Publications

PURPOSE: To examine outcomes of mammography screening among women > or = 80 years to inform decision making.

PATIENTS AND METHODS: We conducted a cohort study of 2,011 women without a history of breast cancer who were age > or = 80 years between 1994 and 2004 and who received care at one academic primary care clinic or two community health centers in Boston, MA. Medical record data were abstracted on all screening and diagnostic mammograms, breast ultrasounds and biopsies performed, all breast cancers diagnosed through December 31, 2006, and on sociodemographics. Date and cause of death were confirmed using the National Death Index.

RESULTS: The majority of patients (78.6%) were non-Hispanic white and 51.4% (n = 1,034) had been screened with mammography since age 80 years. Among women who were screened, eight were diagnosed with ductal carcinoma in situ, 16 with early stage disease (1.5%), two with late stage disease, and one died as a result of breast cancer. Many (110; 11%) experienced a false-positive screening mammogram that led to 19 benign breast biopsies, eight refused work-up, and three experienced a false-negative screening mammogram; 97 were screened within 2 years of their death from other causes. There were no significant differences in the rate, stage, recurrence rate, or deaths due to breast cancer between women who were screened and those who were not screened.

CONCLUSION: The majority of women > or = 80 years are screened with mammography yet few benefit. Meanwhile, 12.5% experience a burden from screening. The data from this study can be used to inform elderly women's decision making and potentially lead to more rational use of screening.

STUDY OBJECTIVE: Although the focus of emergency care is on the diagnosis and treatment of acute illnesses and injuries or the stabilization of patients for ongoing treatment, some patients may benefit from a palliative approach. Little is known about delivering palliative care in the emergency department (ED). We explore the attitudes, experiences, and beliefs of emergency providers about palliative care in the ED, using structured qualitative methods.

METHODS: We studied 3 focus groups with 26 providers, including 14 physicians (10 residents, 4 attending physicians), 6 nurses, 2 social workers, and 4 technicians, working in 2 academic EDs in Boston. We used a grounded theory approach to code responses, resolving discrepancies by consensus.

RESULTS: Six distinct themes emerged: (1) participants equated palliative care with end-of-life care; (2) participants disagreed about the feasibility and desirability of providing palliative care in the ED; (3) patients for whom a palliative approach has been established often visit the ED because family members are distressed by end-of-life symptoms; (4) lack of communication between outpatient and ED providers leads to undesirable outcomes (eg, resuscitation of patients with a do-not-resuscitate order); (5) conflict around withholding life-prolonging treatment is common (eg, between patient's family and written advance directives); and (6) training in pain management is inadequate.

CONCLUSION: Providers ranked improved communication and documentation from outpatient providers as their highest priority for improvement. Attitudinal and structural barriers may need to be overcome to improve palliative care in the ED. Despite targeted recruitment, attending physician participation was low.

BACKGROUND: Prognostic information is becoming increasingly important for clinical decision-making.

OBJECTIVE: To develop and validate an index to predict 5-year mortality among community-dwelling older adults.

DESIGN AND PARTICIPANTS: A total of 24,115 individuals aged >65 who responded to the 1997-2000 National Health Interview Survey (NHIS) with follow-up through 31 December 2002 from the National Death Index; 16,077 were randomly selected for the development cohort and 8,038 for the validation cohort.

MEASUREMENTS: 39 risk factors (functional measures, illnesses, behaviors, demographics) were included in a multivariable Cox proportional hazards model to determine factors independently associated with mortality. Risk scores were calculated for participants using points derived from the final model's beta coefficients. To evaluate external validity, we compared survival by quintile of risk between the development and validation cohorts.

RESULTS: Seventeen percent of participants had died by the end of the study. The final model included 11 variables: age (1 point for 70-74 up to 7 points for >85); male: 3 points; BMI <25: 2 points; perceived health (good: 1 point, fair/poor: 2 points); emphysema: 2 points; cancer: 2 points; diabetes: 2 points; dependent in instrumental activities of daily living: 2 points; difficulty walking: 3 points; smoker-former: 1 point, smoker-current: 3 points; past year hospitalizations-one: 1 point, >2: 3 points. We observed close agreement between 5-year mortality in the two cohorts; which ranged from 5% in the lowest risk quintile to 50% in the highest risk quintile in the validation cohort.

CONCLUSIONS: This validated mortality index can be used to account for participant life expectancy in analyses using NHIS data.

PURPOSE: We sought to determine how women aged 80 years or older value different preventive health measures compared to women aged 65 to 79 years.

