJ to 1.43 in NE. Maximum allowed amounts for Medicare reimbursement (coefficient of variation = 0.09) were less variable than those for Medicaid (coefficient of variation = 0.26, P < .01). The largest absolute disparity was observed for intracranial aneurysm clipping in NY, where the maximum Medicaid reimbursement is $3496.52 less than that of Medicare. Higher MMI was associated with a significantly larger proportion of providers accepting new Medicaid patients (R2 = 0.43, P < .01). Moreover, MMI varied inversely with the number of Medicaid beneficiaries (R2 = 0.12, P = .01). Medicaid reimbursement varies between states reflecting the disparate methods of fee schedule calculation. Lower reimbursement is associated with more limited provider enrollment, especially in states with a greater number of beneficiaries.

Fellowship-trained physicians who let their geriatric medicine certification lapse: A national survey.

Only 62.6% of fellowship-trained and American Board of Internal Medicine (ABIM)-certified geriatricians maintain their specialty certification in geriatric medicine, the lowest rate among all internal medicine subspecialties and the only subspecialty in which physicians maintain their internal medicine certification at higher rates than their specialty certification. This study aims to better understand underlying issues related to the low rate of maintaining geriatric medicine certification in order to inform geriatric workforce development strategies. Eighteen-item online survey of internists who completed a geriatric medicine fellowship, earned initial ABIM certification in geriatric medicine between 1999 and 2009, and maintained certification in internal medicine (and/or another specialty but not geriatric medicine). Survey domains: demographics, issues related to maintaining geriatric medicine certification, professional identity, and current professional duties. 153/723 eligible completed surveys (21.5% response). Top reasons for not maintaining geriatric medicine certification were time (56%), cost of maintenance of certification (MOC) (45%), low Medicare reimbursement for geriatricians' work (32%), and no employer requirement to maintain geriatric medicine certification (31%). Though not maintaining geriatric medicine certification, 68% reported engaging in professional activities related to geriatric medicine. Reflecting on career decisions, 56% would again complete geriatric medicine fellowship, 21% would not, and 23% were unsure. 54% considered recertifying in geriatric medicine. 49% reported flexible MOC assessment options would increase likelihood of maintaining certification. The value proposition of geriatric medicine certification needs strengthening. Geriatric medicine leaders must develop strategies and tactics to reduce attrition of geriatricians by enhancing the value of geriatric medicine expertise to key stakeholders.

Did Medicaid Reimbursements Shape the Effects of Medicaid Expansion on Access to Health Care Among the Low-Income Population?

Whether variation in Medicaid reimbursement fees influenced the impacts of the Medicaid expansions is not well understood. We examine whether changes in health care access associated with Medicaid expansion are different in states with comparatively high Medicaid reimbursement rates compared against expanding in states with lower Medicaid reimbursement rates. Using a difference-in-difference-in-difference (DDD or triple-difference) regression approach, we compare relative differences in Medicaid expansion effects between lower and higher reimbursement states. 512,744 low-income adults aged 20-64 in the 2011-2019 Behavioral Risk Factor Surveillance System. Health insurance coverage status, unmet medical needs due to cost, regular source for health care, and a regular/scheduled checkup within the past year. Medicaid expansion has significant and positive impacts on health coverage and access in both high- and low-fee states. In states with fee levels above the median Medicare-to-Medicaid ratios, expanding Medicaid eligibility reduced uninsurance rate by 15.2 percentage point (ppt, p < 0.01), shrank the cost-associated unmet medical need by 10.3 ppt (p < 0.01), improved access to usual source of care by 1.9 ppt (p < 0.1), and increased regular checkup by 14.4 ppt (p < 0.01), while such effects in low-fee states were 11.7 ppt (p < 0.01), 8.3 ppt (p < 0.01), 3.1 ppt (p < 0.1), and 12.3 ppt (p < 0.01), respectively. Our results suggest that Medicaid expansion effect on unmet medical need due to cost in higher-reimbursing states was 2.98 ppt (p < 0.05) larger than in lower-reimbursing states. Evidence suggests modest increases in health care access were more strongly associated with expansions in higher-fee states. Medicaid's fee structure should be considered as a factor influencing large-scale coverage expansions.

