Medicare Annual Wellness Visit Research Articles

Frailty status determined by an electronic health record embedded frailty index and hospitalization risk among older adults following the initiation of cancer chemotherapy.

12010 Background: Novel strategies are needed to efficiently identify older adults at high risk for hospitalization before and after chemotherapy initiation. An electronic frailty index (eFI) holds promise as a passive digital marker for frailty available to estimate risk at the point of care. The objective of this study was to evaluate the association of pre-treatment eFI with risk of hospitalization after receipt of cancer chemotherapy among older adults. Methods: Consecutive patients (N = 509 aged 65+ with newly diagnosed lung, colorectal or breast cancer treated with chemotherapy) were identified from our cancer registry between 2017 and 2020. Calculation of the eFI is automated in the EMR. It requires at least two ambulatory visits over a 2-year period and utilizes demographic information, vital signs, smoking status, ICD-10 diagnosis codes, select outpatient laboratory measurements, and functional information (if available from Medicare Annual Wellness Visits) during the 2 years prior to diagnosis. Frailty status is categorized as fit (eFI ≤0.10), pre-frail (0.10 < eFI≤0.21), and frail (eFI > 0.21) based on the proportion of deficits present over the total number evaluated (score range 0-1). Non-calculable scores indicate insufficient historical primary care data within two year prior to cancer diagnosis. Outcomes were hospitalization at 3 and 6 months post chemotherapy initiation. Time to first hospitalization was estimated by eFI category, using Cox regression models to estimate the adjusted association between frailty status and hospitalization. Results: The cohort included 509 adults (median age 72.2 yrs, 55% female, 83% white, 13% black, 45.8% stage 4) with lung (N = 312), colorectal (N = 111), and breast (N = 86) cancers. Distribution of eFI categories at diagnosis were fit (26.3%), pre-frail (42.4%), frail (16.3%) and not calculable (14.9%). Hospitalization rates at 3 and 6 months post chemotherapy were 12.0% (fit), 29.9% (pre-frail), 46.3% (frail), 45.9% (not-calculable) and 24.4% (fit), 41.3% (pre-frail), 59.8% (frail) and 49.8% (non-calculable), respectively (p < 0.0001). Adjusting for age, gender, race, stage, and cancer type, the incidence of hospitalization was higher for frail (Hazard Ratio (HR) 2.96, 95% Confidence Interval (CI) 2.05, 4.27), pre-frail (HR 1.41, 95% CI 1.03, 1.94), and not calculable eFI categories (HR 2.01, 95% CI 1.33, 3.03) compared to fit patients. Conclusions: Over forty percent of frail older adults with lung, colorectal, or breast cancer identified by eFI were hospitalized within the first 3 months of chemotherapy initiation. The eFI can inform real-time shared treatment decision-making and identify a sub-set of patients who may benefit from care delivery interventions to decrease unplanned hospitalization and improve quality of care.

Health Economic Analysis of Pharmacist-Led Annual Wellness Visits

Objective To quantify the financial and clinical implications of pharmacists completing Medicare Annual Wellness Visits (AWV). Design Retrospective, observational, population-based health economic analysis utilizing electronic medical record data. Setting A single family-practice clinic within a Missouri-based not-for-profit community health system. Patients/Participants Medicare patients in their second year of coverage who had not been seen for an AWV within the previous 12 months. Intervention Patients attended a subsequent AWV conducted by a licensed ambulatory care pharmacist between July 1 and December 31, 2021. The pharmacist completed all necessary visit requirements and helped facilitate completion of preventive screenings. Main Outcome Measures Primary outcomes measured were financial implications of pharmacists completing AWVs. The primary objective was to quantify the direct and indirect financial benefits for a health system incorporating pharmacist-led AWVs. Direct revenue was calculated based on the number of visits completed multiplied by the reimbursement rate paid to the health care system by the Centers for Medicare & Medicaid Services (CMS). Indirect revenue was estimated based on the number and type of interventions completed by the patient. The secondary outcome measured was the clinical impact of pharmacist-led AWVs through quantifying preventive care service needs and completion of these services. Alongside these measures, the number of medication discrepancies and drug interactions were also measured and cost avoidance estimated. Annual cost in salary of a pharmacist was considered, but additional cost of overhead was beyond the scope of the study. Results Thirty-nine AWVs were completed. Two hundred six recommended screenings, labs, and immunizations were identified, of which 24% were completed. The pharmacists were also able to identify 205 medication issues. These visits generated $4,593.42 in direct revenue. Recommended preventive care generated $2,161.71 in indirect revenue. Conclusion Pharmacist-led AWVs are financially beneficial to the health care system and increases the number of completed AWVs while avoiding demand for additional physician time.

