Abstract
Background:
The utilization of Annual Wellness Visits (AWVs), preventive healthcare visits covered by Medicare Part B, has grown steadily since their inception in 2011. However, longitudinal patterns and variations in use across enrollees, providers, and clinics remain poorly understood.
Objective:
This study aimed to analyze AWV usage trends from 2018 to 2022 among a sizable cohort of Medicare beneficiaries, employing electronic health record (EHR) data. The goal was to assess AWV frequency and explore variations across enrollees, providers, and clinics.
Design:
This retrospective observational study utilized EHR data from Medicare beneficiaries aged 66 and above, receiving continuous primary care from 2018 to 2022 (N = 24,549). Enrollees were classified into three categories based on their AWV utilization over a 5-year period: low users (0–1 AWVs), moderate users (2–3 AWVs), and regular users (4–5 AWVs). AWV usage patterns were examined across individual demographics and provider/clinic characteristics using multilevel regression models.
Key Results:
Over the 2018–2022 period, 58.6% were regular AWV users, 27.7% were moderate users, and 13.7% were low users. Differences in primary care providers and clinics accounted for 56.4% (95% CI, 45.3%–66.9%) of the variation between low and regular users. Among enrollees who visited the same providers and clinics, individuals were less likely to be regular users of AWVs if they were 85 and older, Hispanic, from socioeconomically disadvantaged areas, or had multiple comorbidities.
Conclusions:
The majority of Medicare beneficiaries in the study engaged with AWVs, with 86% having two or more over the 5-year period. These findings underscore the broad acceptance of AWVs among beneficiaries but also show that clinic and provider factors influence usage, especially among older, minoritized, and socioeconomically disadvantaged populations. Interventions at the provider and clinic levels are necessary to further improve AWV uptake, particularly for vulnerable groups.
Keywords: annual wellness visit, health disparities, healthcare utilization, Medicare, preventive healthcare
INTRODUCTION
As global demographics shift toward an aging population, the emphasis on preventive healthcare and healthy aging for older adults becomes increasingly crucial. The strain and burdens of preventable health decline on healthcare systems are profound, magnifying the need for structured interventions that can mitigate healthcare costs and improve quality of life for the aging population.1,2 Central to such preventive strategies in the United States is the Medicare Annual Wellness Visit (AWV), introduced in 2011 under the Affordable Care Act (ACA); with spending estimated around $1.2 billion per year for this service.3 This initiative is designed to promote health maintenance and support healthy aging through the creation of personalized preventive care plans among Medicare beneficiaries, who are eligible for AWVs without copayments or deductibles after their first year of enrollment.4
Distinct from traditional physical examinations, the AWV focuses on comprehensive health risk assessments and evidence-based preventive care.5 These visits are structured to include screenings for conditions like fall risks and depression, review of functional ability, medication assessment to prevent polypharmacy, and discussions on advance care planning.5 This can provide a structured opportunity for primary care providers (PCPs) to address and review age-appropriate preventive care measures, which are vital for maintaining and improving the health of older adults. Although evidence on the impact of AWVs is mixed, leading to some controversy, several studies highlight promising outcomes.3,6–13 For instance, AWVs have been associated with enhanced utilization of preventive services, increased diagnosis rates of Alzheimer’s disease and related dementias (ADRD), improved management of health risks like depression, and decreased healthcare costs.3,6–17 Nationally, the majority (>90%) of AWVs are performed by PCPs.18
Despite these potential benefits, the uptake of AWVs has been inconsistent and relatively slow. From a modest 7% completion rate in 2011, the rates improved to 20% in 2014 and 34.1% in 2019, but detailed data on recent years and longitudinal patterns remain sparse.6,18–20 Current literature has primarily explored the barriers to the initial adoption of AWVs, citing a blend of individual characteristics, practice capabilities, and financial incentives as influencing factors.14,21–24 However, there is a notable gap in understanding the longitudinal engagement of Medicare enrollees with AWVs—whether enrollees engage with AWVs consistently over time or whether such engagements are sporadic. Recognizing this gap, our study investigates the usage patterns of AWVs over a 5-year period (2018–2022) within a large healthcare system. We utilized electronic health record (EHR) data to explore how often Medicare enrollees participate in AWVs and the variability in usage based on individual, provider, and clinic factors. This study aims to shed light on the longitudinal use of AWVs, offering insights that could inform policy adjustments and emphasize the role of AWVs in preventive care, potentially leading to broadened implementation and enhanced clinical outcomes. By understanding these patterns, we can better grasp the full implications of AWVs on the healthcare trajectories of older adults, thereby supporting the overarching goal of preventive healthcare.