The advanced practice nurse role's development and identity: an international review

Healthcare is changing; the physician shortage continues to grow and the complexity of health care continues to increase in relation to aging populations, lower reimbursement rates, and increased documentation requirements; an alternative has to be addressed. Globally, the advanced practice nurse (APN) role has grown enormously. Despite the growing use of APN practitioners worldwide, many facilitators and barriers exist to role implementation. Many countries face similar issues, including a lack of clarity and regulation regarding the APN role. Despite these barriers, APNs continue to make headway. This narrative will review barriers and challenges to role advancement across countries and offer opportunities to facilitate APN role development.

OVERVIEW OF THE NEBRASKA GERIATRIC BEHAVIORAL HEALTH WORKFORCE SURVEY

Abstract According to the US Census, more than 16% of Nebraska’s population is 65 and older. Many older Nebraskans reside in rural communities. Although clinicians in existing state-wide workforce surveys endorse working with older adults, it is unclear how frequently they are involved in geriatric mental health. To identify the needs of those who are providing mental health services to older Nebraskans, the Behavioral Health Education Center of Nebraska (BHECN) conducted an online survey of eligible licensed practitioners from August to December 2022. This presentation highlights the background characteristics of 193 respondents, nearly 40% of whom came from rural areas. Two-thirds identified either as licensed mental health therapists (38%), licensed clinical social workers (26%), or licensed psychologists (14%). More than a quarter did not provide direct clinical services to older adults. On average, respondents estimated devoting 18% of their time working with older adults. Respondents listed insurance restrictions, lower reimbursement rates, and limited specialized geriatric mental health training opportunities as major reasons that had kept them from serving older clients more frequently. These findings support BHECN’s ongoing efforts to further develop training and support, and advocate for potential policy changes to enhance the state’s geriatric behavioral and mental health workforce.

Mobile treatment for opioid use disorder: Implementation of community-based, same-day medication access interventions

BackgroundMedications for Opioid Use Disorder (MOUD) are lifesaving, but <20 % of individuals in the US who could benefit receive them. As part of the NIH-supported HEALing Communities Study (HCS), coalitions in several communities in Massachusetts and Ohio implemented mobile MOUD programs to overcome barriers to MOUD receipt. We defined mobile MOUD programs as units that provide same-day access to MOUD at remote sites. We aimed to (1) document the design and organizational structure of mobile programs providing same-day or next-day MOUD, and (2) explore the barriers and facilitators to implementation as well as the successes and challenges of ongoing operation. MethodsProgram staff from five programs in two states (n = 11) participated in semi-structured interviews. Two authors conducted thematic analysis of the transcripts based on the domains of the social-ecological model and the semi-structured interview guide. ResultsMobile MOUD units sought to improve immediate access to MOUD (“Our answer is pretty much always, ‘Yes, we'll get you started right here, right now,’”), advance equity (“making sure that we have staff who speak other languages, who are on the unit and have some resources that are in different languages,”), and decrease opioid overdose deaths.Salient program characteristics included diverse staff, including staff with lived experience of substance use (“She just had that personal knowledge of where we should be going”). Mobile units offered harm reduction services, broad medical services (in particular, wound care), and connection to transportation programs and incorporated consistency in service provision and telemedicine access.Implementation facilitators included trusting relationships with partner organizations (particularly pharmacies and correctional facilities), nuanced understanding of local politics, advertising, protocol flexibility, and on-unit prescriber hours.Barriers included unclear licensing requirements, staffing shortages and competing priorities for staff, funding challenges due to inconsistency in grant funding and low reimbursement (“It's not really possible that billing in and of itself is going to be able to sustain it”), and community stigma toward addiction services generally. ConclusionsDespite organizational, community, and policy barriers, participants described mobile MOUD units as an innovative way to expand access to life-saving medications, promote equity in MOUD treatment, and overcome stigma.