Adoption and Value of the Medicare Annual Wellness Visit: A Mixed-Methods Study.

Medicare's Annual Wellness Visit (AWV) was introduced in 2011 to encourage the utilization of preventive services, but many clinicians and patients still do not participate in the visit. We qualitatively and quantitatively assessed motivations and clinical and financial value of AWVs from a primary care perspective using interviews and Medicare claims from 2012 to 2019. Primary care providers with the highest acuity patients had AWV utilization rates 11.2 percentage points lower than providers with the lowest acuity patients; utilization rates were 3.8 percentage points lower in rural counties. Adoption was motivated by patient needs and financial incentives. AWVs closed gaps in preventive care, strengthened patient-provider relationships, facilitated advance care planning, and provided an opportunity to improve quality metrics. Overall, the AWV has the potential to increase the use of high-value preventive services although not all clinics have an economic incentive to adopt the visit, which may explain some of the variability in utilization rates.

Outcomes of A Virtual Practice-Tailored Medicare Annual Wellness Visit Intervention.

Interventions are needed to promote utilization of the Medicare Annual Wellness Visit (AWV), an underused opportunity to perform screenings and plan individualized preventive health services. Using remote practice redesign and electronic health record (EHR) support, we implemented the Practice-Tailored AWV intervention in 2021 (during the COVID-19 pandemic) in 3 small community-based practices. The intervention combines EHR-based tools with practice redesign approaches and resources. Outcomes included completion of AWV and fulfillment of recommended preventive services. At baseline the 3 practices had 1,513 Medicare patients with at least 1 visit in the past 12 months. AWV utilization went from 7% at baseline to 54% 8 months postintervention implementation; advance care planning increased 10.7% (from 7.9% to 18.6%); depression screening increased 16.3% (from 51.7% to 68.0%); and alcohol misuse screening increased 17.3% (from 42.6% to 59.9%). Every individual preventive health service was received more often by patients with an AWV than those without. At the patient level, fulfillment of all eligible preventive services (of a maximum of 12 evaluated) went from 47.5% to 53.8% (P < .001). Subgroup analyses showed that patients with AWVs completed a greater percentage of their total recommended preventive health services than those without an AWV. Virtual implementation of an intervention that combined EHR-based tools with practice redesign approaches increased AWV and preventive services utilization in Medicare patients. Given the success of this intervention during the COVID-19 pandemic (when practices had many competing demands), greater consideration should be given to delivering future interventions virtually.

Evaluation of Patient Adherence to Vaccine and Screening Recommendations during Community Pharmacist-led Medicare Annual Wellness Visits in a Family Medicine Clinic.

Background: The Centers for Medicare and Medicaid Services initiated annual wellness visits (AWV) to reduce healthcare costs and improve preventive healthcare for beneficiaries. Provider time constraints and varying preferences to perform AWVs have limited its clinical implementation in some areas, affording pharmacists an opportunity to expand their role. Objective: To evaluate patient adherence to pharmacist recommendations for vaccinations and preventive screenings in an annual wellness visit service at a family medicine clinic in northeast Mississippi. Methods: This study included patients receiving at least one vaccination or screening recommendation during an AWV. Investigators provided vaccination (influenza, pneumococcal and herpes zoster) and screening (mammograms, DEXA, and colorectal cancer) recommendations based on current guidelines. For services not provided in-clinic, investigators contacted outside facilities 45 days post-visit to confirm adherence to recommendations. Primary endpoints included the composite adherence rate of all recommendations and percentage of patients achieving the 60% goal composite adherence rate. Secondary endpoints included individual vaccination and screening adherence rates. Results: Investigators recommended 715 interventions to a total of 254 patients, of which 239 were completed within 45 days for a 33.4 percent composite adherence rate. 20.1 percent of all participants achieved the goal composite adherence rate (60%). Overall, participants were 30.5 and 41 percent adherent to all vaccinations and preventive screening recommendations, respectively. Conclusion: Pharmacists providing AWVs increased patient access to preventive health recommendations. Although, adherence to recommendations remains a challenge and warrants further study. The findings and limitations observed in this study have identified opportunities for future research to evaluate pharmacist-led AWV services.