METHODS
Our study population was identified from individuals within the Atrium Health Wake Forest Baptist (AHWFB) network. AHWFB is the largest healthcare system in western North Carolina, with over 2.2 million clinic visits annually for individuals from 22 counties in North Carolina and southern Virginia. Using comprehensive EHR data, we identified Medicare enrollees aged 66 and older as of January 1, 2018 (baseline date) who received patient care continuously within the network between 2018 and 2022. We included those who had at least one routine office visit each year (identified by Evaluation and Management [E&M] CPT codes 99,201–99,205, 99,211–99,215) with a primary care provider (identified by provider specialty of internal medicine, family medicine, and geriatric medicine) (N = 57,528) (Supplement Figure 1). We excluded individuals who died during 2018–2022, were not covered by Medicare, and did not reside in North Carolina or Virginia. This study was part of a broader project which also aimed to assess the potential impact of regular AWV use on the diagnosis of ADRD. Consequently, individuals with a baseline diagnosis of AD/ADRD were excluded. Additionally, we excluded PCPs with fewer than 10 primary care visits annually as this criterion likely indicated a temporary provider. The final study cohort included 24,549 individuals with continuous primary care within the network from 2018 to 2022. Our study protocol for data acquisition and development was approved by the Wake Forest University School of Medicine Institutional Review Board.
Our main outcome of interest was the per-person frequency of AWVs received during 2018–2022. As the study cohort includes Medicare enrollees aged 66 and older, all were eligible for an AWV annually without out-of-pocket costs.4 We identified AWVs using CPT codes G0438 and G0439, and defined dichotomous indicators of AWV use (0/1) during each calendar year.25 We defined a cumulative indicator of the number of years AWV was received during the 5-year periods (0 to 5). To examine longitudinal patterns of AWV use over the 5-year study period, we classified enrollees into three categories based on their total number of AWVs: regular users (4–5 visits), moderate users (2–3 visits), and low users (0–1 visits). This classification was chosen to capture both the frequency and consistency of AWV engagement over time, rather than focusing solely on initial uptake. The goal was to assess sustained utilization of AWVs, as repeated engagement is likely to reflect deeper integration of preventive care into routine clinical practice. Additionally, this approach provided a more comprehensive understanding of AWV utilization patterns across the cohort.
To characterize the differences in AWV frequency, we identified individual, provider, clinic, and area-level indicators. We obtained individual age at baseline (categorized as 66–74, 75–84 and 85 or older), sex, and race/ethnicity (Hispanic, non-Hispanic Black, non-Hispanic White, Other, and Unknown). Using health conditions (ICD-10-CM codes) identified in all encounters in 2018, we obtained dichotomous indicators (0/1) of the 29 Elixhauser comorbidities and categorized overall comorbidity burden based on the number of comorbidities identified (0–1, 2–3, and 4 or more).26 Identifying baseline frequency of outpatient visits as a potential factor in AWV use, we obtained the total number of E&M visits in 2018 separately with PCPs (categorized as 0–2, 3–5, and 6 or more) and specialist providers (categorized as 0, 1–3, and 4 or more). The type of Medicare coverage (Fee for Service or Medicare Advantage) was determined at baseline.
We identified the primary care provider for each enrollee based on all E&M encounters in 2018; in the case of multiple providers, we selected the provider that the patient visited over the longest time, measured by the time interval between visits from the same provider. We identified the primary care clinic for each enrollee by the clinic location of the primary care provider; in the case of multiple locations, we selected the location with the highest volume of E&M visits in 2018 for the provider. To examine provider volume as a potential factor in AWV use, we obtained the total volume of E&M visits in 2018 for PCPs and clinics.
In the absence of individual-level information on social risk indicators, we obtained zip code-level measures from 2018 Census data. Using the zip code of enrollee’s residence, we defined dichotomous indicators (0/1) of individuals residing in zip code with: higher poverty rate (poverty rate ≥20%), higher rate of Supplemental Nutrition Assistance Program use (SNAP rate ≥20%), higher proportion of adults aged 25 and older with less than high school education (proportion ≥20%), higher proportion of non-White population (proportion ≥40%), and nearest healthcare clinic at least 6 miles away.27
We measured the longitudinal trends in AWV uptake overall and among subgroups by AWV use frequency (i.e., regular, moderate, and low AWV users). We performed bivariate comparisons of the individual, provider, clinic, and residence area characteristics by AWV use frequency. To assess the potential role of PCPs and clinics in understanding individual-level variation in AWV frequency, we used the multilevel structure of the analytic data—with a three-tiered hierarchy of individuals, providers, and clinics—and estimated random effects logit regression models to estimate the proportion of the overall variation in AWV frequency associated with providers and clinics. We obtained the intraclass correlation (ICC) estimate to measure the extent of clustering of AWV frequency at provider and clinic levels. To assess the role of individual characteristics, we examined individuals receiving primary care from the same providers and clinics. Specifically, we used generalized linear models with provider and clinic fixed effects to estimate the association between AWV frequency and individual characteristics among enrollees obtaining care from the same provider and clinic. We used two-sided tests of model estimates, with significance assessed at a p-value ≤0.05. All statistical analyses were performed using Stata Version 16.1 from May 20, 2023, to February 7, 2024.
