ALZHEIMER’S DRUG THERAPY INITIATIVE

Seniors’ Medication Study

Recruitment ends March 31, 2011

Dear Physician:

Pharmaceutical Services is currently providing physicians with a list of their patients in

the Alzheimer’s Drug Therapy Initiative (ADTI) to help identify possible referrals to the
Seniors’ Medication Study (SMS). We are now looking for ChEI-naïve patients who
started treatment during the last 12 months.

The results of the SMS will improve physician understanding of how these medications
affect Alzheimer’s patients, their families and the impact on B.C.’s health care system
and help inform the validity of the SMMSE.

It is easy to participate in the SMS. After a patient receives ADTI Special Authority
approval, your involvement as physician is limited to submitting the attached SMS
Referral Fax and three Clock-Drawing Tests over the course of 18 months. Once the
referral is made, you will be notified by fax when your patient is accepted into the SMS.

To compensate you for your time spent participating in the research, MSP fees are
available (see attached fee items).

If you have any questions, please contact the Seniors’ Medication Study researchers
toll free at 1 866 511-2594 or 250 721-6574 or by email to smstudy@uvic.ca.

Please note: ChEI coverage through the ADTI will continue after March 2011;
physicians can continue registering and re-registering their patients for coverage
until March 2012.

_____________________________________________________
 MSP FEE ITEMS FOR THE
SENIORS’ MEDICATION STUDY

97004 Patient Referral to the Seniors’ Medication Study $50

(submit Referral Fax to University of Victoria Study
Office – estimated time to complete 1 to 2 minutes)

97006 Patient Assessment at 6, 12 and 18 months (submit $50

Clock Drawing Test to UVic Study Office - estimated
time to complete - 3 to 5 minutes)

97007 Inform Study Office when patient stops medication $15

(submit Medication stop fax to UVic Study Office -
estimated time to complete - up to 3 minutes)
 Referral Fax*
PATIENT & CAREGIVER REFERRAL

From:
Physician Name (office stamp or fill in):

Physician Billing Number (MSP): _______________________________________________________________

Physician providing follow-up care (if different): __________________________________________________

*Please note: no other study documents are required with the Referral Fax; the Study Office will mail further study
documents before the next follow-up visit.

Re: The patient and caregiver have indicated an interest in receiving more information about the study, and
to agree to have their contact information forwarded to the Study Team.

Patient Name:
Patient Address:
Patient Phone:
Care Card Number:

Caregiver Name:
Caregiver Phone:

Questions: Myriam Gerber Hedge, Project Administrator SMS

Chelsie Kadgien, Interview Supervisor CS 1-866-511-2594

Concerns about ethics: Call the UVic Office of Research Services at 250-472-4545

Please Fax To: 1-250-853-3799

MSP CLAIM 97004