DESIGN AND METHODS: We surveyed 107 women aged 80 years or older and 93 women aged 65 to 79 years; we randomly selected all of them from a large academic primary care practice. We measured perceived importance and priority placed on different preventive health measures, including screening tests; counseling on healthy lifestyle and geriatric health issues; immunizations; and recommendations for over-the-counter prevention medications.

RESULTS: Of the 200 women, 28.5% were aged 80 to 84 and 25.0% were aged 85 years or older. The majority of the women were non-Hispanic White (65.5%), had private insurance (82.0%), and were in good health condition (52.0%). Women aged between 65 and 79 were more likely than women aged 80 or older to consider screening tests and exercise counseling essential or very important to maintaining their health. Women aged 80 or older did not value any preventive health measure more highly than did younger women. Women who were 65 to 79 years of age ranked mammography screening as their most valued preventive health measure, with five of their top six measures being screening tests. Women who were 85 years of age or older prioritized flu shots, recommendations for aspirin, and then mammography screening.

IMPLICATIONS: Screening tests and exercise counseling are more highly valued by women aged 65 to 79 years than by women aged 80 years or older. Regardless of age, mammography screening is prioritized over other preventive health measures. Understanding how older women value different preventive health measures may help clinicians improve their preventive health counseling.

BACKGROUND: Experts recommend that clinicians target mammography and colon cancer screening to individuals with at least 5 years life expectancy. Generally, immunizations and exercise counseling are recommended for all women aged > or =65 years, while Pap smears are generally not encouraged for these women.

METHODS: We used the 2005 National Health Interview Survey to examine receipt of several preventive health measures simultaneously among community dwelling US women aged > or =65 years by age and health status. We used functional status, significant diseases, and perceived health to categorize women into those most likely to be in above-average, average, or below-average health status. We used age and health status to estimate life expectancy.

RESULTS: Of 4683 participants, 25.8% were > or =80 years; 81.8% were non-Hispanic white; 21% were in above-average and 20% were in below-average health status. Receipt of mammography and colon cancer screening decreased with age and was not associated with health status for women aged > or =80 years. Nearly half (49%) of women aged > or =80 years in below-average health received mammography screening, while 19% of women aged 65-79 years in above-average health did not report receiving mammography. Nearly half of women aged 65-79 years (49%) in above-average health did not report receiving colon cancer screening. Pap smear screening was common among older women. Few (34%) reported receiving exercise counseling. Many did not report receiving pneumococcal (43%) or flu vaccinations (40%).

CONCLUSIONS: In our comprehensive review of preventive health measures for older women, we found evidence to suggest a need to improve delivery and targeting of preventive health services.

PURPOSE: We sought to examine the use of preventive health services among older women and to assess how age and illness burden influence care patterns.

METHODS: The charts of 299 women aged > or =80 and 229 women aged 65-79 years who did not have dementia or terminal illness at 1 academic primary care practice in Boston were reviewed between July and December 2005 to determine receipt of screening tests (e.g., mammography), counseling on healthy lifestyle (e.g., exercise), and/or geriatric health issues (e.g., incontinence), and immunizations. Illness burden was quantified using the Charlson Comorbidity Index (CCI).

RESULTS: Women aged > or =80 were more likely than women aged 65-79 to have a CCI of > or =3 (24.0% vs. 16.7%) and were less likely to receive all screening tests. However, receipt of mammography (47.8%) and colon cancer screening (51.2%) was still common among women aged > or =80 and was not targeted to older women in good health. Women aged > or =80 were less likely to be screened for depression (adjusted relative risk [aRR] 0.6; 95% confidence interval [CI], 0.5-0.8), osteoporosis (aRR, 0.6; 95% CI, 0.5-0.9), or counseled about exercise (aRR 0.8; 95% CI, 0.6-0.9) than younger women, but were more likely to receive counseling about falls (aRR 1.9; 95% CI, 1.4-2.6) and/or incontinence (aRR 1.8; 95% CI, 1.2-2.6). However notes documenting discussions about mood (28.6%), exercise (40.0%), falls (28.8%), or incontinence (20.8%) were low among all women.

CONCLUSION: In a comprehensive review of preventive health measures for elderly women, many in poor health were screened for cancer. Meanwhile, many older women were not screened for depression or counseled about exercise, falls, or incontinence. There is a need to improve delivery of preventive health care to older women.

BACKGROUND: Although guidelines recommend that clinicians consider life expectancy before screening older women for breast cancer, many older women with limited life expectancies are screened. We aimed to identify factors important to mammography screening decisions among women aged 80 and older compared to women aged 65-79.

