The effect of direct cognitive assessment in the Medicare annual wellness visit on dementia diagnosis rates

The Effect of Medicare Annual Wellness Visits on Breast Cancer Screening and Diagnosis

OBJECTIVE

The Medicare Annual Wellness Visit (AWV)-a prevention-focused annual check-up-has been available to beneficiaries with Part B coverage since 2011. The objective of this study was to estimate the effect of Medicare AWVs on breast cancer screening and diagnosis.

DATA SOURCES AND STUDY SETTING

The National Cancer Institute's Surveillance, Epidemiology, and End Results cancer registry data linked to Medicare claims (SEER-Medicare), HRSA's Area Health Resources Files, the FDA's Mammography Facilities database, and CMS "Mapping Medicare Disparities" utilization data from 2013 to 2015.

STUDY DESIGN

Using an instrumental variables approach, we estimated the effect of AWV utilization on breast cancer screening and diagnosis, using county Welcome to Medicare Visit (WMV) rates as the instrument.

DATA COLLECTION/EXTRACTION METHODS

66,088 person-year observations from 49,769 unique female beneficiaries.

PRINCIPAL FINDINGS

For every 1-percentage point increase in county WMV rate, the probability of AWV increased by 1.7 percentage points. Having an AWV was associated with a 22.4-percentage point increase in the probability of receiving a screening mammogram within 6 months ( P <0.001). There was no statistically significant increase in the probability of breast cancer diagnosis (overall or early stage) within 6 months of an AWV. Findings were robust to multiple model specifications.

CONCLUSIONS

Performing routine cancer screening is an evidence-based practice for diagnosing earlier-stage, more treatable cancers. The AWV effectively increases breast cancer screening and may lead to more timely screening. Continued investment in Annual Wellness Visits supports breast cancer screening completion by women who are most likely to benefit, thus reducing the risk of overscreening and overdiagnosis.

Perioperative Primary Care Utilization and Postoperative Readmission, Emergency Department Use, and Mortality in Older Surgical Patients

BACKGROUND

Postdischarge primary care follow-up is associated with lower readmission rates after medical hospitalizations. However, the effect of primary care utilization on readmission has not been studied in surgical patients.

METHODS

Retrospective cohort study of Medicare beneficiaries aged 65 and older undergoing major inpatient diagnostic or therapeutic procedures (n = 3,552,906) from 2017 through 2018, examining the association between postdischarge primary care visits within 14 days of discharge (primary exposure), and Annual Wellness Visits in the year prior (secondary exposure), with 30-day unplanned readmission (primary outcome), emergency department visits, and mortality (secondary outcomes).

RESULTS

Overall, 9.5% (n = 336,837) had postdischarge visits within 14 days, 2.9% (n = 104,571) had Annual Wellness Visits in the year preceding the procedure, 9.5% (n = 336,401) were readmitted, 9% (n = 319,054) had emergency department visits, and 0.6% (n = 22,103) of the cohort died within 30 days. Our fully adjusted propensity-matched proportional hazards Cox regression analysis showed that postdischarge visits were associated with a 5% lower risk of readmission (hazard ratio [HR], 0.95, 95% confidence interval [CI], 0.93-0.97), 43% higher risk of emergency department use (HR, 1.43, 95% CI, 1.40-1.46) and no difference in mortality risk (HR, 0.98, 95% CI, 0.90-1.06), compared with not having a visit within 14 days of discharge. In a separate set of regression models, Annual Wellness Visits were associated with a 9% lower risk of readmission (HR, 0.91, 95% CI, 0.88-0.95), 45% higher risk of emergency department utilization (HR, 1.45, 95% CI, 1.40-1.49) and an 18% lower mortality risk (HR, 0.82, 95% CI, 0.75-0.89) compared with no Annual Wellness Visit in the year before the procedure.

CONCLUSIONS

Both postdischarge visits and the Medicare Annual Wellness Visit appear to be extremely underutilized among the older surgical population. In those patients who do utilize primary care, compared with propensity-matched patients who do not, our study suggests primary care use is associated with modestly lower readmission rates. Prospective studies are needed to determine whether targeted primary care involvement can reduce readmission.

