2021 Annual Report by American Academy of Neurology

FROM THE PRESIDENT AND CEO Dear AAN Member, We are pleased to announce the AAN grew its membership for a second straight year during the COVID-19 pandemic, with 38,000 members, or five-percent growth, in 2021. This is on top of four-percent growth in 2020. We believe this is due to the Academy’s resolve to commit to delivering value to our members no matter where you are in your career, or where you happen to be practicing around the world. The Academy’s leadership has heard of, and experienced firsthand, the continuous challenges imposed on our workforce since the pandemic began in 2020. We know members have been beleaguered by frontline clinical support staff shortages. We’ve heard of challenges related to workforce departures and applicants who do not want to be vaccinated. You’ve shared your frustrations about the disruptions to your education or teaching, and your concerns about the increased risks to your personal health and work/life balance. Throughout 2021, the AAN focused on developing the necessary resources to help you manage employee shortages and transitions, to help you maximize reimbursement and access to your patients through telehealth, and to provide wellness initiatives to ease the stresses of these difficult times. The Academy was determined to provide members with the best education and science programming possible given the pandemic. The neurology community responded heartily to our virtual Annual Meeting in April, which featured more than 2,200 abstracts and drew a record professional attendance of 12,851, on par with an in-person meeting. This was followed by the highly successful virtual Sports Concussion Conference, the 12-week Advanced Practice Provider Neurology Education Series, and the virtual Fall Conference. Again, high participation rates demonstrated the hunger of neurology professionals to keep their knowledge and skills up to date. In support of the Academy’s mission and members’ vital education needs during this challenging time, the American Board of Psychiatry and Neurology generously provided the AAN with $2M in grants to support CME and self-assessment programming as well as the Axon Registry® in 2021.

Our legislative and regulatory advocacy efforts in the United States continued unabated, even if most lobbying needed to be conducted virtually, as was the case with Neurology on the Hill and the Legislative Summit. The AAN prodded the US Congress to support key telehealth initiatives and make telehealth reforms permanent following the public health emergency. The Academy worked closely with the medical community to convince Congress to avert the nearly 10-percent reductions known as the “Medicare Cliff” and expand funding for federal medical research for 2022. We also succeeded in key areas of the 2022 Medicare Physician Fee Schedule final rule. Practicing neurologists found value in our continued efforts to mitigate the effects of the pandemic with helpful webinars, tools, and resources. We continued to deliver insightful clinical practice guidelines and timely quality improvement measures, and solidified our relationship with Verana Health, the AAN’s ingestion partner for our Axon Registry. The need for equity and inclusiveness in health care has never been greater. In 2021, in the effort to identify and address disparities among both neurologists and patients, the AAN established a new Inclusion, Diversity, Equity, Anti-racism, and Social Justice (IDEAS) Subcommittee. The subcommittee ensures the AAN and its actions reflect the breadth and diversity of its members, and works to identify strengths, issues, gaps, and opportunities related to IDEAS within the AAN and to maintain an inclusive environment. Our work on IDEAS resulted in dozens of presentations and abstracts presented during the virtual Annual Meeting, and webinars and published articles throughout the year. AAN publications stood strong, with the Neurology® journals delivering the latest in research, Neurology Today® covering timely news topics, and AANnews® keeping members current on Academy events, products, and new tools and resources that increase the value of their memberships. We are proud to note 2021 was the 70th anniversary for the Neurology journal and 20th anniversary for Neurology Today.

2021 ANNUAL REPORT | AMERICAN ACADEMY OF NEUROLOGY | FROM THE PRESIDENT AND CEO

Neurology professionals demonstrated their need for and devotion to the AAN as membership continued its strong pace in 2021 despite the pandemic. Final data shows membership retention in 2021 was 94 percent for dues-paying US neurologists. In addition, there are now more than 1,900 APP members and 23 percent of AAN members are international. Membership for residents, fellows, and students also showed record growth. Also in 2021, the AAN selected a new customer relationship management system, enabling more robust enhancements in our collection of data allowing a deeper understanding of our members to better enable the Academy to meet the needs of our members and demonstrate our commitment to our mission and vision. From a financial standpoint, 2021 surpassed our expectations. Amid the many uncertainties caused by the pandemic, we tightened our expenses both in our initial budget and incrementally throughout the year, spending $44 million, with our education activities for members leading with 24 percent of costs. Our revenues were $52.9 million, where strong support from our royalties and publications contributed 44 percent of that income. We are proud that 80 cents of every dollar are directly applied to benefits for our members.

remained virtual. Some staff returned to our Minneapolis headquarters intermittently through the fall and early winter, but with the rise of the omicron variant the Executive Team planned for a soft return to office for staff through the first quarter of 2022. We secured a new office near Capitol Hill for the Washington, DC, staff, who will begin working there in 2022. Though the AAN finished the year in a strong position with regard to membership and finances, we are not taking anything for granted as we look to 2022. Even with our vast knowledge and skills, the medical profession—indeed, all of us, everywhere—have been humbled by this predatory and unpredictable virus. Nonetheless, the member leaders and staff of the AAN remain firm in our resolve to deliver on the value of your membership. In these uncertain times, of this you can be certain.

