Reducing Racial and Ethnic Disparities in Medicare Annual Wellness Visit Uptake

摘要 来自历史上被社会排斥的群体，如少数种族和族裔的老年人面临健康问题。 不平等表现为不成比例的高疾病和死亡负担。研究还表明 在被社会排斥的老年人群体中，预防服务的接受率较低，自我评估的健康状况较低。 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 医疗保险的形式的检查访问，并已提供给医疗保险登记，零共付额，因为 2011.我们团队最近的一项综述表明，成人初级保健中的检查可改善临床 预防服务完成情况和患者报告的结果。检查也降低了四分之二的死亡率 老年人的随机试验。尽管老年人检查有潜在的巨大好处， 已发表的研究和来自我们卫生系统的数据显示， 是黑人或拉丁裔/西班牙裔，与白人相比。此外，很少有人知道如何最大化AWV 在被社会排斥的群体中完成。虽然早期的研究已经确定了一些患者层面的障碍， AWV完成，没有高质量的对照研究前瞻性地评估了干预措施，以增加 AWV完成，没有针对种族/少数民族人口。然而，由于大多数AWV 预约由实践或卫生系统发起，AWV由初级保健团队提供， 解决AWV差异的干预措施必须结合患者和临床医生的意见， 持份者我们假设，一个有针对性的，社区参与的干预发展方法可以 提高老年黑人和拉丁美洲/西班牙裔患者的AWV完成率，进而提高其护理质量 和患者报告的结果。我们的第一个具体目标是制定和完善一项干预措施， 种族/民族差异在医疗AWV完成。我们将进行焦点小组的看法， 学术附属机构和安全网中讲英语和西班牙语的患者的AWV障碍 初级保健实践。然后，一个多方利益相关者社区咨询委员会将与我们的卫生部门合作， 设计和实施访视前、诊室内和访视后AWV干预的系统 设置.在第二个具体目标中，我们将在两个社区基层医疗机构进行试点 实践，为最终的全面有效性试验做准备。我们将随机抽取6名医生 志愿者，并为90名患者提供干预。主要结果将是完成Medicare AWV。 次要结果包括预防性服务完成情况、自评健康状况和与健康相关的 生活在试点试验结束时，实施干预措施的护理团队将通过以下方式告知未来的工作： 提供有关干预、培训和实施战略的反馈。该项目符合 国家老龄问题研究所优先制定战略，以改善不同地区老年人的健康状况 人口（目标F），并可以就如何促进老年人的健康公平得出可推广的发现。

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.