Older adults and planning for firearm safety: A qualitative study of healthcare providers.

Firearm injury, particularly self-directed, is a major source of preventable morbidity and mortality among older adults. Older adults are at elevated risk of serious illness, cognitive impairment, and depression-all known risk factors for suicide and/or unintentional injury. Healthcare providers are often the first to identify these conditions and, although they commonly deliver safety guidance to such patients, little is known about how they approach firearm safety conversations with older adults. We conducted semi-structured interviews with healthcare providers who care for older adults (November 2020-May 2021). We used inductive and deductive thematic analyses to develop themes. We present themes and representative quotes from our analysis. We interviewed 13 healthcare providers who regularly care for older adult firearm owners. Emergent themes were: circumstances that prompt firearm safety conversations; strategies for addressing firearm safety in routine and acute circumstances; barriers to addressing firearm safety; and available or desired resources. Planning for firearm safety should occur "early and often" as part of a longitudinal relationship with older adult patients. Age-related safety issues such as driving are regularly addressed with older adult patients, likely because there are standard processes and established pathways. Establishing processes and provider/ patient resources would help improve provider efficacy to address firearm safety and relinquishment for older adult firearm owners. Integrating firearm safety conversations into routine encounters (e.g., Medicare Annual Wellness Visit, problem-focused visits) templates could be a promising initial step but resources for follow-up to the firearm screening must be available to both provider and patient.

HEALTH RISKS AMONG OLDER ADULTS ACCORDING TO PRIMARY LANGUAGE: EVIDENCE FROM MEDICARE ANNUAL WELLNESS VISITS

Abstract Emerging evidence suggests that older adults benefit from the Medicare Annual Wellness Visit (AWV). Lind and colleagues found that between 2011 and 2016, utilization of the AWV increased from 8.1% to 23.0%. However, compared with non-Hispanic whites, AWV utilization is 11.6% points lower for Hispanic/Latinos and 10.2% lower for non-Hispanic Blacks. AWV differences by primary language have not been previously reported. We examined the rate of AWV utilization for older adults with English vs. Limited English Proficiency (LEP) among patients seen at a large urban health system in northeastern Ohio. Using Bonferroni-corrected chi-square and t-tests, we also evaluated the association between LEP and health risks (e.g., depression, falls, activities of daily living, cognitive status) assessed during the AWV. Using the electronic health record, we identified 41,262 Medicare patients aged 65+ who were eligible for the AWV. Of those identified, 42.8% completed an AWV between 2019 to 2021. Persons who were white (41.7%), Hispanic (37%), male (39.9%), Spanish-speaking (37.2%) or other LEP (41.2%) had lower utilization of AWVs (p&amp;lt;.001). Pain and fatigue ratings, depressive symptoms, and oral health problems and were similar between language groups, while cognitive impairment (p&amp;lt;.001), functional independence (p&amp;lt;.001), and self-rated health (p&amp;lt;.001) were substantially worse among non-English speakers. LEP is associated with a lower rate of AWV utilization and worse self-rated health. A clearer understanding of how speaking a different language from that in which the AWV is conducted is important for clarifying discrepancies and disparities in minority population health.