This is not to say we were not tested by the lingering disruptions of the pandemic. Once again, the health and safety of our members and staff was foremost in mind throughout the year, and most meetings

Orly Avitzur, MD, MBA, FAAN President, AAN oavitzur@aan.com Twitter: @OrlyA

Mary E. Post, MBA, CAE AAN Chief Executive Officer MPost@aan.com Twitter: @MaryPostCEO

MEMBERSHIP

50.7%

TOTAL MEMBERS

29,500 US MEMBERS 8,500 INTERNATIONAL MEMBERS 14,500 US NEUROLOGISTS

38,000

1.2% 7.9%

NEUROLOGIST/PHYSICIAN: 50.7%

138 COUNTRIES REPRESENTED

JUNIOR/INTERN: 16.9%

16.9%

2.5%

SENIOR/HONORARY: 7.5%

7.5%

RESEARCHER: 2.5%

13.3%

STUDENT: 13.3%

2021 ANNUAL REPORT | AMERICAN ACADEMY OF NEUROLOGY | MEMBERSHIP

ADVANCED PRACTICE PROVIDER: 7.9% BUSINESS ADMINISTRATOR: 1.2%

2016

2017

2018

2019

2020

2021 38,000

36,000

34,000 32,000

GROWTH

WORLD’S LARGEST PROFESSIONAL ASSOCIATION OF NEUROLOGISTS

IN 2021

REMARKABLE GROWTH: BY THE NUMBERS

Membership continued its strong pace in 2021 despite the pandemic, with 5 percent growth in total membership, bringing the total number of members to 38,000. Membership retention was 94 percent for dues-paying US neurologists. The AAN now has a record 1,900 APP members and membership for residents, fellows, and students also saw record growth.

94%

RETENTION

*May reflect members with multiple volunteer positions. **Reflects retention of US neurologist members.

6,800* MEMBER VOLUNTEERS

92%

OF CURRENT US MARKET SHARE OF NEUROLOGISTS

200 STAFF

1,900+ APP MEMBERS

As a member of the AAN Family, I am grateful for the opportunity to participate in the AAN's

CONTINUED GROWTH AND DEVELOPMENT, AND SUCCESS.

SECTIONS AND SYNAPSE

The new Synapse Mobile App was launched for SynapseSM Member Communities, which now includes 25,000 AAN members participating in more than 60 communities.

Rodney O. Leacock, MD

BECOMING INVOLVED, both at the AAN and within my local hospital system, HAS BEEN MY ANTIDOTE TO BURNOUT…. Although we cannot fix all the problems plaguing our practice and career, trying to contribute to solutions has been very rewarding. [And], working with some amazing colleagues across the AAN has been inspirational and creates a new level of collegiality. Michael Markowski, DO, FAAN

2021 ANNUAL REPORT | AMERICAN ACADEMY OF NEUROLOGY | MEMBERSHIP

The Wellness Subcommittee was appointed as part of Dr. Avitzur’s presidential platform, creating a centralized entity to oversee the AAN’s wellness programming. The virtual Live Well education learning area (ELA) presentations were the second most-viewed ELA at the virtual Annual Meeting, showing a strong interest in wellness among neurology professionals. Additional work was done to improve digital wellness resources and develop additional wellness training that is accessible to all members.

24%

JOB VIEWS OVER 2020

46%

JOB APPLICATIONS

INCLUSION, DIVERSITY, EQUITY, ANTI-RACISM, AND SOCIAL JUSTICE (IDEAS)

The AAN made great progress with its IDEAS initiatives in 2021, including the establishment of the Advancing Women in Academics Subcommittee, the IDEAS Subcommittee, and changing the Diversity Officer Work Group to the Diversity Officer Subcommittee. The Academy published a Position Statement on the Use of Neck Restraints in Law Enforcement and began the development of an anti-racism education program for members. Webinars were offered on health care disparity, anti-racism, and diversity. More than 600 people attended the inaugural Health Care Equity Symposium at the virtual Annual Meeting. The meeting featured 35 IDEAS-themed presentations and 31 Health Care Disparity abstracts. The new Health Care Equity Scholarship Program kicked off in April. Twenty members will graduate from this program in March 2022 after concluding a year-long curriculum and personal project.

35 SYMPOSIUM ATTENDEES

IDEAS PRESENTATIONS

NEUROLOGY CAREER CENTER

The COVID-19 pandemic sparked career reassessments and job changes in all walks of life, including neurology. The Neurology Career Center saw an increase in job views to more than 140,000, or 24 percent over 2020. Likewise, job applications increased 46 percent to 4,100+. Job recruiters helped increase revenue to $1.7 million.

31 IDEAS ABSTRACTS

GRADUATES

MEMBERSHIP

WELLNESS

EVENTS 2021 VIRTUAL ANNUAL MEETING

After cancelling the 2020 Annual Meeting due to the pandemic, the AAN was determined to bring the neurology community together in 2021. The Academy held its first virtual Annual Meeting in April, achieving a record professional attendance of 12,851 from 115 countries with over 10,500 attending live, exceeding Academy registration and revenue goals. Attendees engaged with one another on social media with #AANAM, resulting in an incredible 33.5 million impressions.

ATTENDEES GAVE THE VIRTUAL ANNUAL MEETING A SATISFACTION RATING OF EXCELLENT/GOOD

for these items: Overall Annual Meeting, Education courses, Plenary sessions, Scientific sessions, and Virtual platform.

2021 ANNUAL REPORT | AMERICAN ACADEMY OF NEUROLOGY | EVENTS

FIRST ANNUAL MEETING VIRTUALLY.

IT WAS INCREDIBLE.

Looking forward to attending the next one early next year.

Jaleed Gilani, MBBS

EVENTS

Partook in my

Though virtual meetings can be exhausting, both @AANMember and @ChildNeuroSoc

WORKED HARD TO KEEP US ENGAGED AND CONNECTED.

VIRTUAL FALL CONFERENCE

Held virtually for the second year in a row, the November 5–7 Fall Conference gathered 688 registrants. There was good engagement throughout the conference, with Neurology Update being the biggest draw for attendees. Fall Conference On Demand extends available CME through September 2022.

Yasmin Khakoo, MD, FAAN

THE AAN STAFF SETS UP THE BEST ORGANIZED VIRTUAL EVENTS… . It is heart warming to still get a sense of community [and] exchange [with] passionate people across the country despite the pandemic! Olivia Begasse de Dhaem, MD, FAHS

2021 ANNUAL REPORT | AMERICAN ACADEMY OF NEUROLOGY | EVENTS

ADVANCED PRACTICE PROVIDER NEUROLOGY EDUCATION SERIES

In this 12-week virtual series on a variety of neurology-related topics, six of the 12 sessions included live Q&A with the speakers. The program attracted 638 registrants. The AAN bundled the APP series and NeuroReady: APP Edition at a 20-percent discount for the month of December.