Disparities in brachytherapy utilization in cervical cancer in the United States: A comprehensive literature review

Brachytherapy (BT) is an integral component of treatment for patients with locally advanced cervical cancer, significantly improving local control and overall survival. There is an overall trend of decreased utilization of BT in United States (US) in the last few decades with around 50% of patients being treated without BT. The cause of decreased utilization is multifactorial including physician comfort, facility volume, low reimbursements rates and costs of starting and maintaining a brachytherapy program. This decrease coincides with an increase in the use of newer advanced techniques like intensity modulated radiation therapy (IMRT) and stereotactic body radiation therapy (SBRT) boost resulting in inferior oncological outcomes and increased toxicity. Moreover, racial and socioeconomic disparities in BT utilization have been widely reported in the US. Various factors including age, race, socio-economic status, location, facility type, facility volume and insurance status result in limited access to brachytherapy, which jeopardizes oncologic outcomes. This comprehensive review discusses the BT utilization in the US, examines the impact of race and socioeconomic factors on BT utilization, and highlights its impact on outcomes.

Physician responses to Medicare reimbursement rates

This paper investigates how office-based physicians respond to Medicare reimbursement changes. Using variation from an Affordable Care Act policy that increased reimbursements for office-based care in four states, we use a triple difference analysis, comparing physicians with higher and lower reimbursement changes in treated states to similar physicians in untreated states. We find two mechanisms through which physicians respond. First, the reimbursement change affected integration—physicians with larger increases in office-based reimbursement were less likely to vertically integrate with hospitals and more likely to continue providing office-based care than physicians with smaller reimbursement increases. Second, we find some evidence that physicians who continued practicing in an office setting increased the volume of services provided.

Revision total knee arthroplasty results in financial deficits within the Swiss healthcare system.

Revision total knee arthroplasty (RTKA) results in high costs with inadequately low reimbursement in different healthcare systems. Therefore, a financial analysis was performed comparing costs and reimbursements of primary total knee arthroplasty (PTKA) versus RTKA using financial and total knee arthroplasty-register data from a large tertiary hospital, the Cantonal Hospital of St. Gallen (KSSG), Switzerland. All PTKA and RTKA performed between January 2012 and September 2019 at the KSSG were included. Financial and TKA-register data for each case were collected, including detailed cost allocation, reimbursement, patients' insurance status, type and indication for surgery and length of hospital stay. RTKA was further subdivided in one-stage and two-stage RTKA. Direct hospital costs were analyzed and compared to reimbursement in both groups. Cost-coverage ratios were calculated. 730 PTKA and 106 RTKA were included. The RTKA group contained 66 one-stage and 40 two-stage RTKA. Cost-coverage ratio for PTKA and RTKA showed to be 110.9% and 81.3%, respectively. Cost-coverage ratio was lower for two-stage RTKA than for one-stage RTKA with 74.1% and 92.3%, respectively. RTKA leads to financial deficits especially for tertiary hospitals within the Swiss healthcare system. Restructuring of the reimbursements for PTKA and RTKA should be considered in favor of RTKA. Otherwise, tertiary hospitals will face a growing financial burden with the constantly increasing annual number of RTKA procedures, predominantly performed in this type of hospitals. III.

What We Learned About the Economic and Workforce Issues in Pediatric Ophthalmology: Access to Eye Care and Possible Solutions.

To provide a blueprint reviewing the major economic and workforce issues in pediatric ophthalmology and its effect on access to pediatric eye care, as well as potential solutions. This was a systematic review of the landmark studies examining the economic and workforce issues in pediatric ophthalmology was performed. The number of residents pursuing pediatric ophthalmology fellowship has steadily declined since the early 2000s. Increasing overhead costs, low Medicaid reimbursements, practice pattern changes, and workforce shortages have all contributed to a significant crisis in access to pediatric eye care. Solutions to improve access to pediatric eye care involve pursuing more economical strategies within the confines of the pediatric ophthalmology practice, early exposure to the field during medical education, and enhancing residents' interest through faculty mentorship. Low reimbursements are a major driver contributing to extended appointment wait times for pediatric ophthalmology visits at major academic eye centers. Legislative changes at both the federal and state levels are needed to make appropriate increases in reimbursements, starting with states in the lowest quartile of Medicaid reimbursements. [J Pediatr Ophthalmol Strabismus. 2023;60(5):323-329.].

