Reducing Racial and Ethnic Disparities in Medicare Annual Wellness Visit Uptake

摘要 来自种族和少数民族等历史上被社会排斥的群体的老年人面临健康问题 不平等表现为疾病和死亡负担过高。研究还表明， 在被社会排斥的老年人群体中，预防性服务接受率较低，自评健康水平较低。 医疗保险年度健康访问(AWV)是解决这些差异的一个有前途的工具。Awv是 联邦医疗保险的体检访问形式，并已向联邦医疗保险参与者提供，自 2011年。我们团队最近的一项审查表明，成人初级保健的体检改善了临床 预防服务完成率和患者报告的结果。体检也降低了四分之二的死亡率 老年人的随机试验。尽管体检对老年人有潜在的巨大好处， 已发表的研究和来自我们健康系统的数据显示，在老年人中， 与白人相比，他们是黑人或拉丁裔/西班牙裔。此外，人们对如何最大化AWV知之甚少 在被社会排斥的群体中完成。尽管早期的研究已经确定了一些患者水平的障碍 AWV完成，没有高质量的对照研究已前瞻性评估干预增加 完成了AWV，没有一个以种族/少数民族人口为目标。然而，由于大多数AWV 预约是由诊所或卫生系统发起的，AWV是由初级保健团队提供的， 解决AWV差异的干预措施必须包括患者和临床的意见 利益相关者。我们假设，有针对性的、社区参与的干预开发方法可以 增加老年黑人和拉丁裔/西班牙裔患者的AWV完成率，进而改善他们的护理质量 以及患者报告的结果。我们的第一个具体目标是开发和完善干预措施，以减少 完成联邦医疗保险AWV的种族/民族差异。我们将就人们的看法和 英语和西班牙语患者在学术背景和安全网中使用AWV的障碍 初级保健实践。然后，一个由多个利益相关者组成的社区咨询委员会将与我们的健康 设计和实施贯穿访问前、访问中和访问后的AWV干预的系统 设置。在我们第二个具体目标中，我们将在两个以社区为基础的初级保健中进行试点试验 实践，为最终的全面有效性试验做准备。我们将随机挑选六名医生 志愿者，并向90名患者提供干预。主要结果将是联邦医疗保险AWV的完成。 次要结果包括预防服务完成率、自我评估的健康和与健康相关的质量 生活。在试点试验结束时，实施干预措施的护理小组将通过以下方式通知未来的工作 提供有关干预、培训和实施策略的反馈。这一项目符合 国家老龄优先事项研究所制定战略，改善不同地区老年人的健康状况 (目标F)，并可就如何促进老年人的健康公平提出一般性的结论。

ABSTRACT Older adults from historically socially excluded groups such as racial and ethnic minorities face health inequities in the form of disproportionately high burdens of illness and mortality. Research has also shown lower preventive service uptake and lower self-rated health in socially excluded groups of older adults. Medicare Annual Wellness Visits (AWVs) are a promising tool to address these disparities. AWVs are Medicare’s form of the checkup visit, and have been available to Medicare enrollees, with zero copay, since 2011. A recent review by our team demonstrated that checkups in adult primary care improve clinical preventive services completion and patient-reported outcomes. Checkups also reduced mortality in two of four randomized trials in older adults. Despite the potentially dramatic benefits of checkups in older adults, published research and data from our health system have shown lower AWV completion in older adults who are Black or Latino/Hispanic, compared with Whites. Also, little is known about how to maximize AWV completion in socially excluded groups. Though early studies have identified some patient-level barriers to AWV completion, no high-quality, controlled studies have prospectively evaluated an intervention to increase AWV completion, and none have targeted racial/ethnic minority populations. However, since most AWV appointments are initiated by practices or health systems and AWVs are delivered by primary care teams, interventions to address disparities in AWVs must incorporate input from both patients and clinical stakeholders. We hypothesize that a targeted, community-engaged approach to intervention development can increase AWV completion in older Black and Latino/Hispanic patients and, in turn, improve their quality of care and patient-reported outcomes. Our first specific aim is to develop and refine an intervention to reduce racial/ethnic disparities in Medicare AWV completion. We will conduct focus groups on perceptions and barriers to AWVs among English- and Spanish-speaking patients in academically affiliated and safety net primary care practices. Then, a multi-stakeholder Community Advisory Board will collaborate with our health system to design and implement an AWV intervention across the continuum of pre-visit, in-office, and post-visit settings. In our second specific aim, we will conduct a pilot trial at two community-based primary care practices, in preparation for an eventual full-scale effectiveness trial. We will randomize six physician volunteers, and deliver the intervention to 90 patients. The primary outcome will be Medicare AWV completion. Secondary outcomes include preventive services completion, self-rated health, and health-related quality of life. At the conclusion of the pilot trial, care teams that implemented the intervention will inform future work by providing feedback about the intervention, training, and implementation strategies. This project aligns with National Institute on Aging priorities to develop strategies to improve the health status of older adults in diverse populations (Goal F), and can produce generalizable findings on how to advance health equity in older adults.