RESULTS
Our study cohort consisted of 24,549 older adults who received primary care continuously from 2018 to 2022 (Figure 1). Longitudinally, the proportion with AWV was 66.1% in 2018 and 67.7% in 2022. Stratifying the cohort by AWV frequency, 58.6% (14,392) were regular users, 27.7% (6793) were moderate users, and 13.7% (3364) were low users. In 2022, the proportion with AWV was 75.9% among regular users, 20.7% among modest users, and 3.4% among low users. An examination of the year-to-year transition of AWV use status indicates that while a majority of individuals received an AWV, a sizable proportion received no AWV during the 5 years (Supplement Figure 2).
FIGURE 1.
Annual Wellness Visit uptake, 2018–2022. The study cohort (N = 24,549) was stratified into three groups based on the overall count of years in which AWV occurred during the 2018–2022 period: Regular (4 or 5 years), moderate (2–3 years), and low (0–1). AWV, Annual Wellness Visit.
Comparison of the subgroups by AWV use frequency indicates that a larger proportion of low AWV users are aged 85 and older (7.8%) compared with regular AWV users (5.8%) (Table 1). A larger proportion of low AWV users are Hispanic or non-Hispanic Black (19.8%) compared with regular AWV users (9.3%). In addition, low AWV users are more likely to have high comorbidity burden compared with regular AWV users. PCPs and clinics with higher visit volumes have a higher proportion of regular AWV users (Supplement Figure 3). Regular AWV users were more likely to receive care from providers specializing in internal medicine, while low AWV users were more likely to be cared for by providers specializing in family medicine or geriatrics. Enrollees with low AWV use are more likely to reside in areas with higher poverty, SNAP use, those with less than high school education, and non-White population.
TABLE 1.
Study cohort characteristics at baseline.
| Characteristics | All cohort | Low AWV users | Moderate AWV users | Regular AWV users |
|---|---|---|---|---|
| Number of primary care patients | 24,549 (100%) | 3364 (13.7%) | 6793 (27.7%) | 14,392 (58.6%) |
| Individual characteristics | ||||
| Age: Median [Interquartile range] | 73 [69, 77] | 72 [68, 77] | 73 [69, 78] | 73 [69, 77] |
| Age (%) | ||||
| 66–74 | 14,885 (60.6%) | 2093 (62.2%) | 4071 (59.9%) | 8721 (60.6%) |
| 75–84 | 8052 (32.8%) | 1008 (30.0%) | 2210 (32.5%) | 4834 (33.6%) |
| 85+ | 1612 (6.6%) | 263 (7.8%) | 512 (7.5%) | 837 (5.8%) |
| Female % | 14,690 (59.8%) | 1921 (57.1%) | 4135 (60.9%) | 8634 (60.0%) |
| Race/ethnicity, % | ||||
| Hispanic | 265 (1.1%) | 88 (2.6%) | 91 (1.3%) | 86 (0.6%) |
| Black, non-Hispanic | 2736 (11.1%) | 577 (17.2%) | 902 (13.3%) | 1257 (8.7%) |
| White, non-Hispanic | 21,057 (85.8%) | 2630 (78.2%) | 5640 (83.0%) | 12,787 (88.8%) |
| Other | 367 (1.5%) | 58 (1.7%) | 112 (1.6%) | 197 (1.4%) |
| Unknown | 124 (0.5%) | 11 (0.3%) | 48 (0.7%) | 65 (0.5%) |
| Number of comorbidities | ||||
| 0–1 | 6479 (26.4%) | 819 (24.3%) | 1597 (23.5%) | 4063 (28.2%) |
| 2–3 | 9905 (40.3%) | 1237 (36.8%) | 2647 (39.0%) | 6021 (41.8%) |
| 4 or more | 8165 (33.3%) | 1308 (38.9%) | 2549 (37.5%) | 4308 (29.9%) |
| Individual annual E&M visits, primary care | ||||
| 0–2 | 9118 (37.1%) | 1309 (38.9%) | 2399 (35.3%) | 5410 (37.6%) |
| 3–5 | 10,171 (41.4%) | 1163 (34.6%) | 2722 (40.1%) | 6286 (43.7%) |
| 6 or more | 5260 (21.4%) | 892 (26.5%) | 1672 (24.6%) | 2696 (18.7%) |
| Individual annual E&M visits, specialty | ||||
| 0 | 10,242 (41.7%) | 1312 (39.0%) | 2645 (38.9%) | 6285 (43.7%) |
| 1–3 | 8336 (34.0%) | 1146 (34.1%) | 2356 (34.7%) | 4834 (33.6%) |
| 4 or more | 5971 (24.3%) | 906 (26.9%) | 1792 (26.4%) | 3273 (22.7%) |
| Physician/Clinic characteristics | ||||
| Physician annual E&M volume | ||||
| 10–800 | 6522 (26.6%) | 1609 (47.8%) | 2096 (30.9%) | 2817 (19.6%) |
| 801–1500 | 7057 (28.7%) | 712 (21.2%) | 1805 (26.6%) | 4540 (31.5%) |
| 1501 + | 10,970 (44.7%) | 1043 (31.0%) | 2892 (42.6%) | 7035 (48.9%) |