Economic costs for outpatient treatment of eating disorders in Japan

BackgroundFew studies have examined the economic costs of outpatient care for eating disorders in Japan. This study aimed to clarify the reimbursement for outpatient treatment of eating disorders and compare the costs between the departments of Psychosomatic Medicine and Psychiatry in Japan.MethodA multicenter, prospective, observational study of patients with an eating disorder was conducted in the Psychosomatic Medicine departments of three centers and the Psychiatry departments of another three centers in Japan. We analyzed medical reimbursement for an outpatient revisit, time of clinical interviews, and the treatment outcome measured by the Eating Disorder Examination Questionnaire (EDE-Q) global scores and body mass index (BMI) at 3 months. Multivariate linear regression models were performed to adjust for covariates.ResultsThis study included 188 patients in the Psychosomatic Medicine departments and 68 in the Psychiatry departments. The average reimbursement cost for an outpatient revisit was 4670 yen. Even after controlling for covariates, the Psychosomatic Medicine departments had lower reimbursement points per minute of interviews than the Psychiatry departments (coefficient = − 23.86; 95% confidence interval = − 32.09 to − 15.63; P < 0.001). In contrast, EDE-Q global scores and BMI at 3 months were not significantly different between these departments.ConclusionsThis study clarifies the economic costs of treating outpatients with eating disorders in Japan. The medical reimbursement points per interview minute were lower in Psychosomatic Medicine departments than in Psychiatry departments, while there were no apparent differences in the treatment outcomes. Addressing this issue is necessary to provide an adequate healthcare system for patients with eating disorders in Japan.

"It Has a Lot to Do With the Cumbersome Paperwork": Barriers and Facilitators of Center-Based Early Care and Education Program Participation in the Child and Adult Care Food Program.

The Child and Adult Care Food Program (CACFP) is a federally regulated feeding program that reimburses early care and education (ECE) programs for providing nutritious meals to low-income children. Participation in CACFP is voluntary and varies widely across states. This study assessed barriers and facilitators of center-based ECE program participation in CACFP and identified potential strategies to promote the participation of eligible programs. This was a multimethod (eg, interviews, surveys, and document reviews) descriptive study. Participants included stakeholders from 22 national and state agencies that work with ECE programs to promote CACFP, nutrition, and quality care; representatives of 17 sponsor organizations; and 140 center-based ECE program directors from Arizona, North Carolina, New York, and Texas. Barriers, facilitators, and recommended strategies to promote CACFP that emerged from interviews were summarized with relevant illustrative quotes. Survey data were analyzed descriptively using frequencies and percentages. Key barriers to center-based ECE program participation in CACFP shared by participants included the cumbersome CACFP paperwork, difficulty meeting eligibility requirements, strict meal patterns, difficulties with meal counts, penalties for noncompliance, low reimbursements, inadequate ECE staff to assist with paperwork, and limited trainings. Facilitators to participation included supports provided by stakeholders and sponsors through outreach, technical assistance, and nutrition education. Potential strategies recommended to promote CACFP participation would require policy change (eg, streamlining paperwork, modifying eligibility requirements, and leniency toward noncompliance) and systems-level change (eg, more outreach and technical assistance) by stakeholders and sponsor organizations. Stakeholder agencies recognized the need to prioritize CACFP participation and highlighted ongoing efforts. Policy changes are needed at the national and state levels to address barriers and ensure consistent CACFP practices among stakeholders, sponsors, and ECE programs.

A propensity score matched analysis of robotic and open hepatectomy for treatment of liver tumors. Clinical outcomes, oncological survival, and costs comparison.