PERSPECTIVES OF UNDER-RESOURCED PATIENTS ABOUT THE MEDICARE ANNUAL WELLNESS VISIT

Abstract The Medicare Annual Wellness Visit (AWV) involves a personalized risk assessment and prevention plan to help prevent disease and disability among older adults. Though studies have shown that AWV uptake is suboptimal, little is known about the perspectives and experiences of patients completing it. Family medicine physicians are conducting AWVs at a Rhode Island pilot teaching clinic participating in the GWEP's Age-Friendly Health Systems Initiative. To evaluate perspectives of the clinic's under-resourced patients, 20 qualitative telephone interviews were conducted following their AWV. Interview recordings were analyzed for content and themes. Few patients recognized the term ‘Annual Wellness Visit’ or recognized it was significantly different from other visits: “I noticed it was a bit different, but not that different. I’m usually not covered for a visit like that by Medicare.” Mental health, mobility and medications were discussed at most of the AWVs. Some patients noticed that a physician did the medication review instead of the nurse. Patients had varying experiences of how advance directives were discussed, and some thought it unnecessary since a family member knows their preferences. A few patients were dissatisfied that their physician did not focus on their chronic or acute health problems. However, most patients “trusted” their physicians to do “whatever is necessary” for them, and were glad to have had the AWV because “instead of talking about being sick all the time, talking about how to stay well”. Recommendations for patient education to improve understanding and the experience of the AWV will be offered.

ADAPTING PRIMARY CARE WORKFLOWS TO PROMOTE ADVANCE CARE PLANNING WITH AN EMPHASIS ON A DEDICATED ACP FACILITATOR

Abstract The COVID-19 pandemic has sharpened attention regarding the need to proactively plan for a future medical crisis. Advance Care Planning (ACP) has emerged in the last 30 years as a potential way to improve individuals’ end-of-life care by ensuring that patients explore and communicate personal values, goals, and preferences regarding future medical care to surrogate decision makers and medical providers. Elevating ACP as a core function of direct patient care, the University of Southern Indiana’s (USI) Geriatric Workforce Enhancement Program (GWEP) embedded a multi-modal ACP initiative in a primary care clinic, anchored by the Medicare Annual Wellness Visit (AWV). Within this initiative, the role of a dedicated ACP Facilitator embedded in the practice is highlighted to promote and bill (Medicare CPT codes 99494, 99498) for ACP conversations. The addition of an ACP Facilitator (who is a licensed clinical social worker) as part of the primary care team complements the efforts of the providers to focus on What Matters most to patients. This is particularly important to patients with serious illness. This presentation will summarize the re-alignment efforts of the primary care clinic to prioritize ACP conversations for older adults, amounting to 10,000 visits per year.

Preventive Care and Outcomes of Interprofessional Medicare Annual Wellness Visits for Older Adults.

As we anticipate a growing population of older adults, we will see an increase in chronic conditions such as dementia and falls. To meet these public health needs, we must systematically provide screening, education, preventive care, and supportive care for older patients and their caregivers in a primary care setting. This will require a workforce trained in providing for the complex medical and psychosocial needs of an older adult population in an interprofessional and collaborative fashion. By integrating geriatric screening tools into an interdisciplinary Annual Wellness Visit teaching clinic, we were able to successfully improve rates of geriatric screening for dementia, depression, falls, medication reconciliation and advance care planning. We also saw improvements in patient care and satisfaction and provided the opportunity for interprofessional collaboration and education for students in medicine, nursing, pharmacy and social work.

Factors Associated With Yearly Fluctuations in Mild Neurocognitive Disorder Status Among Older Primary Care Patients

<h3>Research Objectives</h3> While cognitive assessment is included in the Medicare annual wellness visit, fluctuation of cognitive status among older adults in a yearly basis has not been investigated. The objective of this study was to identify characteristics and risk factors associated with the fluctuation of cognitive status. <h3>Design</h3> Prospective longitudinal cohort study. <h3>Setting</h3> Primary care patients in Boston MA area communities. <h3>Participants</h3> This study included 258 participants (mean age 76) from the Boston Rehabilitative Impairment Study of the Elderly (Boston RISE), who completed neuropsychological testing, physical performance testing, and questionnaires at baseline to 2-year follow-up. <h3>Interventions</h3> N/A. <h3>Main Outcome Measures</h3> Participants were categorized into four groups based on their yearly cognitive status (cognitively normal or mild Neurocognitive Disorder (mNCD)). Repeated measures multinomial regression analysis was used to examine the differences between the cognitive groups and associated characteristics. <h3>Results</h3> Fifty-five percent of participants were persistently cognitively normal, 14% were persistently mNCD, and 31% of participants fluctuated in their cognitive status over 2 years of follow-up. Better mobility (Short Physical Performance Battery (Relative Risk Reduction: 0.73), greater physical activity (RRR: 0.97), and higher level of education (RRR: 0.46) were associated with risk reduction and increase in depression score (RRR: 1.11) and non-white race (RRR: 3.57) were associated with greater risk of being classified into the persistently mNCD compared to cognitively normal. <h3>Conclusions</h3> We observed variability across change in cognitive status over time. We observed modifiable and non-modifiable risk factors associated with fluctuating and persistently mNCD groups. This study reinforces the potential benefit of multifaceted exercise treatment for preventing and treating older adults with fluctuating cognition. <h3>Author(s) Disclosures</h3> The authors declare no conflict of interest.

