Dementia Detection Rates Do Not Improve with Medicare Annual Wellness Visits

By Will Boggs MD

NEW YORK (Reuters Health) - Medicare annual wellness visits (AWV) are not associated with increased detection of Alzheimer's disease and related dementias, according to a retrospective study.

"Although detection of cognitive impairment is one of the required elements of the Medicare Annual Wellness Visit, our study did not find any clinically meaningful differences in cognitive-related outcomes in the group who had an Annual Wellness Visit," Dr. Nicole R. Fowler from Indiana University, in Indianapolis, told Reuters Health by email.

Cognitive function is assessed through direct observation and information from family members, caretakers and others as part of the AWV, which Medicare began covering in 2011.

Dr. Fowler and colleagues used data from more than 66,000 matched pairs of AWV Medicare beneficiaries and Medicare controls to examine the effect of the AWV on the detection of cognitive impairment and on follow-up cognitive care for older adults.

During the 12-month follow-up period, 6.16% of the AWV group received a diagnosis of cognitive impairment, compared with 6.86% of the control group (P<0.001), the team reports in the Journal of the American Geriatrics Society, online April 2.

In the first 90 days of follow-up, the AWV group was significantly more likely than the control group to receive a test for thyroid-stimulating hormone (40% vs. 28%), B12 (10% vs. 7%) and folate (5% vs. 4%), more likely to receive neuropsychological testing (0.75% vs. 0.55%) and less likely to undergo brain imaging (11% vs. 12%).

The AWV did not alter clinicians' prescribing behaviors for Alzheimer's disease and related dementia medications (1% of both cohorts initiated treatment with cholinesterase inhibitors or memantine).

"Our study results suggest that, although the AWV is correlated with an increase in some measures of laboratory testing for reversible causes of cognitive impairment, it does not appear to have a substantial effect on its detection," the researchers conclude. "Future studies that aim to measure the effect of policies such as the AWV benefit on cognitive outcomes could benefit from use of clinical data that include types of screening tools used, results of the screening, and other provider-initiated interventions after the AWV."

"Centers for Medicare and Medicaid Services (CMS) guidelines for the visit stipulate what must be conducted for the provider to bill for an Annual Wellness Visit, so, from the perspective of the Annual Wellness Visit detection of cognitive impairment is as important as the other required elements," Dr. Fowler said. "It is true that primary care providers are asked to do a lot in a short amount of time."

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"Some health systems have designed special clinics for older adults and the Annual Wellness Visit which are staffed by nurses and other providers such as Advanced Practice nurses and Physician Assistants," she said. "Additionally, and similar to other screening programs, having clearly defined pathways for patients to receive follow-up diagnostic services is critical to the implementation of the Annual Wellness Visit."

"Discussion of cognition and possible cognitive impairment is not easy for the patient, their family, or the primary care provider," Dr. Fowler added. "While it is a required element of the Annual Wellness Visit, other encounters between the patient and PCP that discuss cognition can occur over multiple encounters and be supported with information about resources that can be helpful for the patient and family and follow-up care."

"These discussions could decrease the burden on patients who develop dementia and their family members by increasing opportunities for earlier medical, social, and advanced care planning interventions; increase the likelihood that patients participate in the care planning process and; ensure earlier understanding of patient symptoms," she said.

Dr. J. Wesson Ashford from Stanford University, in Stanford, California, who has researched various aspects of cognitive impairment and its detection, told Reuters Health by email, "Physicians should seek better, easier tests for the AWV. The tests should be much simpler, easier, and more precise. Also, participants should be able to do their own testing on a computer in their own home or in the clinician's office, with a computer-generated report sent to the clinician."

"There is a huge need for cognitive tests constructed with modern methods, modern test theory, (and) computerized administration (none of those available meet this description, perhaps except for www.memtrax.com)," said Dr. Ashford, who was not involved in the study. "Accurate long-term monitoring is really needed."

Dr. John E. Morley from Saint Louis University School of Medicine's division of geriatric medicine, in St. Louis, Missouri, who also was not involved in the research, said, "The Medicare AWV is only as good as how it is done and implemented. Physicians need to be trained to look for reversible causes of dementia and lifestyle interventions, such as seen in the FINGER study."

"It is not surprising that some imaging tests were not used, as these have little clinical value," he told Reuters Health by email. "The major message is that clinicians need to learn how to do appropriate preventive approaches in older persons."

SOURCE: https://bit.ly/2qFFrw2

J Am Geriatr Soc 2018.

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