Minimally invasive robotic hepatectomy is gaining popularity with a faster rate of adoption when compared to laparoscopic approach. Technical advantages brought by the robotic surgical system facilitate a transition from open to minimally invasive technique in hepatic surgery. Published matched data examining the results of robotic hepatectomy using the open approach as a benchmark are still limited. We aimed to compare the clinical outcomes, survival, and costs between robotic and open hepatectomy undertaken in our tertiary hepatobiliary center. With IRB approval, we prospectively followed 285 consecutive patients undergoing hepatectomy for neoplastic liver diseases between 2012 and 2020. Propensity score matched comparison of robotic and open hepatectomy was conducted by 1:1 ratio. Data are presented as median (mean ± SD). The matching process assigned 49 patients to each arm, open and robotic hepatectomy. There were no differences in R1 resection rates (4% vs 4%; p = 1.00). Differences in perioperative variables between open and robotic hepatectomy included postoperative complications (16% vs 2%; p = 0.02) and length of stay (LOS) [6 (7 ± 5.0) vs 4 (5 ± 4.0) days; p = 0.002]. There were no differences between open and robotic hepatectomy regarding postoperative hepatic insufficiency (10% vs 2%; p = 0.20). No difference was seen in long-term survival outcomes. While there were no differences in costs, robotic hepatectomy was associated with lower reimbursement [$20,432 (39,191 ± 41,467.81) vs $33,190 (67,860 ± 87,707.81); p = 0.04] and lower contribution margin [$-11,229 (3902 ± 42,572.43) vs $8768 (34,690 ± 89,759.56); p = 0.03]. Compared to open approach, robotic hepatectomy robotic offers lower rates of postoperative complications, shorter LOS and similar costs, while not compromising long-term oncological outcomes. Robotic hepatectomy may eventually become the preferred approach in minimally invasive treatment of liver tumors.

Surgical sexism in Canada: structural bias in reimbursement of surgical care for women.

It is well established that female physicians in Canada are reimbursed at lower rates than their male counterparts. To explore if a similar discrepancy exists in reimbursement for care provided to female and male patients, we addressed this question: Do Canadian provincial health insurers reimburse physicians at lower rates for surgical care provided to female patients than for similar care provided to male patients? Using a modified Delphi process, we generated a list of procedures performed on female patients, which we paired with equivalent procedures performed on male patients. We then collected data from provincial fee schedules for comparison. In 8 out of 11 Canadian provinces and territories studied, we found that surgeons were reimbursed at significantly lower rates (28.1% [standard deviation 11.1%]) for procedures performed on female patients than for similar procedures performed on male patients. The lower reimbursement of the surgical care of female patients than for similar care provided to male patients represents double discrimination against both female physicians and their female patients, as female providers predominate in obstetrics and gynecology. We hope our analysis will catalyze recognition and meaningful change to address this systematic inequity, which both disadvantages female physicians and threatens the quality of care for Canadian women.

Current Diagnostic Pathways for Alzheimer's Disease: A Cross-Sectional Real-World Study Across Six Countries.

Diagnostic pathways for patients presenting with cognitive complaints may vary across geographies. To describe diagnostic pathways of patients presenting with cognitive complaints across 6 countries. This real-world, cross-sectional study analyzed chart-extracted data from healthcare providers (HCPs) for 6,744 patients across China, France, Germany, Spain, UK, and the US. Most common symptoms at presentation were cognitive (memory/amnestic; 89.86%), followed by physical/behavioral (87.13%). Clinical/cognitive tests were used in > 95%, with Mini-Mental State Examination being the most common cognitive test (79.0%). Blood tests for APOE ɛ4/other mutations, or to rule out treatable causes, were used in half of the patients. Clinical and cognitive tests were used at higher frequency at earlier visits, and amyloid PET/CSF biomarker testing at higher frequency at later visits. The latter were ordered at low rates even by specialists (across countries, 5.7% to 28.7% for amyloid PET and 5.0% to 27.3% for CSF testing). Approximately half the patients received a diagnosis (52.1% of which were Alzheimer's disease [AD]). Factors that influenced risk of not receiving a diagnosis were HCP type (higher for primary care physicians versus specialists) and region (highest in China and Germany). These data highlight variability in AD diagnostic pathways across countries and provider types. About 45% of patients are referred/told to 'watch and wait'. Improvements can be made in the use of amyloid PET and CSF testing. Efforts should focus on further defining biomarkers for those at risk for AD, and on dismantling barriers such low testing capacity and reimbursement challenges.