Impact of Clinical Pharmacy Expansion within a Rural Federally Qualified Health Center through Implementation of Pharmacist-Led Medicare Annual Wellness Visits.

Medicare Annual Wellness Visits (AWVs) are annual appointments with the primary care team to prepare personalized prevention plans and focus on gaps in care. Although beneficial, AWVs are often difficult for providers to schedule and complete due to the increased time commitments compared to other visits. The purpose of this study was to assess the clinical, economic and patient-level value of newly implemented pharmacist-led AWVs within a rural Federally Qualified Health Center (FQHC). This retrospective, cohort study included patients who completed an AWV between 1 October 2021, and 14 February 2022. The primary objective was to compare the per clinician rate of completed AWVs between pharmacists and providers. The secondary objectives were to compare revenue generated, interventions made, and patient satisfaction between pharmacist- and provider-led AWVs. During the study period, nine providers completed 139 AWVs (15.4/provider) and two pharmacists completed 116 AWVs (58/pharmacist). Proportions of interventions ordered among those due in eligible patients were similar between pharmacists and providers (47.6% vs. 44.5%; p = 0.356). Patient satisfaction was overall positive with no difference between groups. Pharmacist-led AWVs increased completion of AWVs by 83% over a 20-week period, including significantly more initial, compared to subsequent, AWVs than providers. Sustainability of pharmacist-led AWVs at this FQHC is supported by study outcomes.

Association between medicare annual wellness visits and prevention of falls and fractures in older adults in Texas, USA

Fall-related injuries contribute to increased frailty, disability, and premature death in older adults (≥65 years). The US Centers for Medicare and Medicaid Services began reimbursing annual wellness visits (AWVs) in 2011. In the present study, we assessed the effect of AWV receipt in 2017 on fall and fracture prevention through December 31, 2018. Using Texas Medicare data for 2014–2018, we identified cohorts of Medicare beneficiaries ≥68 years, matched for the presence/absence of an AWV in 2017 by propensity score, and observed two outcomes: fracture as a primary diagnosis, and fall occurrences. Rates of each outcome were estimated using the Kaplan–Meier method. Of the 2017 beneficiaries, 32.2% received an AWV. For the 742,494 beneficiaries in the matched cohort, conditional Cox proportional hazards models revealed that receiving an AWV in 2017 was associated with reduced risks for future falls (3.9%) and fractures (4%). The effect of the AWV was stronger on fall reduction in rural residents (HR: 0.799; 95% CI: 0.679 to 0.941) and on fracture reduction in beneficiaries with ≥4 morbidities (HR: 0.918; 95% CI: 0.867 to 0.972). Receipt of an AWV in three consecutive years (2015–2017) further lowered the risk of future falls. We conclude that the risks for future falls/fractures are lower in older adults receiving AWVs. Our study underscores the need for expanded public education programs that raise awareness about AWVs and the potential for AWV data to inform fall prevention interventions and other health promotion practices.

Medicare's annual wellness visit: 10 years of opportunities gained and lost.

