Division of Geriatric Medicine and Gerontology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA.
Center for Transformative Geriatrics Research, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA.
J Am Geriatr Soc. 2022 Feb;70(2):579-584. doi: 10.1111/jgs.17546. Epub 2021 Nov 5.
The Medicare Annual Wellness Visit (AWV) requires screening for geriatrics conditions and can include advance care planning (ACP). We examined (1) the prevalence of positive screens for falls, cognitive impairment, and activities of daily living (ADL) impairment, (2) referrals/orders generated potentially in response, and (3) the increase in ACP among those with two AWVs.
In this retrospective analysis, we used electronic medical record data from a Mid-Atlantic group ambulatory practice. We included adults age > 65 who had ≥1 AWV (n = 16,176) in years 2014-2017. Analyses on high-risk prescribing were limited to those (n = 13,537) with ≥3 months of follow up and ACP to those (n = 9097) with two AWVs. We used responses from the AWV health risk questionnaire to identify screening status for falls, cognitive and ADL impairment and whether an older adult had an ACP. For each screen we identified orders/referrals placed potentially in response (e.g., physical therapy for falls). High-risk medications were based on the 2019 Beers Criteria.
Positive screening rates were 38% for falls, 23% for cognition, and 32% for ADL impairment. The adjusted odds of having an order placed potentially in response to the screening were 1.8 (95% CI 1.6-2.0) for falls, 1.4 (1.3-1.7) for cognition, 2.8 (2.4-3.3) for ADL impairment. The adjusted odds of a high-risk prescription in the 3 months after a positive screen were 2.1 (95% CI 1.8-2.5) for falls and 1.9 (95% CI 1.6-2.4) for cognition. Of those with two AWVs, 48% had an ACP at the first AWV. Among the remaining 52% with no ACP at the first AWV, the predicted probability of having an ACP at the second AWV was 0.22 (95% CI 0.18-0.25).
Our results may indicate positive effects of screening for geriatric conditions at the AWV, and highlight opportunities to improve geriatrics care related to prescribing and ACP.
医疗保险年度健康访视（AWV）要求对老年病状况进行筛查，并且可以包括预先护理计划（ACP）。我们检查了（1）跌倒、认知障碍和日常生活活动（ADL）障碍的阳性筛查率，（2）潜在的回应性转介/医嘱，以及（3）在两次 AWV 中有 ACP 增加的患者比例。
在这项回顾性分析中，我们使用了一家中大西洋地区门诊实践的电子病历数据。我们纳入了 2014-2017 年期间年龄大于 65 岁且至少有一次 AWV（n=16176）的成年人。高风险处方的分析仅限于那些（n=13537）有至少 3 个月随访的患者，而 ACP 则限于那些（n=9097）有两次 AWV 的患者。我们使用 AWV 健康风险问卷的回复来确定跌倒、认知和 ADL 障碍的筛查状态，以及老年人是否有 ACP。对于每个筛查，我们确定了潜在的回应性医嘱/转介（例如，跌倒的物理治疗）。高风险药物基于 2019 年 Beers 标准。
跌倒的阳性筛查率为 38%，认知障碍的筛查率为 23%，ADL 障碍的筛查率为 32%。与筛查结果相对应的潜在医嘱/转介的调整后比值比（OR）为 1.8（95%置信区间[CI]为 1.6-2.0），认知障碍的调整后 OR 为 1.4（1.3-1.7），ADL 障碍的调整后 OR 为 2.8（2.4-3.3）。在阳性筛查后的 3 个月内，高风险处方的调整后 OR 为 2.1（95% CI 为 1.8-2.5），认知障碍的调整后 OR 为 1.9（95% CI 为 1.6-2.4）。在有两次 AWV 的患者中，48%的患者在第一次 AWV 时就有 ACP。在其余 52%的患者中，他们在第一次 AWV 时没有 ACP，在第二次 AWV 时进行 ACP 的预测概率为 0.22（95% CI 为 0.18-0.25）。
我们的结果可能表明 AWV 对老年病状况进行筛查有积极影响，并突出了在处方和 ACP 方面改善老年护理的机会。
