Preventive Health Care among Older Women: Missed Opportunities and Poor Targeting
Article Outline
Abstract
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 ≥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 ≥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 ≥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 ≥80 years. Nearly half (49%) of women aged ≥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.
Keywords: Cancer screening, Exercise, Older women, Prevention
Many preventive health measures are available to elderly women.1 Because life expectancy greatly varies with health status, geriatricians recommend that services be targeted to elderly individuals most likely to benefit.2 In the case of breast and colon cancer screening, experts recommend that screening be targeted to those with at least 5 years of life expectancy.3, 4 Generally, other preventive health measures such as pneumococcal and influenza vaccinations and exercise counseling are recommended for all women aged 65 years and older, while Pap smears are generally not encouraged for these women.5, 6, 7
Several studies have examined targeting of mammography and Pap smear screening to older women according to health.8, 9, 10 These studies found that decisions to screen older women for cancer generally are related to health; however, they also showed that many older women in good health are not screened while many in poor health are screened. No studies have examined how a wide range of preventive health services are targeted to older women by health status. Yet, in practice, primary care physicians are faced with the responsibility of discussing a large scope of preventive services with their older female patients and prioritizing which services to pursue. Because our previous work found that clinicians often find discussing stopping cancer screening uncomfortable and there are many competing demands during clinic visits, older women in poor health may receive some preventive health measures from which they are unlikely to benefit (eg, Pap smears), while not receiving other preventive health measures from which they would benefit (eg, flu shots, exercise counseling).11 Our study considers multiple preventive health measures simultaneously to closely represent the complexities of decision-making and service delivery faced in primary care. We hypothesized that cancer screening tests would be poorly targeted to elderly women with regards to health status, while immunizations and exercise counseling would be underutilized across all age and health strata.
Methods
Data Source
We used the 2005 National Health Interview Survey (NHIS), a continuing, in-person household survey of the civilian, non-institutionalized US population, conducted by the Census Bureau for the National Center for Health Statistics.12 The NHIS collects information from a nationally representative sample including sociodemographic factors, functional status, insurance coverage, and access to health care for all household members. One randomly selected adult from each responding family is asked to complete “the sample adult module,” which includes questions about medical conditions, receipt of immunizations, and exercise recommendations (n
=31,428). In 2005, these respondents also were asked to complete a cancer module that included questions on receipt of cancer screening. The overall response rate was 69.0%.
Study Sample
The 2005 NHIS interviewed 5601 women 65 years or older. We excluded 594 women who had not seen a health care provider in the past year because we planned to examine reported receipt of several preventive services delivered in the past year. We also excluded 281 women with proxy respondents and 43 women with dementia. Our final sample consisted of 4683 women, representing an estimated 30 million US community dwelling women aged 65 years or older. We categorized women into 5 age groups: 65-69, 70-74, 75-79, 80-84, and ≥85 years.
Outcomes
Preventive Health ServicesWe examined receipt of cancer screening (mammography, colon cancer screening, and Pap smears), immunizations (pneumococcal and influenza), and exercise counseling. We defined women as having undergone mammography screening if they did not have a history of breast cancer and they reported having a mammogram as part of a routine examination within 2 years. We defined women as having undergone colon cancer screening if they did not have a history of colon cancer and they reported a colonoscopy within 10 years, a sigmoidoscopy within 5 years, or a fecal occult blood test within 1 year, all as part of a routine examination. We defined women as having received cervical cancer screening if they still had a uterus and reported having a Pap smear as part of a routine examination within 3 years. Women who reported having a flu shot in the past year and women who reported ever receiving a pneumonia shot were defined as having received these immunizations. We considered women to have received exercise counseling if they reported that a medical professional recommended that they begin or continue to do any type of exercise or physical activity in the past year. We excluded women who refused, did not answer, or were missing, whether or not they had received the specific measure.
Health Status
Walter and Covinsky3 proposed that although it is impossible for physicians to predict the exact life expectancy of an individual patient, it is possible for physicians to make reasonable estimates of whether a patient is likely to live more, less, or as long as the average person their age. After deciding whether a patient is in above-average, average, or below-average health, clinicians may then use life expectancy charts divided by age and quartiles of health to estimate individual life expectancy.3 For example, a woman aged 80-84 years in above-average health has an estimated life expectancy of 13 years, while one in average health has an estimated life expectancy of 8.6 years and one in below-average health has an estimated life expectancy of 4.6 years.3 Because the NHIS represents the noninstitutionalized population of the US, our aim was to categorize the women in our sample into those most likely to be in above-average, average, or below-average health status to approximate life expectancy. We used functional status, significant diseases, and perceived health to categorize women into these groups of health status. We chose these measures because experts recommend that clinicians use functional status and comorbidity in addition to age when estimating patient life expectancy4 and perceived health is an independent predictor of survival.13 We included only significant diseases that are included in the Charlson Comorbidity Index and were available in the NHIS: heart disease, diabetes, stroke, cancer (excluding nonmelanomatous skin cancer), chronic obstructive pulmonary disease, kidney failure, and liver failure.14
We considered women to be in below-average health status if they had 3 or more significant diseases or a functional limitation (dependent in a basic or instrumental activity of daily living) or perceived themselves to be in poor health. We considered women to be in above-average health status if they did not have any significant diseases or functional limitations and perceived themselves to be in very good/excellent health. We considered women to be in average health status if they had 1 to 2 significant diseases or perceived themselves to be in good/fair health but had no functional limitations.