Medicare annual wellness visits (AWV) were initiated 10 years ago. Though AWVs emphasize on disease prevention and health promotion for older adults was a huge step forward, the current "one size fits all" approach does not adequately meet the wellness needs of a diverse population of older adults. Current AWVs do not sufficiently take into consideration the medical, psychological, functional, racial, cultural and socio-economic diversity of older adults. Updated AWVs should be tailored to meet the needs and priorities of older adults receiving them. Several geriatrics approaches to care, including geriatrics Glidepaths and the 4Ms of an Age-Friendly Health System, could help develop and guide a more patient-specific geriatrics focused approach to AWVs. Medicare's IPPE is an ideal time to advise new Medicare beneficiaries regarding what they should and should not do to maximize their ability to be healthy and functionally independent into their 80s, 90s, and 100s.

Association between an electronic health record (EHR)–embedded frailty index and survival among older adults receiving cancer chemotherapy.

12009 Background: Innovative strategies to facilitate rapid frailty screening are critically needed to enhance personalized oncology care among vulnerable older patients. An electronic frailty index (eFI) holds promise as a passive measure of frailty. The eFI was initially designed for primary care. The objective of this study was to establish feasibility, estimate prevalence of frailty, and evaluate the predictive value of the eFI for overall survival (OS) among older adults with cancer planned to receive chemotherapy. Methods: Consecutive patients (N = 509) aged 65+ with newly diagnosed lung, colorectal or breast cancer treated with chemotherapy were identified from our cancer registry between 2017 and 2020. Calculation of the eFI requires at least two ambulatory visits over a 2-year period and utilizes demographic information, vital signs, smoking status, ICD-10 diagnosis codes, select outpatient laboratory measurements, and functional information (if available from Medicare Annual Wellness Visits) during the 2 years prior to diagnosis. Frailty status is categorized as fit (eFI ≤0.10), pre-frail (0.10 &lt; eFI≤0.21), and frail (eFI &gt; 0.21) based on the proportion of deficits present over the total number evaluated (score range 0-1). Non-calculable scores indicate insufficient historical primary care data within two years prior to cancer diagnosis. OS was estimated by eFI category using Kaplan Meier curves and compared using log rank testing. Cox proportional hazards models evaluated the adjusted association between eFI categories and mortality. Results: The cohort included 509 adults (median age 72.2 yrs, 55% female, 83.5% white, 13.4% black, 45.8% stage 4) with lung (N = 312), colorectal (N = 111) and breast (N = 86) cancer. Distribution of eFI categories at diagnosis were fit (25.9%), pre-frail (41.1%), frail (17.3 %) and not calculable (15.7%). The proportion of patients categorized as “fit” differed by disease type (19.9% lung, 30.6% colorectal, 41.9% breast, p &lt; 0.0001). In univariate analyses, eFI frailty category was associated with OS (median OS for fit, pre-frail, frail and not calculable were &gt; 54, 25, 19 and 10 months respectively, p &lt; 0.0001.). Adjusting for age, gender, race, stage, and cancer type, the hazard of death was higher for pre-frail (Hazard Ratio, [HR] 1.7, 95% Confidence Interval [CI] 1.2-2.4), frail (HR 2.3, 95% CI 1.5-3.4) and not calculable eFI categories (HR 2.8, 95% CI 1.8-4.2) compared to fit patients. Conclusions: Calculating an EHR embedded eFI at the time of diagnosis among older adults treated with chemotherapy was feasible and identified nearly one-fifth of patients as frail. eFI-defined frailty status was associated with survival, with poorer survival among the most frail supporting eFI validity. The eFI is a promising scalable tool to efficiently conduct frailty screening in oncology clinical practice.

Standardized Patient Assessments at the Medicare Annual Wellness Visit: Results from the AAFP National Research Network.

The Centers for Medicare and Medicaid Services (CMS) has set requirements for the Medicare Annual Wellness Visit (AWV). A cross-sectional online survey to explore the variability in assessments and tools used during the AWV was completed by 159 primary care providers from 145 practices in 36 states. The results confirmed wide variation in use of specific tools during AWV and provider interest in using several specific tools if available. The results indicated a need for more comprehensive AWV content and a preference for more structured and objective ways to conduct AWV assessment.