| Clinic annual E&M volume | ||||
| 30–4000 | 9026 (36.8%) | 1330 (39.5%) | 2509 (36.9%) | 5187 (36.0%) |
| 4001–7000 | 7587 (30.9%) | 1372 (40.8%) | 2712 (39.9%) | 3503 (24.3%) |
| 7001 + | 7936 (32.3%) | 662 (19.7%) | 1572 (23.1%) | 5702 (39.6%) |
| Clinic specialty | ||||
| Family medicine | 12,776 (52.0%) | 1785 (53.1%) | 3728 (54.9%) | 7263 (50.5%) |
| Geriatric medicine | 244 (1.0%) | 174 (5.2%) | 56 (0.8%) | 14 (0.1%) |
| Internal medicine | 11,529 (47.0%) | 1405 (41.8%) | 3009 (44.3%) | 7115 (49.4%) |
| Residence area characteristics | ||||
| Proportion of beneficiaries in zip code with | ||||
| Poverty rate >= 20% | 5136 (20.9%) | 842 (25.0%) | 1391 (20.5%) | 2903 (20.2%) |
| SNAP use >=20% | 2493 (10.2%) | 483 (14.4%) | 707 (10.4%) | 1303 (9.1%) |
| >=20% adults aged 25+ with less than high school | 5347 (21.8%) | 745 (22.1%) | 1449 (21.3%) | 3153 (21.9%) |
| education | ||||
| >=40% non-White population | 6566 (26.7%) | 1067 (31.7%) | 1997 (29.4%) | 3502 (24.3%) |
| Nearest healthcare clinic > = 6 miles away | 6404 (26.1%) | 785 (23.3%) | 1752 (25.8%) | 3867 (26.9%) |
Note: The baseline date was 1/1/2018.
Abbreviations: AWV, annual wellness visit; E & M, evaluation and management; SNAP, supplemental nutrition assistance program.
Based on multilevel regression model estimates without individual-level covariates, clinic characteristics accounted for 44.5% (95% CI, 33.7%–55.8%) of the variation between low and regular AWV users and 21.1% (95% CI, 14.1%–30.3%) of the variation between moderate and regular AWV users (Table 2). The combined clinic- and provider-level differences accounted for 57.1% (95% CI, 48.2%–65.5%) of the variation between low and regular AWV users and 30.1% (95% CI, 24.2%–38.6%) of the variation between moderate and regular AWV users. Estimates of corresponding models including individual covariates provided largely similar estimates of variation accounted by provider and clinic differences.
TABLE 2.
Variation in AWV use at provider and clinic levels.
| Source of variation in regular vs. low/moderate AWV use during 2018–2022 | Proportion of variation in low vs. regular AWV use, % [95% confidence interval] | Proportion of variation in moderate vs. regular AWV use, % [95% confidence interval] |
|---|---|---|
| Unadjusted multilevel model | ||
| Proportion of variation at clinic level | 44.5% [33.7%, 55.8%] | 21.1% [14.1%, 30.3%] |
| Proportion of variation at provider and clinic levels | 57.1% [48.2%, 65.5%] | 30.1% [24.2%, 38.6%] |
| Adjusted multilevel model | ||
| Proportion of variation at clinic level | 43.9% [31.4%, 57.2%] | 19.6% [13.2%, 28.0%] |
| Proportion of variation at provider and clinic levels | 56.4% [45.3%, 66.9%] | 29.6% [23.7%, 36.3%] |
Note: (1) Analysis was performed using two subcohorts. The first subcohort included those with low AWV and regular AWV use, and was used to examine the dichotomous indicator of low AWV use (1) treating regular AWV use as the reference cohort (0). The second subcohort included those with moderate AWV and regular AWV use, and was used to examine the dichotomous indicator of moderate AWV use (1) treating regular AWV use as the reference cohort (0). (2) For the unadjusted models, we used multilevel random effects logit regression models of the dichotomous indicator of low/moderate AWV use, in comparison with regular AWV use, with clustering of individuals at provider and clinic levels. We obtained the intraclass correlation at provider and provider + clinic levels. (3) For the adjusted models, we used multilevel random effects logit regression models noted above, including individual-level covariates: age, sex, race/ ethnicity, plan type (Fee for Service/Medicare Advantage), no. Elixhauser comorbidity conditions, baseline year number of primary E&M visits and specialty E&M visits, and zip code-level indicators of poverty rate, SNAP use rate, adults without high school education, proportion non-White, and nearest distance to healthcare clinic over 6 miles.
