Reducing Racial and Ethnic Disparities in Medicare Annual Wellness Visit Uptake

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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.