Implementation of Nurse-Led Cognitive Screening During Medicare Annual Wellness Visits

Dementia is a serious and costly illness. Early identification of cognitive impairment provides opportunity for earlier intervention, and there is growing evidence suggesting that early intervention may help delay the onset of dementia. There is limited concensus and standardized recommendations for when and how cognitive screening should occur. This quality improvement project implemented a standardized nurse-led cognitive screening workflow during the Medicare annual wellness visit. Statistically significant differences were found between the baseline and implementation groups for Mini-Cog screening rates and referral for follow-up for further neurocognitive evaluation. A structured nurse-led workflow improved the cognitive screening process, providing opportunity for further evaluation and intervention.

Achieving Large-Scale Quality Improvement in Primary Care Annual Wellness Visits and Hierarchical Condition Coding.

BackgroundCompletion of Medicare Annual Wellness Visits (AWV) and documentation of Hierarchical Condition Categories (HCC) are important metrics in accountable care organizations (ACO) with quality and financial implications. To improve performance in large healthcare organizations, quality improvement (QI) efforts need to be scaled up in a way that is feasible within available system-wide resources.ObjectiveWe describe a 3-year effort using a multifaceted QI framework called the fractal management system for AWV and HCC performance.DesignPre-post evaluation of a multi-level, health system–wide QI management system intervention between 2018 and 2020. The system provided project management, coaching, communications, feedback of performance, and health informatics.ParticipantsThe intervention was delivered to all 97 primary care practices within an Ohio-based accountable care organization, comprising 72,603 attributed Medicare and Medicare Advantage patients as of 2018. Eighty-nine of these practices were included in the analysis.ApproachAWV completion was defined as percent of eligible patients with a documented AWV during the calendar year. HCC completion was defined as documented reassessment of all prior-year HCC conditions.Key ResultsAWV completion at the practice level increased from 23.7% (SD .14) in 2018 to 34.9% (SD .18) in 2019, and 59.8% (SD .17) in 2020. This was a statistically significant effect of time on AWV completion rates overall (F[2, 87] = 164.43, p < .000). More than half (56.2%) of practices met or exceeded the 60% goal in 2020. Practice-level HCC completion tracking started in 2019 (M = 75.9%, SD 7.4%) and increased in 2020 (M = 79.7%, SD 7.1%); t(172) = 2.0, p < .001.ConclusionsAWV and HCC performance goals were met in 2020, despite service disruptions due to COVID-19. The QI approach we used is applicable to other problems and other large healthcare systems.

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

IntroductionEarly 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.MethodsUsing 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.ResultsBeneficiaries 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.DiscussionIncreasing 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 Association Between Medicare Annual Wellness Visits and Detection and Management of Diabetes Among Older Adults

The rising prevalence of diabetes mellitus (DM) among older adults is an increasing concern in the U.S. and is expected to nearly triple within the next 40 years. The purpose of this study is to investigate the effectiveness of Medicare Annual Wellness Visits (AWV) utilization on the management of DM among Medicare beneficiaries using data from 26,703 Medicare beneficiaries seen at 13 primary care community clinics (clinic visits between 2017 and 2019). A total of 34% of Medicare beneficiaries participated in an AWV. The total sample was, on average, 72.6 years old (SD=7.0), 57% female, 84% White, and 91% non-Hispanic and had between zero and three co-morbid conditions. The AWV group was significantly younger (mean difference 2.0 years; p<.001) and had fewer comorbid conditions (mean difference 0.1; p<.001) than the non-AWV group at their initial visits. Comparing AWV and non-AWV groups at the first patient visit and last patient visit, there were significantly fewer patients with DM in the AWV group compared to the non-AWV groups (19.2% vs. 24.7%; p<.001 and 53.5% vs. 59.2%; p<.001). DM management was better in the AWV group compared to the non-AWV group at both the first and last patient visits, as exhibited by lower A1C levels (M= 5.9(SD=0.8) vs. M=6.2(SD=1.1); p<.001 and M= 6.6(SD=0.8) vs. M=6.9(SD=1.4); p=.013), lower glucose levels (M=114.0(SD=34.0) vs. M=123.0(SD=51.0); p<.001), and fewer DM medications (M=0.1(SD=.4) vs. M=0.2(SD=0.5); p<.001 and M=0.2(SD=0.6) vs. M=0.3(SD=0.6); p<.001). These results suggest that AWV are effective managing diabetes in older adults Medicare beneficiaries.