Abbreviation: AWV, Annual Wellness Visit.
Among low and regular AWV users receiving care from the same providers (and clinics), those aged 85 and older were 4.2% (95% CI, 2.2%–6.2%) more likely to be low AWV users relative to those aged 66–74 (Table 3). Hispanic patients had a 17.8% (95% CI, 11.6%–24.0%) higher likelihood of being low AWV users relative to non-Hispanic White patients. Interestingly, individuals with more primary care E&M visits (in baseline year) were less likely to be low AWV users, with a 4.0% decrease in the likelihood (−4.0%; 95% CI, −5.1% to −2.9%) among those with three to five visits compared with those with zero to two visits. In contrast, individuals with more specialist E&M visits were more likely to be low AWV users. Supplementary Table 1 further supports these findings, showing that patients in geriatric medicine clinics had a higher proportion of both primary and specialty care visits compared with family and internal medicine clinics, with 43.4% of geriatric patients having six or more primary care visits annually. Corresponding analysis among moderate and regular AWV users receiving care from the same providers and clinics also indicated that individuals aged 85 and older, Hispanic patients, and those with higher comorbidity burden were more likely to be moderate AWV users.
TABLE 3.
Individual-level characteristics associated with AWV use differences across patients with same provider and clinic.
| Characteristics | Estimated difference in the proportion of patients with low AWV use and proportion with regular AWV use | Estimated difference in the proportion of patients with moderate AWV use and proportion with regular AWV use |
|---|---|---|
| Reference Cohort | 18.7% [17.2%, 20.3%] | 26.7% [24.8%, 28.7%] |
| Age (reference = 66–74) | ||
| 75–84 | −1.1% [−2.1%, −0.1%] | 0.5% [−0.8%, 1.7%] |
| 85+ | 4.2% [2.2%, 6.2%] | 7.7% [5.2%, 10.1%] |
| Female | −2.1% [−3.1%, −1.1%] | −0.2% [−1.5%, 1.0%] |
| Race/ethnicity (reference = non-Hispanic White) | ||
| Hispanic | 17.8% [11.6%, 24.0%] | 15.9% [9.1%, 22.7%] |
| Black, non-Hispanic | 0.7% [−1.2%, 2.5%] | 1.9% [−0.3%, 4.2%] |
| Number of comorbidities (reference = 0 or 1 condition) | ||
| 2 or 3 conditions | 0.6% [−0.6%, 1.8%] | 1.9% [0.4%, 3.3%] |
| 4 or more conditions | 2.7% [1.4%, 4.1%] | 5.8% [4.1%, 7.4%] |
| Baseline annual no. primary E&M visits (reference = 0 to 2 visits) | ||
| 3–5 visits | −4.0% [−5.1%, −2.9%] | −1.0% [−2.4%, 2.8%] |
| 6 or more visits | −3.0% [−4.4%, −1.5%] | 2.0% [2.6%, 3.8%] |
| Baseline annual no. specialty E&M visits (reference = 0 visits) | ||
| 1–3 visits | 1.8% [0.6% 2.9%] | 1.8% [0.3%, 3.2%] |
| 4 or more visits | 3.7% [2.3%, 5.1%] | 3.0% [1.3%, 4.6%] |
| Medicare Advantage (reference = Fee for Service) | 1.2% [0.2%, 2.2%] | 0.5% [−0.7%, 1.7%] |
Note: (1) We examined two subcohorts. The first subcohort included those with low AWV and regular AWV use, and was used to examine the dichotomous indicator of low AWV use (1) treating regular AWV use as the reference cohort (0). The second subcohort included those with moderate AWV and regular AWV use, and was used to examine the dichotomous indicator of moderate AWV use (1) treating regular AWV use as the reference cohort (0). (2) We used a linear probability regression model with fixed effects for providers and clinics, in addition to the individual-level characteristics. (3) The regression models included all individual and area-level characteristics listed in Table 1. The characteristics listed above in the table are those with a statistically significant estimate. We found no significant differences associated with area-level differences in socioeconomic status, indicating lack of intra-provider and intra-clinic differences across patients with different area-level socioeconomic status. (4) The reference cohort is individuals aged 66–74, male, non-Hispanic White, with Fee for Service coverage, no comorbidities, and no adverse zipcode-level socioeconomic status. The estimate of 18.7% reported above indicates that among the reference cohort, the proportion with low AWV use was 18.7% higher than the proportion with regular AWV use.