The Annual Wellness Visit Health Risk Assessment: Potential of Patient Portal-Based Completion and Patient-Oriented Education and Support

Background and Objectives

Patient portals are secure online platforms that allow patients to perform electronic health management tasks and engage in bidirectional information exchange with their care team. Some health systems administer Medicare Annual Wellness Visit (AWV) health risk assessments through the patient portal. Scalable opportunities from portal-based administration of risk assessments are not well understood. Our objective is 2-fold-to understand who receives vs misses an AWV and health risk assessment and explore who might be missed with portal-based administration.

Research Design and Methods

This is an observational study of electronic medical record and patient portal data (10/03/2021-10/02/2022) for 12 756 primary care patients 66+ years from a large academic health system.

Results

Two-thirds (n = 8420) of older primary care patients incurred an AWV; 81.0% of whom were active portal users. Older adults who were active portal users were more likely to incur AWV than those who were not, though portal use was high in both groups (81.0% with AWV vs 76.8% without; p < .001). Frequently affirmative health risk assessment categories included falls/balance concerns (44.2%), lack of a documented advanced directive (42.3%), sedentary behaviors (39.9%), and incontinence (35.1%). Mean number of portal messages over the 12-month observation period varied from 7.2 among older adults affirmative responses to concerns about safety at home to 13.8 for older adults who reported difficulty completing activities of daily living. Portal messaging varied more than 2-fold across affirmative health risk categories and were marginally higher with greater number affirmative (mean = 13.8 messages/year no risks; 19.6 messages/year 10+ risks).

Discussion and Implications

Most older adults were active portal users-a group more likely to have incurred a billed AWV. Efforts to integrate AWV risk assessments in the patient portal may streamline administration and scalability for dissemination of tailored electronically mediated preventive care but must attend to equity issues.

Increasing Medicare Annual Wellness Visit Utilization: An RN-Led Model of Care Pilot

Annual wellness visits (AWVs) are an important component of primary care as they provide preventive services and an opportunity to identify safety and health risk factors for Medicare beneficiaries. However, primary care practices are facing unprecedented demands with high patient volumes, multimorbidity, a rapidly growing aging population, and primary care provider (PCP) shortages. RN-led models of care are increasingly recognized as a major key to providing quality care while relieving PCP demands. This article describes the implementation of an RN-led model of care pilot in an urban family practice to increase Medicare AWV completion and alleviate PCP burden.

Understanding barriers to and facilitators of clinician-patient conversations about brain health and cognitive concerns in primary care: a systematic review and practical considerations for the clinician

BACKGROUND

Primary care clinicians (PCCs) are typically the first practitioners to detect cognitive impairment in their patients, including those with Alzheimer's disease or related dementias (ADRD). However, conversations around cognitive changes can be challenging for patients, family members, and clinicians to initiate, with all groups reporting barriers to open dialogue. With the expanding array of evidence-based interventions for ADRD, from multidomain care management to novel biotherapeutics for early-stage AD, incorporating conversations about brain health into routine healthcare should become a standard of care. We conducted a systematic review to identify barriers to and facilitators of brain health conversations in primary care settings.

METHODS

We systematically searched PubMed, Scopus, Web of Science, and the Cochrane Library for qualitative or quantitative studies conducted in the US between January 2000 and October 2022 that evaluated perceptions of cognition and provider-patient brain health conversations prior to formal screening for, or diagnosis of, mild cognitive impairment or ADRD. We assessed the quality of the included studies using the Mixed Methods Appraisal Tool.

RESULTS

In total, 5547 unique abstracts were screened and 22 articles describing 19 studies were included. The studies explored perceptions of cognition among laypersons or clinicians, or provider-patient interactions in the context of a patient's cognitive concerns. We identified 4 main themes: (1) PCCs are hesitant to discuss brain health and cognitive concerns; (2) patients are hesitant to raise cognitive concerns; (3) evidence to guide clinicians in developing treatment plans that address cognitive decline is often poorly communicated; and (4) social and cultural context influence perceptions of brain health and cognition, and therefore affect clinical engagement.

CONCLUSIONS

Early conversations about brain health between PCCs and their patients are rare, and effective tools, processes, and strategies are needed to make these vital conversations routine.