45 IRT +1.6M

INDUSTRY

The AAN celebrated a record number of 45 industry companies/organizations as members of the Industry Roundtable (IRT) in 2021. This garnered $1.6 million in support from IRT companies’ membership dues in 2021. Revenue for the Leadership Programs met or exceeded each individual program's budget. For the portfolio of programs, more than $658,000 was raised for a 35-percent increase over the 2021 budget. For the 2021 virtual Annual Meeting, the AAN offered an Exhibit Hall, Industry Therapeutic Updates, and Sponsorships/Advertising to Industry Partners.

EVENTS

VIRTUAL SPORTS CONCUSSION CONFERENCE

This popular two-day conference was presented virtually July 30–31. It captured 471 registrants, an increase from the 2020 virtual event. International (not including Canada) attendance more than doubled since the 2020 virtual meeting and has increased significantly compared to the last in-person meeting.

The AAN’s ONLINE EDUCATION RESOURCES WERE A LIFELINE for me in 2021. I felt like I was able to continue learning and STAYING ON TOP OF DEVELOPMENTS IN MY FIELD without missing a beat. Kara Stavros, MD

2021 ANNUAL REPORT | AMERICAN ACADEMY OF NEUROLOGY | EDUCATION

NEUROLEARN TO NEUROBYTES

Developed in 2012, the NeuroLearn program was a new concept in online learning at the AAN, but learners cannot always devote an hour watching a full-length lecture. In response to their needs, NeuroLearn has transformed into NeuroBytes, a microlearning format with more than 75 engaging, five-minute videos across a broad range of neurology topics. Quickly produced―often in immediate response to global events and time-sensitive topics, such as “Aducanumab for Alzheimer’s Disease”― the NeuroBytes program is a popular, new concept for e-learning and continues to grow with a limited expansion series, NeuroBytes: Medical Student Series.

ACADEMIC NEUROLOGY

To help academic neurology departments face their many challenges, it was imperative that the AAN examine these needs in a holistic manner and develop tangible resources and solutions in support of the future of academic neurology. Thus, the AAN created an Academic Neurology Committee as well as the Department Chair Subcommittee, Diversity Officer Subcommittee, Division Chief Subcommittee, and Advancing Women in Academics Subcommittee.

EDUCATION

Fall Conference Sports Concussion Annual Meeting APP Education Series

ANNUAL MEETING ON DEMAND

The change of the 2021 Annual Meeting to an all-virtual meeting experience presented opportunities to curate content for members. Annual Meeting On Demand expanded to all conferences now being available On Demand, allowing the AAN to reach learners on a global level as well as providing continued access to meeting content throughout the year. The value of these On Demand offerings has been appreciated by the members and supports the mission of the AAN.

Continuum journal, Continuum Audio, Continuum ReadAloud, NeuroSAE, NeuroBytes, and all of the On Demand conferences are the MAINSTAY OF MY NEUROLOGY EDUCATION. Lindsey Johnson, MD

2021 ANNUAL REPORT | AMERICAN ACADEMY OF NEUROLOGY | EDUCATION

18,807

20,799

5,539

ANNUAL MEETING ON DEMAND UNIQUE ENROLLMENTS

ANNUAL MEETING ON DEMAND COURSE VIEWS

4,150.5 ANNUAL MEETING ON DEMAND CME HOURS

PRESENTATIONS

EDUCATION

4,653

NEUROBYTES VIEWS

x1,000

UNIQUE NEUROBYTES PARTICIPANTS

NEUROBYTES VIDEOS RELEASED

VIDEOS IN NEUROBYTES LIBRARY

LEADERSHIP PROGRAMS

The AAN EMERGING LEADERS PROGRAM STANDS APART. Nothing compares. I use or reflect on what I learned through that program EVERY DAY.

The pandemic did not deter the need for AAN members to learn how to become effective leaders, but it did force the seven leadership programs to be conducted virtually.

LIFE-CHANGING MEANINGFUL MOTIVATING PERSONALIZED POWERFUL REWARDING STIMULATING STRATEGIC SUPPORTIVE THOUGHT-PROVOKING TRANSFORMATIVE UNIFYING VALUABLE WORTHWHILE PRESTIGE UNDERREPRESENTED CHALLENGING AMAZING THOUGHTFUL AWESOME CAREER-CHANGING COLLABORATIVE STIMULATING CONFIDENT ENLIGHTENING WORTHWHILE INVALUABLE

VIRTUAL LEADERSHIP

In 2021, seven leadership programs were conducted virtually. The first Leadership Experiential Learning Area was presented at the 2021 virtual Annual Meeting; presentations were well received, and engagement was high. Industry funding of the leadership programs exceeded expectations.

Bhooma Aravamuthan, MD, DPhil

EDUCATION AWARDS AND SCHOLARSHIPS

For 2021, education awards and scholarships offered to trainees and their educators were modified to be able to offer an equivalent virtual experience as they would have had in person.

2021 ANNUAL REPORT | AMERICAN ACADEMY OF NEUROLOGY | EDUCATION

James R. Brasic, MD

3,300 RITE

Administration of the RITE® (Residency In-training Examination) was modified to ensure the exam was offered in a safe environment. The test window increased to 18 days from the usual five and the exam used a web-based platform which allowed for flexible scheduling. More than 3,300 residents sat for the exam, consistent with previous years. The popularity of the online delivery platform has led to an extension of its use for future test administrations.

EDUCATION

I continue to use the educational activities of the AAN that are approved by ABPN. Now EARNING CREDIT APPROVED BY THE ABPN IS CRUCIAL to my decisions where to focus.