Abbreviations: AWV, Annual Wellness Visit; E &M, evaluation and management.
DISCUSSION
The findings of this study provide valuable insights into the utilization patterns of AWVs over a 5-year period within a large healthcare system. Our analysis revealed several key points that merit discussion regarding the uptake and implications of AWVs for promoting preventive healthcare among older adults. First, our study identified that a substantial proportion of Medicare enrollees engaged in regular AWVs, with nearly 6 out of 10 individuals classified as regular users. This indicated a significant adoption of these preventive services within the studied population.6,18,19,28 Some of the operational processes for AWVs within our large health network might have contributed to the high uptake, including the integration of Medicare-recommended AWV questions into the EHR via a standardized smartform and smartset, as well as a best practice alert (BPA) tied to AWV completion, which serves as a quality metric and incentivizes providers to prioritize these visits. Additionally, our study demonstrated that patients with more frequent primary care visits were more likely to engage in regular AWV use, as increased interactions with the healthcare system provide more opportunities for AWV completion. Specifically, individuals with three to five primary care visits had a 4.0% lower likelihood of being low AWV users, reinforcing the value of consistent primary care engagement for promoting preventive services. However, despite this encouraging trend, a sizable portion of enrollees (e.g., those aged 85 and older, Hispanic patients, and with higher comorbidity burden) exhibited low or moderate engagement with these visits, suggesting that barriers continue to persist.
Clinic characteristics were found to be associated with variations seen in AWV frequency, highlighting the influence that organizational factors may play on patient engagement with AWVs. While patient preferences may contribute to this variability, differences in practice patterns, workflows, and staffing likely play a crucial role as well.29–33 For example, evidence suggests that utilizing registered nurses for assessments and education during AWVs may enhance the capacity for these visits and improve patient outcomes by providing more comprehensive preventive care.34,35 Additionally, models such as the Geriatric Resources for Assessment and Care for Elders (GRACE), which incorporate interprofessional care and in-home assessments as part of the AWV, have shown promise.36,37 Further research is necessary to better understand these potential drivers and to identify strategies to standardize and improve AWV uptake across different settings.
Our study also found that provider-level differences were associated with the variability in AWV utilization, emphasizing the importance of provider–patient dynamics and interpersonal factors in promoting AWVs.38,39 It is plausible that these differences could be attributed to variations in clinic cultures and norms, as well as individual convictions held by healthcare providers regarding the significance of AWVs.6 Prior studies have elucidated the substantial impact of these factors on AWV adoption rates.6,19 Interestingly, we observed that enrollees seen by geriatricians were less likely to be regular AWV users. This finding may reflect the nature of geriatric practice, which focuses on managing complex patients for whom some preventive activities may be either unnecessary or inappropriate based on their care goals. Further research is needed to explore how geriatricians’ focus on complex patients influences preventive care engagement in the outpatient setting. Furthermore, systematic differences in patient profiles across providers and clinics may also contribute to variations seen at the provider and clinic levels. Thus, further investigations are warranted to better understand the barriers clinics and providers face in promoting AWVs.6,40,41
Among enrollees cared for by the same providers and clinics, our study revealed that individuals with a higher comorbidity burden were less likely to engage in regular AWVs. This observation suggests that healthcare providers might prioritize addressing immediate health issues over preventive measures in patients with multimorbidity.42 In addition to preventive health, AWVs also serve as a valuable opportunity for screening for geriatric syndromes, such as dementia, falls, and incontinence, and for engaging in advance care planning discussions. Further investigation is needed to explore whether disparities exist in the adoption of both preventive measures and geriatric syndrome screening among older adults with multimorbidity who undergo regular AWVs compared with those who do not.21,43 Moreover, the primary drivers of multimorbidity are age and socioeconomic disadvantage, underscoring the imperative of addressing social determinants of health and implementing tailored interventions to alleviate disparities to promote the adoption of AWVs.44
We also found that individuals aged 85 and older were also less likely to be regular AWV users. Given that the likelihood of benefit from preventive care measures in older adults depends on both the time-to-benefit and their life expectancy—for instance, cancer screenings like colorectal or breast cancer screenings typically have a time-to-benefit of 10 years—this might explain the observed trend.45 In addition, similar to what we observed with geriatricians, providers may deliberately eschew AWVs in this age group, focusing instead on patient-centered care plans that prioritize the management of chronic conditions over routine preventive screenings, especially for patients with limited prognoses. However, it is important to note that there are other crucial preventive care measures that should be emphasized within this age cohort, including fall prevention, polypharmacy, depression screening, vaccinations, exercise, healthy diet, and many more.9 It is important to note that the Centers for Medicare & Medicaid Services (CMS) covers AWVs for