Catalyzing dementia care through the learning health system and consumer health information technology

To advance care for persons with Alzheimer's disease and related dementias (ADRD), real-world health system effectiveness research must actively engage those affected to understand what works, for whom, in what setting, and for how long-an agenda central to learning health system (LHS) principles. This perspective discusses how emerging payment models, quality improvement initiatives, and population health strategies present opportunities to embed best practice principles of ADRD care within the LHS. We discuss how stakeholder engagement in an ADRD LHS when embedding, adapting, and refining prototypes can ensure that products are viable when implemented. Finally, we highlight the promise of consumer-oriented health information technologies in supporting persons living with ADRD and their care partners and delivering embedded ADRD interventions at scale. We aim to stimulate progress toward sustainable infrastructure paired with person- and family-facing innovations that catalyze broader transformation of ADRD care.

Medicare's Annual Wellness Visit and diagnoses of dementias and cognitive impairment

Introduction

Early detection of Alzheimer's disease and related dementias allows clinicians and patients to prepare for future needs and identify treatment options. Medicare's Annual Wellness Visit (AWV) requires detection of cognitive impairment and may increase dementia diagnosis. We estimated the relationship between AWV receipt and incident dementia.

Methods

Using a retrospective cohort of Medicare Fee-For-Service (FFS) beneficiaries enrolled for at least 3 years from 2009 to 2016 and two-stage least squares, we quantified the relationship between AWV and incident diagnosis of cognitive impairment/dementia, and by race/ethnicity. The county-level change in percent of beneficiaries receiving AWVs was used as an instrumental variable to account for unobserved factors associated with individuals' AWV receipt and diagnosis. Sample included 3,333,617 beneficiaries ages 67 years and older, without dementia at the beginning of the study.

Results

Beneficiaries included 2,713,573 White, 251,958 Black, 196,845 Hispanic, 95,719 Asian, 11,727 American Indian/Alaska Native, and 63,795 of other race/ethnicity. Using ordinary least squares, dementia incidence was -0.79 percentage points (95% CI -0.81 to -0.76) lower for persons receiving an AWV compared to no AWV. Using instrumental variables reversed the direction of the effect: AWV receipt increased dementia diagnoses by 0.47 percentage points (95% CI 0.14 to 0.80), 15% over baseline. AWVs increased diagnoses 2.0 percentage points (95% CI 0.05 to 3.94) among Blacks, 0.40 percentage points (95% CI 0.05 to 0.75) among Whites, but est were imprecise for Hispanics and Asians.

Discussion

Increasing AWV take-up and supporting physicians' performance of cognitive assessment may further improve dementia detection in the population and among groups at higher risk of undiagnosed dementia.

The effect of direct cognitive assessment in the Medicare annual wellness visit on dementia diagnosis rates

OBJECTIVE

To evaluate the relationship between direct cognitive assessment introduced with the Medicare Annual Wellness Visit (AWV) and new diagnoses of dementia, and to determine if effects vary by race.

DATA SOURCES

Medicare Limited Data Set 5% sample claims 2003-2014 and the HRSA Area Health Resources Files.

STUDY DESIGN

Instrumental Variable approach estimating the relationship between AWV utilization and new diagnoses of dementia using county-level Welcome to Medicare Visit rates as an instrument.

DATA COLLECTION/EXTRACTION METHODS

Three hundred twenty-four thousand three hundred and eighty-five fee-for-service Medicare beneficiaries without dementia when the AWV was introduced in 2011.

PRINCIPAL FINDINGS

Annual Wellness Visit utilization was associated with an increased probability of new dementia diagnosis with effects varying by racial group (categorized as white, black, Hispanic/Latino, or Asian based on Social Security Administration data). Hazard ratios (95% confidence intervals) for new dementia diagnosis within 6 months of AWV utilization were as follows: 2.34 (2.13, 2.58) white, 2.22 (1.71, 2.89) black, 4.82 (2.94, 7.89) Asian, and 6.14 (3.70, 10.19) Hispanic (P < .001 for each). Our findings show that estimates that do not control for selection underestimate the effect of AWV on new diagnoses.

CONCLUSIONS

Dementia diagnosis rates increased with AWV implementation with heterogenous effects by race and ethnicity. Current recommendations by the United States Preventive Services Task Force state that the evidence is insufficient to recommend for or against screening for cognitive impairment in older adults.