Online education resources have been EXTREMELY HELPFUL BRINGING US TOGETHER EVEN THOUGH WE ARE APART. Synapse community webinars, to the virtual AAN Annual Meeting and many interesting articles published in Neurology journals, I was happy to experience it all. Fabricio Ferreira de Oliveira, MD, BBA, MSc, PhD

2021 ANNUAL REPORT | AMERICAN ACADEMY OF NEUROLOGY | EDUCATION

Online education activities are an READY

EXCELLENT WAY TO EASILY REMAIN UP TO DATE.

I particularly have enjoyed the QOD app.

Ali R. Malek, MD, FAHA

EDUCATION

TRAINEE PROGRAMS

Medical Student Symposium: Careers in Neurology offered panels during the virtual Annual Meeting. Trainee and Faculty Networking Career Panels expanded to offer virtual program posters and career panel sessions during the virtual Annual Meeting and throughout the year. The Virtual Resident Education Lecture Series allowed residents to have access to subspecialty expertise that may not be available at their institution.

RESEARCH ABSTRACTS

VIRTUAL ANNUAL MEETING ABSTRACTS

PRESENTATIONS

VIEWS

The AAN received 2,757 abstracts and accepted 2,207 for presentation during the virtual Annual Meeting. Abstracts were presented orally during scientific sessions and in poster format. To further help members, the poster site was available through October 2021 and received over 50,000 views.

THE COVID-19 PANDEMIC CHANGED THE ENTIRE RESEARCH INFRASTRUCTURE OF MY INSTITUTION. There were multiple restrictions

placed on clinical research activities. I reached out to the AAN with some of these challenges and the program was understanding and flexible, which has been instrumental in allowing me to do the science that I hope to do and move my career forward. Elan L. Guterman, MD

2021 ANNUAL REPORT | AMERICAN ACADEMY OF NEUROLOGY | RESEARCH

$3,090,000 2021 RESEARCH PROGRAM SCHOLARSHIP AWARDS

Awarded 16 scholarships to the 2021 Research Program recipients which included a total of $3,090,000 in funding. This included 8 awards funded by AANI at $1,800,000 and 8 awards funded by the American Brain Foundation and funding partners for $1,290,000.

USER EXPERIENCE UPGRADE

Research Program application was enhanced to improve the experience for members as applicants and reviewers.

CURE ONE, CURE MANY AWARD

Administered the application and review process for the American Brain Foundation’s Cure One, Cure Many Award—a research award for early diagnosis of Lewy body disease. This award is a $3 million, multi-year award with funding from the Alzheimer’s Association, American Brain Foundation, and Michael J. Fox Foundation.

RESEARCH

AWARDS

Scientific awardees were recognized through the virtual Awards Theater. Awardees had the opportunity to record a presentation or acknowledgement of their award that was available during the meeting.

PRACTICE PRACTICE MANAGEMENT

The AAN met the FDA’s controversial approval of aducanumab for treating Alzheimer’s disease with timely resources and a helpful position statement, "Decisions with Patients and Families Regarding Aducanumab in Alzheimer's Disease." The Academy’s belief in the vital importance of telehealth was underscored by a "Telehealth Position Statement" and the formation of the Telehealth Subcommittee of the Medical Economics and Practice Committee. The 2021 Neurology Compensation and Productivity survey drew a record number of more than 4,000 responses.

The AAN members at practice@aan.com reviewed my billing for virtual visits and

HELPED ME GENERATE CLEAN CODING

so that I got paid. The team walked me through this minefield and helped us survive yet another year. [We are] very thankful for their expertise. Lon Burba, MD

VALUE-BASED CARE

The Position Statement on Neurology Advanced Practice Providers was updated. The Academy made two care model case studies available to members and engaged with CMS on stroke MIPS Value Pathways (MVP).

AAN Summary of Practice Advisory Update for Clinicians

AAN Summary of Practice Guideline for Clinicians

AAN Summary of Practice Guideline Update for Clinicians

Practice Advisory Update Summary: Antiseizure Medication Withdrawal in Seizure-free Patients

Dopaminergic Therapy for Motor Symptoms in Early Parkinson Disease Practice Guideline

Oral and Topical Treatment of Painful Diabetic Polyneuropathy Practice Guideline Update

Please refer to the full guideline at AAN.com/guidelines for more information, including descriptions of the processes for classifying evidence, deriving conclusions, and making recommendations.

Recommendations Related to Adults

Level

Rationale There is low confidence that the risk of seizure recurrence is significantly higher among patients with a history of seizures who have been seizure-free over 24–60 months who taper antiseizure medications (ASMs), when compared with patients who do not taper ASMs. Once epilepsy is masked, it is unknowable if you continue to have epilepsy or not. Patients should be part of the medical decision-making process, especially when there is clinical equipoise. Although there is evidence for the predictive power of epileptiform abnormality in EEGs in children, there is no evidence above Class IV in adults. Moreover, the evidence in children cannot be used as related evidence in adults, as it is based on Class III data. The same applies for the small chance of medication resistance seen after ASM withdrawal. To enable patients to make decisions, all the clinically relevant information should be made available. There are multiple factors in making this decision: • Low-quality evidence suggests no difference in quality of life between patients with well-controlled epilepsy who stop versus continue taking ASMs. • Factors contributing to quality of life are potentially highly individual and may include ease of ASM administration (e.g., dose frequency), experience of side effects, seizure recurrence, and comorbidities. • In the 1-year follow-up of 1 trial, there were no deaths, and in the 6-year follow-up of the other trial the only deaths that occurred were in patients who continued taking ASMs. There does not seem to be an increased risk of status epilepticus in patients who are seizure-free for 2 years who withdrew ASMs; however, the risk of status epilepticus may be small in the cohorts of the study, and there may not be enough patients and time to detect a difference. There is no evidence that 2 years has special significance. It is well known that status epilepticus is cause of mortality in epilepsy patients.1

Recommendation

In adults who are seizure-free for at least 2 years, there should be a discussion between the clinician and the patient and/or caregiver, if any, about the risks and benefits of ASM withdrawal, which specifically includes and documents:

Recommendation 1 Level B

1. there is possibly higher seizure recurrence in patients who had ASM withdrawal, and 2. that if seizures recur during or after withdrawal, there is a small chance they will no longer respond to medications.