all Medicare beneficiaries, without age distinctions. Additionally, we found that those who were Hispanic and living in a geographic area of high socioeconomic disadvantage were less likely to be regular AWV users. These findings align with previous studies showing that factors such as race, ethnicity, income, and education level are often associated with disparities seen in the use of preventive services, including AWVs.19,22 Regrettably, these ethnoracial inequalities appear to persist as highlighted in our findings and raise concerns about inequitable access to AWVs. Although we did not capture data on patients’ primary language or access to technology—both of which may contribute to disparities in AWV uptake—our system mitigates these barriers by having staff ask AWV questions in person during visits and using interpretation services for non-English-speaking patients. Additionally, practices serving patients with significant social determinants of health (SDOH) often face limited staffing, and medically and socially complex patients may prioritize immediate concerns (e.g., food insecurity) over preventive care, further exacerbating these disparities.21 Addressing these inequalities will likely require a multifaceted approach, including screening for SDOH and linking patients to community resources that can help alleviate barriers to care. By addressing critical needs such as food insecurity, housing, and transportation, we can create a more supportive environment for AWV adoption. Efforts must also be made not just at the individual provider level, but also within the broader health care system to combat any structural and systemic racism that may be exacerbating these inequities.46 Additionally, policymakers should create incentive opportunities to test interventions aimed at increasing the adoption of AWVs among marginalized populations.17 Further research is also needed to explore the long-term impact of AWVs on health outcomes and healthcare costs, particularly in diverse and high-risk populations. Understanding the specific components of AWVs that drive positive outcomes can inform more effective and tailored interventions. Additionally, examining the role of emerging technologies, such as telehealth, in facilitating AWVs could provide innovative solutions to increase accessibility and engagement.47 By addressing these areas, we can better understand and leverage AWVs as a tool for preventive care, aiming to achieve broader and more equitable health improvements across the Medicare population.48 This will help ensure that the benefits of AWVs are fully realized, contributing to the overarching goal of preventive healthcare and healthier aging.
LIMITATIONS
We recognize several limitations of this study. First, the study population was confined to Medicare enrollees within a single health system, which may limit the generalizability of our findings to other health systems and the broader Medicare population. Additionally, our dataset did not capture healthcare utilization outside this system, potentially underestimating AWV utilization for some individuals. However, because the study includes only those with continuous routine outpatient care (at least one E&M visit each year from 2018 to 2022), the extent of missed AWVs may be limited. Second, our regression estimates indicate a correlation between AWV frequency and characteristics of enrollees, providers, and clinics, but do not establish causal relationships. Our intent was to explore potential sources of the variation in AWV use across the study population. Third, we recognize that the observation period coincided with the onset and continuation of the COVID-19 pandemic, which led to global declines in outpatient visits. Although patients have reported intentionally missing visits due to COVID-19 concerns, Hernandez et al. (2024) found that older adults missed fewer visits compared with their younger counterparts and that attendance increased as the pandemic progressed.49 In addition, CMS expanded telehealth services to include AWVs during the COVID-19 pandemic. Furthermore, to be considered a regular AWV user, patients only need to have completed at least four visits over a 5-year period. Consequently, we did not find a decrease in AWV uptake in 2020 among any of the subgroups, and therefore the extent to which our findings are influenced by the COVID emergency may be limited. Additionally, we did not capture data on patients’ primary language or access to technology, which may have impacted AWV adoption, particularly for non-English-speaking patients or those without access to online platforms like mychart. While AWV questions are typically asked in person at our institution, technology access and language barriers may still pose challenges to AWV completion in other settings and systems. Finally, we restricted our cohort to individuals who remained alive during the study period and those without a diagnosis of AD/ADRD, which may limit the generalizability of our findings to healthier individuals with longer life expectancy.
CONCLUSION
This study offers insights into AWV utilization patterns over 5 years in a large healthcare system, highlighting progress and challenges in promoting preventive care among Medicare enrollees. While regular AWV utilization is encouraging, disparities persist, with many individuals showing low or moderate engagement. Clinic and provider characteristics may play significant roles in AWV utilization, emphasizing the need to address organizational and interpersonal factors for effective promotion of AWVs. Notably, individuals with multimorbidity, those aged 85 and older, Hispanic individuals, and those in socioeconomically disadvantaged areas were less likely to engage in regular AWVs, indicating potential disparities based on age, health status, ethnicity, and socioeconomic status. Addressing these disparities and implementing targeted interventions have the potential to maximize AWVs as a cornerstone of preventive care, advancing health equity, and improving outcomes for older adults in diverse communities.
