Annual wellness visit policy: Impact on disparities in early dementia diagnosis and quality of healthcare for Medicare beneficiaries with Alzheimer's Disease and Its Related Dementias

项目摘要/摘要 阿尔茨海默病及相关痴呆患者认知功能障碍及及时性的早期识别 (ADRD)诊断是最佳痴呆症护理的关键。数据显示，早期ADRD识别与较少的 暴露于可能不适当的药物(PIM)，更少的急性护理使用倾向，更低的跌倒发生率， 以及更多地采用提前护理计划。提高对ADRD早期识别的一个潜在方法是 年度健康访问(AWV)-一项免费的预防服务，涵盖认知和跌倒风险评估， 药物对账和个性化的预防计划。医疗保险和医疗补助服务中心 (CMS)于2011年开始向AWV报销。阿尔茨海默氏症协会(AA)已经提请人们注意 ADRD在女性中的患病率和风险高于男性，黑人和西班牙裔美国人高于白人。收据 AWV的使用可能会缩小健康差距；然而，迄今为止的证据并不一致。 这一为期5年的R01项目的重点是社区居住的ADRD患者，并基于 医疗保健改进的4MS框架--一个适合老年人的医疗系统，4MS：重要的是什么，心理健康， 机动性和药物治疗。我们将进行一项收敛的并行混合方法设计研究 评估AWV政策对ADRD早期诊断和缩小健康差距的影响。我们将分析 国家医疗保险数据，健康退休调查-医疗保险联系数据，以及国家健康和老龄化趋势 研究-医疗保险联系数据，以了解AWV实施对缩小健康差距的影响 跨性别、种族/民族、社会经济地位和城乡居住地。此外，我们还将收集主要数据 (电话采访)来自180名ADRD患者的家庭照顾者(6组中每组约30人：西班牙裔男性， 西班牙裔女性、黑人男性、黑人女性、白人男性和白人女性)和400名临床医生(每名约100名 4个医疗保险地区，4个证书领域各约25个：家庭医学、内科初级保健、 老年医生、护士从业者)了解AWV是如何传递给ADRD患者的，以便确定 通过AWV缩小健康差距的潜在机制。对于家庭照顾者，我们将使用滚雪球 与AA和国际扶轮网络的抽样方法，以及AA的TrialMatch®平台，以达到 全国范围内的潜在目标。对于临床医生，我们将从2019年CMS中随机选择全国范围内的临床医生 医生和临床医生国家档案。我们将与机管局合作，确保收集和发展合理的数据 为政策/实践提供信息的实际影响。我们的三个具体目标是： 目的1：评估AWV对ADRD诊断(心理)的及时性的影响； 目标2：评估AWV对提前护理计划咨询(重要的是什么)、抑郁症的影响 ADRD的精神状态、跌倒和骨折(活动能力)、PIM使用和ADRD治疗(药物) 不同性别、种族/民族、社会经济地位和城乡居住地的患者；以及 目标3：确定在ADRD患者的AWV分娩中哪些有效，哪些无效。

PROJECT SUMMARY/ABSTRACT Early recognition of cognitive impairment and timeliness in Alzheimer’s Disease and Related Dementias (ADRD) diagnoses are key to optimal dementia care. Data show that early ADRD recognition is linked to less exposure to potentially inappropriate medications (PIM), less propensity for acute care use, lower rates of falls, and increased adoption of advance care planning. One potential way to improve early recognition of ADRD is Annual Wellness Visits (AWVs)—a free preventive service that covers cognition and fall risk assessment, medication reconciliation, and personalized prevention plans. The Centers for Medicare & Medicaid Services (CMS) began reimbursing AWVs in 2011. The Alzheimer’s Association (AA) has drawn attention to the higher prevalence and risk of ADRD among women than men and black and Hispanic Americans than whites. Receipt of AWVs might decrease health disparities; however, evidence to date is inconsistent. This 5-year R01 project has a focus on community-dwelling ADRD patients and is based on the Institute for Healthcare Improvement’s 4Ms framework of an age-friendly health system, 4Ms: what matters, mentation, mobility, and medication. We will conduct a convergent parallel mixed-methods design research study to assess the effect of AWV policy on early ADRD diagnosis and reducing health disparities. We will analyze national Medicare data, health retirement survey-Medicare linkage data, and National Health & Aging Trends study-Medicare linkage data to understand the effect of AWV implementation on reducing health disparities across sex, racial/ethnic, socioeconomic status, and rural/urban residence. Also, we will collect primary data (phone interviews) from 180 family caregivers of ADRD patients (~30 in each of the 6 groups: Hispanic men, Hispanic women, black men, black women, white men, and white women) and 400 clinicians (~100 in each of 4 Medicare regions, ~25 in each of 4 credential areas: family medicine, internal medicine primary care, geriatricians, nurse practitioners) to understand how AWV is delivered to ADRD patients in order to identify the potential mechanism for reducing health disparity through AWV. For family caregivers, we will use a snowball sampling method with AA’s and Rotary International networks, and AA’s TrialMatch® platform to reach potential subjects nationwide. For clinicians, we will randomly select clinicians nationwide from the 2019 CMS doctors and clinicians national file. We will partner with AA to ensure sound data collection and development of practical implications to inform policy/practice. Our three specific aims are: Aim 1: Assess the effects of AWV on the timeliness of ADRD diagnosis (mentation); Aim 2: Assess the effects of AWV on advance care planning consultation (what matters), depression (mentation), fall and fracture (mobility), and PIM use and ADRD treatment (medication) for ADRD patients across sex, racial/ethnic, socioeconomic status, and rural/urban residence; and Aim 3: Identify what works and what does not work in AWV delivery for ADRD patients.