Level C

When discussing either ASM withdrawal or continuation with patients, since there is no statistically significant evidence to support either option, clinicians may consider individual patient characteristics and preferences.

Level A

Counseling must include discussion that there is not strong evidence regarding the relationship between ASM withdrawal and changes in the risk of mortality and status epilepticus, and, as such, these risks have not been excluded by the evidence.

Level B

Clinicians should counsel that recurrent seizures put people at risk for status epilepticus and death, although existing data do not suggest an increased risk of status epilepticus or death after ASM withdrawal.

Level A

Clinicians must explore contributors to the quality of life of individual patients as part of shared decision-making regarding ASM discontinuation.

Level B

Clinicians should discuss with seizure-free patients that it is unknown if EEG or imaging studies inform the decision to withdraw ASMs.

AAN.com

This is a summary of the American Academy of Neurology (AAN) guideline, “Dopaminergic Therapy for Motor Symptoms in Early Parkinson Disease Practice Guideline,” which was published in Neurology ® online on November 15, 2021, and appears in the November 16, 2021, print issue. Please refer to the full guideline at AAN.com/guidelines for the full systematic review of the evidence as well as descriptions of the processes for classifying evidence, deriving conclusions, and making recommendations.

Levodopa vs Dopamine Agonists vs Monoamine Oxidase Type B (MAO-B) Inhibitors

Level

Recommendation

Recommendation 1

Level B

Clinicians should counsel patients with early PD on the benefits and risks of initial therapy with levodopa, dopamine agonists, and MAO-B inhibitors based on the individual patient’s disease characteristics to inform treatment decisions.

Level C

Clinicians may prescribe dopamine agonists as the initial dopaminergic therapy to improve motor symptoms in select early PD in patients <60 years who are at higher risk for the development of dyskinesia.

Level B

Clinicians should not prescribe dopamine agonists to patients with early-stage PD at higher risk of medication-related adverse effects, including individuals >70 years-of-age, patients with a history of ICDs, and patients with preexisting cognitive impairment, excessive daytime sleepiness, or hallucinations.

Rationale Clinical trials have failed to provide evidence of disease modification when the initial therapy prescribed is levodopa,1 a dopamine agonist,2 or an MAO-B inhibitor.3 Studies comparing treatment with levodopa to treatment with MAO-B inhibitors early in the disease course provide Class IV evidence. These studies demonstrate greater improvement in mobility with levodopa than with MAO-B inhibitors, a higher risk of adverse event-related discontinuation with MAO-B inhibitors, and that more than 60% of individuals randomized to MAO-B inhibitors will require additional therapy within 2 to 3 years. Initial treatment of early Parkinson disease (PD) with levodopa provides greater benefit for motor symptoms than initial treatment with dopamine agonists, as shown in the majority of studies that demonstrate greater improvement in the Unified Parkinson’s Disease Rating Scale (UPDRS) part III score for the first 5 years of follow-up. Initial treatment with levodopa is more likely to induce dyskinesia than initial treatment with dopamine agonists for up to 5 years of follow-up, but the prevalence of severe or disabling dyskinesia during this 5-year period is low. While initial treatment with dopamine agonists is possibly more likely to cause hallucinations than treatment with levodopa, the difference between treatments for this outcome is small for the first 5 years of treatment. Treatment with dopamine agonists in early PD is associated with a higher risk of impulse control disorders (ICDs). Patient and disease characteristics influence the risk of adverse effects related to the use of levodopa and dopamine agonists and may affect initial treatment choices. Younger age of disease onset,4 lower body weight,5, 6 female sex,7 and increased disease severity 8-10 are all predisposing factors for the development of levodopa-induced dyskinesia. Predisposing patient characteristics for ICDs are male sex, younger age, history of ICDs, history of mood disorders (particularly depression), the presence of apathy, and a family history of ICDs and addiction.11-14 Older patients are at greater risk for cognitive and behavioral adverse effects of dopamine agonists.15 Dopamine agonists are associated with a greater risk of excessive daytime somnolence and sleep attacks; therefore, patients whose employment requires driving or operating heavy machinery may face greater impairment from these adverse effects.16 © 2021 American Academy of Neurology

This is a summary of the American Academy of Neurology (AAN) practice advisory update, “Oral and topical treatment of painful diabetic polyneuropathy practice guideline update summary,” which was published in Neurology ® online on December 27, 2021, and appears in the January 4, 2022, print issue. Please refer to the full guideline at AAN.com/guidelines for more information, including for descriptions of the processes for classifying evidence, deriving conclusions, and making recommendations.

Recommendation 1

Recommendation 3

Rationale Painful peripheral neuropathy is a common complication of diabetes and is more common in patients with longer durations of diabetes and poor glycemic control.1-3 Patients with diabetes should be assessed for the presence of peripheral neuropathy and neuropathic pain periodically, although the optimal frequency of such assessment is not clear. Most studies of treatments for painful diabetic peripheral neuropathy have assessed pain using visual analog scales, numerical rating scales, or similar measures. Such scales are commonly used in practice, but they do not provide insight into the effect of pain on patients’ functioning and well-being. Other scales that assess pain interference (BPI-DPN) 4 or effects on quality of life (Norfolk QOL-DN)5 may provide more relevant information to assess the need for treatment and success of such treatment.

Rationale In treating patients with painful diabetic neuropathy, it is important to assess other factors that may also affect pain perception and quality of life. Patients with diabetes are more likely to have mood disorders (most commonly, major depression) and sleep disorders (especially obstructive sleep apnea) than the general population.7,8 Mood and sleep can both influence pain perception.9,10 Therefore, treating concurrent mood and sleep disorders may help reduce pain and improve quality of life, apart from any direct treatment of the painful neuropathy. Some treatments for painful neuropathy may also have beneficial effects on mood and sleep (e.g., TCAs and SNRIs) and, therefore, may produce some of their benefits through these pathways.