Supplementary Material
SUPPORTING INFORMATION
Additional supporting information can be found online in the Supporting Information section at the end of this article.
Supplementary Table 1. Individual annual E&M visits by clinic specialty. (1) This table is a cross-tabulation involving 3 measures defined in Table 1: the clinic specialty (family medicine, geriatric medicine, and internal medicine) and the number of E&M visits by each individual (separately with primary care and specialist providers). (2) For instance, among the 244 individuals who received primary care in a geriatric medicine clinic, 70 (28.7%) had 0 to 2 E&M visits with primary care providers during the year, and 106 (43.4%) had 6 or more E&M visits with primary care providers.
Supplement Figure 1. Study cohort identification.
Supplement Figure 2. Decomposition of the study cohort by year-to-year AWV use status, 2018–2022. (1) As each individual may use or not use AWV each year, there are a total of 32 possible combinations for AWV utilization over the 5-year period. Stratifying the study cohort (N = 24,549) into 32 groups, the above alluvial plot indicates the size of each group. The blank bar for each year indicates the proportion with AWV use (“Yes”) and the proportion with no AWV use (“No”). For instance, the largest group at the bottom is those with AWV use (Yes) every year.
Supplement Figure 3. Correlation between AWV uptake and primary care provider and clinic E&M visit volume. (1) For each primary care provider and clinic, we obtained the total number of E&M visits for patients aged 66 and older in the base year (2017). (2) AWV uptake was obtained for the base year (2017). (3) We estimate a non-linear (fractional polynomial) regression of AWV uptake on the provider visit volume, with no other covariates. The estimated relationship along with the 95% confidence interval area (shaded area) are plotted in Appendix Figure 3a. (4) Appendix Figure 3b gives the corresponding relationship between AWV uptake and clinic visit volume.
Key points
The study highlights that nearly 6 out of 10 older adults were regular users of the Medicare Annual Wellness Visit (AWV) over a 5-year period between 2018 and 2022.
Clinic characteristics and provider-level differences were associated with variations in AWV utilization, underscoring the need for targeted interventions to address these organizational and interpersonal factors.
Disparities persist in AWV utilization, particularly among vulnerable demographic groups, necessitating a comprehensive approach that addresses individual, provider, and systemic-level factors to enhance access and engagement with AWV, helping advance health equity among older adults.
Why does this paper matter?
This study holds significance for several reasons. First, it sheds light on the evolving landscape of preventive healthcare for older adults, particularly in the context of AWV utilization patterns over a 5-year period. By uncovering trends and disparities in AWV engagement, the study provides valuable insights for policymakers, healthcare providers, and systems seeking to enhance the delivery of preventive care services to Medicare enrollees. Second, the identification of clinic and provider characteristics as influential factors in AWV utilization underscores the importance of organizational and interpersonal factors in promoting preventive care. Addressing these factors through targeted interventions and policy adjustments can help optimize clinic workflows, enhance patient–provider communication, improve access to preventive services, and ultimately lead to better health outcomes for older adults. Lastly, the study’s findings regarding disparities in AWV utilization highlight the pressing need to address inequities in access to healthcare among vulnerable populations. By understanding the demographic and socioeconomic factors associated with lower engagement in AWVs, healthcare systems can tailor interventions to mitigate barriers and promote equitable access to preventive care services, thus advancing health equity and improving outcomes for older adults across diverse communities.
Funding information
National Institute on Aging, Grant/Award Number: K23AG070234
SPONSOR’S ROLE
The sponsor had no role in the development of this manuscript.
FINANCIAL DISCLOSURE
Dr. Gabbard was supported by the National Institute on Aging (NIA) of the National Institutes of Health (NIH) under Award Number K23AG070234. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.
Footnotes
CONFLICT OF INTEREST STATEMENT
None.
ETHICS STATEMENT
This study was approved by the Atrium Wake Forest Institutional Review Board (IRB).
DATA AVAILABILITY STATEMENT
All data summarized in the publications will be made available upon email request to the study PI and upon completion of a data-sharing agreement. The data-sharing agreement will require that the data be used only for research purposes, that no attempts will be made to identify individual participants, that the data will be kept secure, that the user will not distribute the data to other researchers, that the user will return the files or destroy them once the project is completed, and that the user will acknowledge the data source.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials
Data Availability Statement
All data summarized in the publications will be made available upon email request to the study PI and upon completion of a data-sharing agreement. The data-sharing agreement will require that the data be used only for research purposes, that no attempts will be made to identify individual participants, that the data will be kept secure, that the user will not distribute the data to other researchers, that the user will return the files or destroy them once the project is completed, and that the user will acknowledge the data source.