METHODS: Telephone surveys of 107 women aged 80+ and 93 women aged 65-79 randomly selected from one academic primary care practice who were able to communicate in English (60% response rate). The survey addressed the following factors in regards to older women's mammography screening decisions: perceived importance of a history of breast disease, family history of breast cancer, doctor's recommendations, habit, reassurance, previous experience, mailed reminder cards, family/friend's recommendations or experience with breast cancer, age, health, and media. The survey also assessed older women's preferred role in decision making around mammography screening.

RESULTS: Of the 200 women, 65.5% were non-Hispanic white and 82.8% were in good to excellent health. Most (81.3%) had undergone mammography in the past 2 years. Regardless of age, older women ranked doctor's recommendations as the most important factor influencing their decision to get screened. Habit and reassurance were the next two highly ranked factors influencing older women to get screened. Among women who did not get screened, women aged 80 and older ranked age and doctor's counseling as the most influential factors and women aged 65-79 ranked a previous negative experience with mammography as the most important factor. There were no significant differences in preferred role in decision-making around mammography screening by age, however, most women in both age groups preferred to make the final decision on their own (46.6% of women aged 80+ and 50.5% of women aged 65-79).

CONCLUSION: While a doctor's recommendation is the most important factor influencing elderly women's mammography screening decisions, habit and reassurance also strongly influence decision-making. Interventions aimed at improving clinician counseling about mammography, which include discussions around habit and reassurance, may result in better decision-making.

BACKGROUND: Despite uncertain benefit, many women over age 80 (oldest-old) receive screening mammography.

OBJECTIVE: To explore decision-making and physician counseling of oldest-old women around mammography screening.

DESIGN: Qualitative research using in-depth semi-structured interviews.

PARTICIPANTS: Twenty-three women aged 80 or older who received care at a large academic primary care practice (13 had undergone mammography screening in the past 2 years) and 16 physicians at the same center.

APPROACH: We asked patients and physicians to describe factors influencing mammography screening decisions of oldest-old women. We asked physicians to describe their counseling about screening to the oldest-old.

RESULTS: Patients and/or physicians identified the importance of physician influence, patient preferences, system factors, and social influences on screening decisions. Although physicians felt that patient's health affected screening decisions, few patients felt that health mattered. Three types of elderly patients were identified: (1) women enthusiastic about screening mammography; (2) women opposed to screening mammography; and (3) women without a preference who followed their physician's recommendation. However, physician counseling about mammography screening to elderly women varies; some individualize discussions; others encourage screening; few discourage screening. Physicians report that discussions about stopping screening can be uncomfortable and time consuming. Physicians suggest that more data could facilitate these discussions.

CONCLUSIONS: Some oldest-old women have strong opinions about screening mammography while others are influenced by physicians. Discussions about stopping screening are challenging for physicians. More data about the benefits and risks of mammography screening for women aged 80 or older could inform patients and improve provider counseling to lead to more rational use of mammography.

OBJECTIVES: To compare the national prevalence of reported receipt of clinician exercise counseling across four age groups of women (50-64, 65-74, 75-84, and > or =85) and to determine whether age or health are barriers to reported receipt of exercise counseling.

DESIGN: 2000 National Health Interview Survey (NHIS).

SETTING: United States.

PARTICIPANTS: Six thousand three hundred eighty-five women aged 50 and older who responded to the 2000 NHIS, representing an estimated 34.5 million noninstitutionalized women nationally.

MEASUREMENTS: Exercise counseling, disease burden, functional dependency, and physical inactivity were assessed by questionnaire.

RESULTS: Of the 6,385 women, 52.2% were aged 50 to 64, 24.8% were aged 65 to 74, 18.0% were age 75 to 84, and 5.1% were aged 85 and older. Overall, 28.3% reported that a clinician had recommended that they begin or continue to perform any type of exercise or physical activity during the previous year: 31.4% of women aged 50 to 64, 29.2% of women aged 65 to 74, 21.6% of women aged 75 to 84, and 14.4% of women aged 85 and older. Women aged 75 to 84 (adjusted odds ratio (AOR)=0.8, 95% confidence interval (CI)=0.6-1.0) and women aged 85 and older (AOR=0.6, 95% CI=0.4-0.9) were substantially less likely to report clinician counseling about exercise, before and after adjustment. Further adjustment for illness burden and functional dependency did not attenuate the effect of receipt of exercise counseling.

CONCLUSION: Reported receipt of exercise counseling by older women is low nationally. Despite known benefits of late-life exercise, women aged 75 and older are less likely to report receiving exercise counseling from their clinicians than women aged 50 to 64. Interventions should be aimed at increasing clinician counseling about exercise, especially to older women.