Annual Wellness Visit a Missed Chance to Spot Cognitive Woes

Megan Brooks

July 28, 2016

TORONTO ― The Medicare annual wellness visit (AWV) is mandated by the Affordable Care Act and includes cognitive testing. It is vastly underutilized nationally, but it is being successfully implemented on a large scale in one large Midwestern health system.

Allina Health was "an early adopter of the annual wellness visit," said Pamela Mink, PhD, MPH, of Allina Health, Minneapolis, Minnesota, speaking here at the Alzheimer's Association International Conference (AAIC) 2016.

"Within Allina as a system, we are committed to doing the annual wellness visits, and providers have commented that they see particular value in doing the Mini-Cog [Mini-Cogitive Assessment Instrument for Dementia] in patients who come in year after year for these visits as an opportunity to look at change over time," she said.

To gauge the uptake and potential impact of the AWV at Allina Health's 90 clinics, the researchers combed through electronic health record data for more than 100,000 ambulatory patients aged 65 years and older who had made at least one outpatient Medicare claim in the prior year and had made at least two visits to an Allina clinic between January 1, 2011, and March 1, 2015.

Overall, roughly 44% of eligible Allina patients attended at least one AWV during the study period. Participation increased over the years, from about 20% in 2011 to about 30% in 2015. Nationally, in 2013, only 11% of Medicare patients used the AWV, "so even when starting out in 2011, Allina is above average compared to the national average," Dr Mink noted.

Individuals most likely to take advantage of the Medicare AWV were female, white, Asian, non-Hispanic, 70 to 74 years of age, and living in the South and East metropolitan regions.

Positive Mini-Cog scores indicating cognitive impairment (6% overall) were more prevalent among patients who were male, African-American, Hispanic, or in older age strata.

"Unfortunately, even in our study, the people most vulnerable to dementia are skipping the annual wellness visit, while healthier people show higher usage," Dr Mink said.

Nonetheless, this study shows that the Medicare AWV "can be implemented on a broad scale and sustained over time in health systems, and offers a regular opportunity to establish a baseline measurement and identify changes that may indicate Alzheimer's or another dementia."

A Complete Failure

In a conference statement, Maria Carrillo, PhD, chief science officer of the Alzheimer's Association, said it is "concerning to see that ― even in this more successful study group ― still less than half of eligible people are participating in the annual wellness visit, thus missing out on a vital opportunity for detection of cognition impairment.

"Policy makers and healthcare providers need to deliver a powerful message to seniors to take part in the annual wellness visit, especially those in the most at-risk groups," she said.

In an interview with Medscape Medical News, Robert J. Egge, chief public policy officer of the Alzheimer's Association, said, "We know that only about half the people with dementia are diagnosed today, and only in about half of those cases does the person or the caregiver know about the diagnosis when it's made, so it's a complete failure."

After detection, "what ought to happen is a care planning session. That's what we see as the capstone in terms of policy," Egge said.

On that front, he noted that the Health Outcomes, Planning, and Education (HOPE) for Alzheimer's Act of 2015 would pay for dementia care planning.

"The exciting thing," Egge said, "is that not only is Congress, on a bipartisan basis, enthusiastically behind [the bill] now, with majorities in the House and Senate cosponsoring it, but the CMS [Centers for Medicare & Medicaid Services], seeing this, has moved right toward proposing it for reimbursement, so we have kind of leapfrogged where legislation would have brought us."

The study had no commercial funding. The authors have disclosed no relevant financial relationships.

Alzheimer's Association International Conference (AAIC) 2016. Abstract O2-01-05. Presented July 25, 2016.

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