Level

Recommendation

Level B

Clinicians should assess patients with diabetes for peripheral neuropathic pain and its effect on these patients’ function and quality of life.

Prescribing Levodopa

Level

Recommendation

Level B

Clinicians should assess patients with painful diabetic neuropathy for the presence of concurrent mood and sleep disorders and treat them as appropriate.

Recommendation 4

Recommendation 2

Rationale The evidence comparing immediate-release (IR) levodopa to controlledrelease (CR) levodopa or levodopa/carbidopa/entacapone is either of very low confidence or did not detect differences between formulations for improvement in motor symptoms, dyskinesia, hallucinations, or adverse event-related discontinuation in early PD. There are no studies comparing IR levodopa to extended-release (ER) carbidopa/levodopa in early PD.

Rationale Several classes of pharmacologic agents have been demonstrated to reduce pain in patients with painful diabetic neuropathy. However, complete resolution of symptoms is often not achieved. Patients expect a high degree of pain relief, and many expect complete pain resolution.6 In order to promote patient satisfaction, aligning patients’ expectations with the expected efficacy of interventions (approximately 30% pain reduction is considered a success in clinical trials) would be beneficial.

While there is no evidence to support superiority of one formulation of levodopa over another, there are other reasons to favor initiating treatment with IR levodopa. CR levodopa has lower bioavailability and less predictable symptom relief compared to IR levodopa,17, 18 which may necessitate treatment discontinuation in later stages of the disease due to dose failures. While levodopa/carbidopa/entacapone can be helpful for patients who experience end-of-dose wearing-off,19 this is not a usual clinical feature in early PD. IR levodopa is less costly than other levodopa formulations. Clinical trials in early PD demonstrate symptomatic benefit with levodopa/carbidopa at dosages of 150–300 mg/d and a lower risk of dyskinesia with dosages less than 400 mg/d. While the risk is higher with DAs, levodopa may cause ICDs, AAN.com

Level

Recommendation

Level B

When initiating pharmacologic intervention for painful diabetic neuropathy, clinicians should counsel patients that the goal of therapy is to reduce, and not necessarily to eliminate, pain.

Rationale Painful diabetic neuropathy is a highly prevalent condition that greatly affects quality of life.11 Four classes of oral medications have demonstrated evidence of pain reduction in meta-analyses: TCAs, SNRIs, gabapentinoids, and sodium channel blockers. The best estimates of the effect sizes and the corresponding CIs are comparable for all of these drug classes, which makes recommendations for one over another difficult. Level

Recommendation

Level B

In patients with painful diabetic neuropathy, clinicians should offer TCAs, SNRIs, gabapentinoids, and/or sodium channel blockers to reduce pain.

AAN.com

QUALITY IMPROVEMENT

The Academy published three guidelines throughout the year: Dopaminergic Therapy for Motor Symptoms in Early Parkinson Disease; Antiseizure Medication Withdrawal in Seizure-free Patients Practice Advisory Update; and Oral and Topical Treatment of Painful Diabetic Polyneuropathy Practice Guideline. Quality measures published during the year focused on Parkinson’s disease, concussion, multiple sclerosis, and polyneuropathy.

AXON REGISTRY

"Quality of Neurologic Care in the United States: Initial Report From the Axon Registry" was published in Neurology. The findings serve as a baseline assessment of quality of ambulatory neurologic care in the United States and provide insights into future measure design. The Axon Registry® continued the transition from FIGmd to Verana Health to ensure high-quality data and superior experiences for AAN members participating in the clinical improvement database.

PRACTICE

This is a summary of the American Academy of Neurology (AAN), “Practice advisory update summary: Antiseizure medication withdrawal in seizure-free patients,” which was published in Neurology ® online on December 6, 2021, and appears in the December 7, 2021, print issue.

ADVOCACY

I loved the virtual #AANAM and

EXPANDING MY ADVOCACY WORK

through NOH, the Legislative Summit, and PALF! #NeurologyProud

Casey F. Jeffreys, MD THE MEDICARE CLIFF

In December, Congress enacted legislation to eliminate or delay several harmful policies, collectively known as the “Medicare Cliff,” that otherwise would have caused a nearly 10-percent reduction to Medicare reimbursement on January 1, 2022. This legislation was only possible due to the significant advocacy campaign conducted by the physician community, which included hundreds of AAN members responding to action alerts and advocating virtually through Neurology on the Hill and the AAN's Legislative Summit.

$65 BILLION TELEHEALTH

The AAN rallied the US Congress to support key telehealth initiatives, including approving $65 billion investment into fast and reliable broadband infrastructure, affordability, and adoption, and getting a majority of Congress to go on record in support of retaining key telehealth reforms permanently after the public health emergency.

FUNDING FOR RESEARCH

Congress proposed historical levels of funding for federal medical research for fiscal year 2022, including billions of additional funding to the National Institutes of Health, and increases in funding for the BRAIN Initiative. The AAN also helped persuade Congress to express strong support for all of the VA Neurology Centers of Excellence, which focus on epilepsy, headache, MS, and Parkinson’s disease, a decision that has already started driving new investments into these centers for the first time in many years.

2021 ANNUAL REPORT | AMERICAN ACADEMY OF NEUROLOGY | ADVOCACY

SOCIAL MEDIA IMPRESSIONS

VIRTUAL NEUROLOGY ON THE HILL

In May, 185 members from 46 states participated in the AAN’s first virtual Neurology on the Hill, meeting with 246 congressional offices. Members advocated for AAN priority issues, including the permanent expansion of telehealth access, funding for neurologic research recovery, and averting the Medicare Cliff. Participants contributed over 1,300 social media tweets and nearly 900 retweets, totaling over 2 million impressions.

