In the first nationwide study to measure the effect of the Medicare Annual Wellness Visit on early identification of cognitive impairment such as Alzheimer's disease, researchers from the Indiana University Center for Aging Research, Regenstrief Institute and IU Center for Health Innovation and Implementation Science found the visit has only minimal impact on detection of cognitive impairment as well as on subsequent cognitive testing and care.
The large observational study, which used de-identified Medicare data, reported insignificant change in the rate of new diagnoses of Alzheimer's disease and related cognitive impairment as well as in the rate of brain imaging or neuropsychological testing used to diagnosis cognitive impairment. It did, however, identify an increase in the use of laboratory testing for thyroid dysfunction and vitamin B deficiency, which may be used to identify possible causes of reversible causes of cognitive impairment. None of these results varied by gender, race, age, or health status (co-morbidities) of the patient.
The study's first author, Nicole Fowler, PhD, MHSA of the IU Center for Aging Research, Regenstrief Institute and IU Center for Health Innovation and Implementation Science, says that the Annual Wellness Visit is a universally missed opportunity to enhance early detection of cognitive impairment. The new study provides unique insight into the lack of provider-initiated actions to look for potential cognitive impairment during the visit.
"Our study shows that implementing a policy—mandating inclusion of detection of cognitive impairment as one of the required elements of the Medicare Annual Wellness Visit—without guidance on how to implement, means it isn't being done. Brief tools that have been validated in primary care could be employed and coupled with a plan for follow-up if cognitive impairment is suspected, but it does not appear that is being done across the United States.
"Physicians do assess for symptoms and initiate treatment for other conditions that do not have a cure such as heart failure and lung disease," she says. "So why aren't we doing the same for cognitive impairment? For example, learning that a patient is experiencing cognitive problems and is taking a prescription or over the counter anticholinergic medication—a class of drugs which we know are harmful to the brain - could greatly improve an older adult's life."
In January 2011, the Patient Protection and Affordable Care Act added the Annual Wellness Visit as a benefit of Medicare, including a screening for cognitive impairment. However, the mandate did not include guidance on implementation.
"One-Year Impact of the Medicare Annual Wellness Visit on Detection of Cognitive Impairment: A Cohort Study" is published online ahead of print in the Journal of the American Geriatrics Society. Co-authors of the study, in addition to Dr. Fowler are Noll L. Campbell, PharmD, MS of the Regenstrief Institute and the IU Center for Aging Research; Gerhardt M. Pohl, PhD; Leanne M. Munsie, BS and J. Scott Andrews, PharmD of Eli Lilly and Company; Noam Y. Kirson, PhD; Urvi Desai, PhD; Erich J. Trieschman, BA, and Mark K. Meiselbach, MS of Analysis Group, Inc. and Malaz A. Boustani, MD, MPH of the Regenstrief Institute, IU Center for Aging Research and IU School of Medicine. Dr. Boustani is the founding director of the IU Center for Health Innovation and Implementation Science.
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Nicole R. Fowler et al. One-Year Effect of the Medicare Annual Wellness Visit on Detection of Cognitive Impairment: A Cohort Study, Journal of the American Geriatrics Society (2018). DOI: 10.1111/jgs.15330