Excellent straw @nerdag. I agree widespread clinical adoption of Cogstate is not a given and I liked your comparison to a mining service provider, albeit one with a much better business model from a point of view of scalability. If Cogstate were to tap into the clinical market there would be a lot of up side.

Why persist with paper and pen tests?

• They are accessible - just a Google search away and sometimes the printer even works! (Not a given at public hospitals).
• They are familiar to doctors.

What are the reasons for doctors to start using the Cogstate test?

• It makes sense to use the test that was used in the clinical trials.
• The test works in many languages, widening the TAM.
• If the patient can do the test on their time, we don’t have to do it in the review - it’s the functional equivalent of knowing blood test results when the patient arrives versus having to call pathology companies and alternating between being on hold and repeating details.

What would have to be the case to for us to start using it?

• A treatment. The results would have to change what we do for the patient - we only order tests that change management otherwise the test is a waste of the Medicare budget. Right now the results barely change this because there is no treatment for Alzheimers.
• Evidence their test is good for screening and indication for early treatment.
• Accessibility, accessibility, accessibility to use the test. Since they will not be giving it away, this would be a matter of selling the test to health services and GP clinics. I hear this takes patients, persistence and masochism and a long sales pipeline, but is not unachievable.

What about a university developing a test?

• I know a PhD student in immunology who is burned out from doing pitches of ideas. Even universities are thinking more commercially. But, if somebody could make the same, better and free, I agree they would do it.
• Cogstate’s moat here is the large validation studies that have the test available in many different languages and the software delivery package. To do this requires many neuropsychologists who are multilingual. Neuropsychologists are in short supply and can charge out their time at a fair clip. Listen to Brad on the Tiny Giants podcast to get an idea of this.
• A quantitative way to think about this risk would be to estimate how much it would cost to do the above. Would the government be willing to fund a grant that size for something already being done commercially? Then ask, would the lab pull it off in the 3-5 year grant cycle?

In summary, clinical testing is a long way away but has huge upside potential. If you manage to buy Cogstate at a good valuation for the clinical trials segment alone then I think you’re still doing very well.

Cogstate BB (brief battery) was tested on the largest validation sample and had the highest test-retest reliability.

Tsoy2021_Article_CurrentStateOfSelf-Administere.pdf

@mbry9625

Cogstate uses their electronic form of the “Frontal Assessment Battery.” I will update this with a peer reviewed meta analysis comparing it to other tests of cognition that I found quite helpful when my conviction was tested about a year ago.

The frontal assessment battery will be sensitive to lots of things but not specific. I won’t know why my patient has poor cognition, but it will tell me I need to investigate. That’s the same for high or low blood pressure, a high heart rate, fever, or any other clinical sign.

I found myself wishing I could use it for a patient just yesterday who is at risk of cognitive decline. The other tools I have are imprecise and we didn’t have enough time so the juice just wasn’t with the squeeze to do something else. If I did do a paper and pen test and somebody went looking for it later, and it wasn’t lost, it would be too hard for them to find in the file anyway so even though I did the work, there would effectively be no record. But if I could have sent him an app to do in his own time that would have been accessible and not hard to find for somebody else, I would have done it.

(For clarity I am working in a Victorian public psychiatry clinic. You can bet your average GP has better records, but even less time.)

Delirium is a clinical diagnosis so a cognitive test would not be necessary - if a patient has the attention span for a cognitive test they are probably not delirious. Somebody with normal pressure hydrocephalus would probably have worsened cognition, Cogstate’s test wouldn’t tell you it’s that, but a neurologist worth their salt would look for the rest of the clinical syndrome and a non-neurologist would at least refer.