THE EXCEPTIONAL AAN STAFF MAKE IT SO EASY TO GET INVOLVED IN ADVOCACY

via their emails, updates, and action center. Thanks to @AANadvocacy, I've connected with wonderful and passionate peers.

Olivia Begasse de Dhaem, MD, FAHS

ADVOCACY

2,000,000

PUBLICATIONS

All four Neurology® journals reached gender parity in editorial board composition. International representation of all the editorial boards also increased. Luca Bartolini, MD, was appointed editor for Neurology® Clinical Practice.

Volume 97, Number 24, December 14, 2021

Volume 5, Number 1, February 2019

Volume 11, Number 5, October 2021

Neurology.org/N

Neurology.org/NG

Neurology.org/CP

The most widely read and highly cited peer-reviewed neurology journal

A peer-reviewed clinical and translational neurology open access journal

RESEARCH ARTICLE

THE HELIX

RESEARCH

Association of Short-term Heart Rate Variability and Sudden Unexpected Death in Epilepsy 1105

2018: Year in Review and Message from the Editors to Our Reviewers e309

Suicide and Seizures: A National Cohort Study in Veterans

RESEARCH ARTICLE

ARTICLE

RESEARCH

Neurofascin-155 Immunoglobulin Subtypes: Clinicopathologic Associations and Neurologic Outcomes 1108

Gene variants of adhesion molecules predispose to MS: A case-control study e304

Decreasing Emergency Department Visits for Children With Epilepsy

ARTICLE

REVIEW

RESEARCH ARTICLE

Genomic deletions upstream of lamin B1 lead to atypical autosomal dominant leukodystrophy e305

Striking MRI Changes of Focal Cortical Dysplasia Over Time: A Case Series and Literature Review

CLINICAL/SCIENTIFIC NOTE

CASE

Variable reporting of C9orf72 and high rate of uncertain results in ALS genetic testing e301

A Neurostimulation-Triggered Trigeminal Neuralgia-Like Pain: Risk Factors and Management

Simulation-Based Assessment of Graduate Neurology Trainees’ Performance Managing Acute Ischemic Stroke 1110 REVIEW

CNS Involvement in Hereditary Transthyretin Amyloidosis 1111

A peer-reviewed clinical neurology journal for the practicing neurologist

2021 ANNUAL REPORT | AMERICAN ACADEMY OF NEUROLOGY | PUBLICATIONS

The journal impact factors from 2020 were released on July 30, 2021, from Clarivate. Impact factors indicate the number of citations to articles published in the last two full calendar years and help authors decide where to publish their papers. The Impact Factors received for all journals are strong: The Neurology 2020 Impact Factor increased to 9.901 from the 2019 Impact Factor of 8.77. The 2020 Impact Factor for Neurology® Neuroimmunology & Neuroinflammation increased to 8.485 from the 2019 Impact Factor of 7.724. Neurology® Genetics has a 2020 Impact Factor of 3.485, a slight decline from the 2019 Impact Factor of 3.509.

9.901

10.0 9.0 8.0 7.0

8.485 8.77 7.724

6.0 5.0 4.0 3.0

3.485 3.509

2.0 1.0 0.0 2019

2020

PUBLICATIONS

STRENGTH IN IMPACT FACTORS

FINANCIAL SUMMARY

80 CENTS OF EVERY DOLLAR is directly applied to member benefits.

2021 ANNUAL REPORT | AMERICAN ACADEMY OF NEUROLOGY | FINANCIAL SUMMARY

2021 REVENUE: $52.9M

44% 2021 EXPENSES: $44M

Royalties & Publications: Membership Dues: 20%

44%

Grants & Gifts: 15% Other: 3%

20%

24%

Conference & Education: 18%

20%

Education: 24%

General & Administrative: 20%

15%

Membership: 16%

Grants & Awards: 12%

18%

Publications: 12%

16%

Advocacy: 9%

Clinical Practice: 7%

9% 12%

12%

2021–2022 STRATEGIC PLAN VISION:

TO BE INDISPENSABLE

to our members.

MISSION:

To promote the

HIGHEST QUALITY PATIENT-CENTERED NEUROLOGIC CARE

and enhance

MEMBER CAREER SATISFACTION.

The Academy leads with foresight and uses a collaborative strategic management process that engages both physician leaders and AAN staff on a continuous cycle of planning, executing, monitoring, analyzing, and assessing all that is necessary for the Academy to meet its goals and objectives. Foresight is a critical component of leadership—an essential part of the fiduciary responsibility of the AAN and AAN Institute Boards of Directors. Foresight practice adds value and strategic insight to all levels and functional areas of Academy management. At the heart of strategic planning and foresight is the management of risk and uncertainty. The risk and uncertainty of 2021 and beyond has challenged the Academy and our strategic planning process in new ways. Across the Academy, we reimagined our remote workforce and volunteers, acknowledged the major role technology plays in fulfilling our mission and maintaining the Academy’s financial health, and found new ways to engage and communicate with our members and other stakeholders. We navigated the pandemic by realigning our programmatic strategies with the changing needs of our members. We prepared for an uncertain future by realigning parts of the organization to better serve our members. The Board early in 2021 heard the results of a member needs assessment that identified critical assumptions and projections about the future of neurology and the needs of our members. This periodic assessment continues to be a source of critical information for the Board to consider the voices of our members and implications for member engagement and satisfaction. The Board in 2021 also focused on futures planning in the more near term. It engaged in an assessment of trends and identified key drivers of change in considering a five-year envisioned future, and implications for the Academy’s governance in the coming years. No one knows entirely how the future will unfold, but the tools of strategic planning and foresight have assisted the Academy as we prepare for the new reality as it unfolds.

2021 ANNUAL REPORT | AMERICAN ACADEMY OF NEUROLOGY | 2021–2022 STRATEGIC PLAN

OUR 2021–2022 GOALS DESCRIBE how the leaders, members, and staff of the Academy will accomplish our mission and achieve our vision. These goals envision a preferred future to which we aspire for the American Academy of Neurology—a future in which we achieve our vision to be indispensable to all our members.

DEMONSTRATE AND ASSERT THE VALUE OF NEUROLOGY and brain health to policymakers, patients, the public, and other major stakeholders GROW THE NEUROLOGY WORKFORCE and innovate care delivery to meet the future needs for patient care DEMONSTRATE AND COMMUNICATE OUR COMMITMENT to be a fully inclusive, diverse, and anti-racist organization that promotes neurologic health equity and actively works to recruit and support a diverse membership ENSURE THE HEALTH OF THE GLOBAL NEUROLOGY COMMUNITY and enhance member satisfaction, well-being and resiliency, and engagement ADVOCATE AND SUPPORT the financial well-being, continuing viability, and innovation of the practice of neurology EXPAND AND SUPPORT neuroscience research CREATE NOVEL WAYS TO EDUCATE AND ASSIST MEMBERS in providing high-value, team-based, patient-centered, clinical care

THE STORY OF 2021 IS ONE OF CONTINUING RESILIENT ADAPTATION by our leaders, staff, and member volunteers. Notwithstanding our significant challenges, the Academy in 2021 achieved notable progress in accomplishing its goals and objectives. The Academy in 2022 will continue to tell the story of resilient adaptation in support of the entire community of neurology.

AAN BOARD OF DIRECTORS

AAN INSTITUTE BOARD OF DIRECTORS

OFFICERS

President: Orly Avitzur, MD, MBA, FAAN

Chair: Orly Avitzur, MD, MBA, FAAN

President Elect: Carlayne E. Jackson, MD, FAAN

Chair Elect: Carlayne E. Jackson, MD, FAAN

Vice President: Janis Miyasaki, MD, FAAN

Vice Chair: Janis Miyasaki, MD, FAAN

Secretary: Sarah M. Benish, MD, FAAN

Secretary/Treasurer: Jonathan P. Hosey, MD, FAAN

Treasurer: Charles C. Flippen, II, MD, FAAN

Immediate Past Chair: James C. Stevens, MD, FAAN

Immediate Past President: James C. Stevens, MD, FAAN

DIRECTORS

Wayne E. Anderson, DO, FAAN

Brenda Banwell, MD, FAAN

Charlene Gamaldo, MD, FAAN

James N. Goldenberg, MD, FAAN

Larry B. Goldstein, MD, FAAN, FAHA

Lily Jung Henson, MD, MMM, FAAN

Shannon M. Kilgore, MD, FAAN

Brett M. Kissela, MD, FAAN, MS

Bruce I. Ovbiagele, MD, MSc, FAAN

EX OFFICIO (VOTING)

Lyell K. Jones, Jr., MD, FAAN

Bruce H. Cohen, MD, FAAN

Jose G. Merino, MD, MPhil, FAAN, Editor-in-Chief, Neurology®

Brad C. Klein, MD, MBA, FAAN

Natalia Sana Rost, MD, MPH, FAAN, FAHA

Maisha T. Robinson, MD, MS, FAAN

Joseph I. Sirven, MD, FAAN

Jose G. Merino, MD, MPhil, FAAN, Editor-in-Chief, Neurology

EX OFFICIO (NON-VOTING)

Mary E. Post, MBA, CAE

2021 ANNUAL REPORT | AMERICAN ACADEMY OF NEUROLOGY | 2021 BOARDS OF DIRECTORS + COMMITTEE CHAIRS

2020-2021 COMMITTEE CHAIRS AAN DELEGATION TO THE AMA

Mark Milstein, MD, FAAN

AANI EXECUTIVE COMMITTEE

GRIEVANCE COMMITTEE

Peter B. Kang, MD, FAAN

HISTORY AND ARCHIVES COMMITTEE

Orly Avitzur, MD, MBA, FAAN

Douglas J. Lanska, MD, FAAN

ACADEMIC NEUROLOGY COMMITTEE

JOINT AUDIT COMMITTEE

Ralph L. Sacco, MD, MS, FAHA, FAAN

ADVOCACY COMMITTEE

Bruce H. Cohen, MD, FAAN

BOARD PLANNING COMMITTEE

James N. Goldenberg, MD, FAAN

BRAINPAC EXECUTIVE COMMITTEE

Glen R. Finney, MD, FAAN

COMMITTEE ON PUBLIC ENGAGEMENT

David A. Evans, MBA

Natalia Sana Rost, MD, MPH, FAAN, FAHA

Sheri L. Farber, CPA, MBA

JOINT INVESTMENT COMMITTEE

James C. Stevens, MD, FAAN

JOURNAL ARBITRATION COMMITTEE

Lisa M. DeAngelis, MD, FAAN

LEADERSHIP DEVELOPMENT COMMITTEE

Terrence L. Cascino, MD, FAAN

MEDICAL ECONOMICS AND PRACTICE COMMITTEE

Brad C. Klein, MD, MBA, FAAN

MEETING MANAGEMENT COMMITTEE

COMPENSATION COMMITTEE

Ann H. Tilton, MD, FAAN

EDUCATION COMMITTEE

Maisha T. Robinson, MD, MS, FAAN

Jonathan P. Hosey, MD, FAAN Joseph I. Sirven, MD, FAAN

MEMBER ENGAGEMENT COMMITTEE PUBLICATIONS COMMITTEE

ETHICS, LAW, AND HUMANITIES COMMITTEE

Jose G. Merino, MD, MPhil, FAAN

FAIR HEARING PANEL COMMITTEE

Lyell K. Jones, Jr., MD, FAAN

Leon G. Epstein, MD, FAAN Lynne P. Taylor, MD, FAAN

QUALITY COMMITTEE

SCIENCE COMMITTEE

Natalia Sana Rost, MD, MPH, FAAN, FAHA

AMERICAN ACADEMY OF NEUROLOGY

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Minneapolis, MN 55415 AAN.com

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