Finally, we examined appropriate receipt of all 6 preventive health measures in different populations of older women. Because most guidelines would recommend mammography and colon cancer screening as well as immunizations but not Pap smear screening to women aged 70-79 years in above-average health status, we examined the proportion of these women who received the 6 measures appropriately. Similarly, because experts generally would discourage cancer screening among women aged 80 years and older in below-average health status but would encourage their receiving immunizations and exercise counseling, we also examined receipt of appropriate care among these women.
Covariates
We considered factors previously found to be associated with receipt of preventive services as potential confounders.15, 16 These included sociodemographic factors such as race/ethnicity (non-Hispanic white, non-Hispanic black, other), education (less than high school, high school graduate, some college or beyond), annual family income (<$20,000, $20,000-$34,999, $35,000+), insurance (Medicare Part A only/No coverage; Medicare Part A and B; Medicare plus Medicaid; and Medicare Plus Choice, Medicare plus private, and private insurance only), and geographical region (Northeast, Midwest, South, West). We considered 2 indicators of access to care including usual source of medical care (primary care physician or gynecologist, specialist, or having no usual source) and number of doctor visits in the past year.
Statistical Analysis
We used the Mantel-Haenszel test of trend to determine whether health status was a significant predictor of receipt of each preventive health measure within each age group. We also performed multivariable logistic regression models to compare receipt of each preventive health service by age group and health status adjusted for all covariates. We tested for interactions between age and health status on receipt of preventive health measures. All analyses used SAS-callable SUDAAN software, version 9.1 (Research Triangle Institute, Research Triangle Park, NC). Results presented herein are weighted to reflect US population estimates and to adjust for nonresponse.
Results
Of the 4683 women in our study, 30.3% were aged 65-69 years, 23.9% were aged 70-74 years, 20.0% were aged 75-79 years, 15.6% were aged 80-84 years, and 10.2% were aged 85 years or older; the majority (81.8%) were non-Hispanic white. Ten percent had only seen their clinician once within the past year and this varied slightly by age (12.1% of women aged 65-79 years vs. 7.6% of women aged 85 years and older). With respect to health status, 21.3% were in above-average health, 58.3% were in average health, and 20.4% were in below-average health (Table 1).
Table 1. Sample Characteristics (n=4683)⁎
| Overall % | 65-69 Years (n=1330) | 70-74 Years (n=1115) | 75-79 Years (n=971) | 80-84 Years (n=749) | 85+ Years (n=518) | P Value | |
|---|---|---|---|---|---|---|---|
| Race | .29 | ||||||
| Non-Hispanic White | 81.8 | 78.7 | 78.7 | 83.3 | 85.1 | 84.3 | |
| Non-Hispanic Black | 7.6 | 8.0 | 8.3 | 7.5 | 6.2 | 7.3 | |
| Other | 10.6 | 13.4 | 10.5 | 9.3 | 8.7 | 8.4 | |
| Education (4602) | .0001 | ||||||
| <High school | 24.9 | 19.9 | 21.7 | 28.5 | 28.2 | 35.3 | |
| High school graduate | 37.1 | 38.1 | 37.8 | 38.2 | 34.8 | 33.4 | |
| Some college | 21.6 | 22.1 | 22.4 | 19.2 | 23.9 | 19.2 | |
| College or beyond | 16.5 | 19.9 | 18.1 | 14.2 | 13.1 | 12.2 | |
| Income (4287) | <.0001 | ||||||
| <$20K | 27.5 | 22.1 | 23.4 | 32.3 | 32.2 | 37.0 | |
| $20-35K | 40.4 | 40.1 | 40.7 | 39.2 | 42.6 | 39.2 | |
| >$35K | 32.1 | 37.9 | 35.9 | 28.5 | 25.2 | 23.8 | |
| Insurance | <.0001 | ||||||
| Medicare Part A only/no coverage | 2.1 | 2.4 | 2.9 | 2.1 | 1.6 | 0.13 | |
| Medicare Parts A and B only | 21.5 | 21.8 | 20.1 | 22.6 | 19.9 | 23.7 | |
| Medicaid | 7.5 | 8.0 | 8.1 | 6.6 | 7.8 | 5.9 | |
| Private/Medicare+ Choice | 69.0 | 67.8 | 68.8 | 68.8 | 70.8 | 70.3 | |
| Region | .05 | ||||||
| Northeast | 21.2 | 20.6 | 18.4 | 21.8 | 24.0 | 24.0 | |
| Midwest | 24.6 | 26.3 | 23.0 | 22.2 | 24.3 | 28.1 | |
| South | 36.8 | 36.0 | 40.3 | 38.4 | 36.3 | 28.5 | |
| West | 17.5 | 17.1 | 18.3 | 17.6 | 15.5 | 19.4 | |
| Usual care | .01 | ||||||
| Primary care MD | 90.9 | 90.5 | 89.5 | 90.0 | 92.6 | 94.2 | |
| Specialist | 5.0 | 4.7 | 6.4 | 6.7 | 3.0 | 2.1 | |
| No usual source | 4.2 | 4.8 | 4.2 | 3.3 | 4.4 | 3.8 | |
| MD visits in past year | .01 | ||||||
| 1 visit | 10.3 | 12.1 | 11.5 | 8.7 | 8.8 | 7.6 | |
| 2-5 | 47.3 | 49.0 | 42.8 | 50.5 | 44.5 | 51.1 | |
| 6+ visits | 42.4 | 38.9 | 45.8 | 40.8 | 46.7 | 41.3 | |
| Health characteristics | |||||||
| Significant diseases† | .001 | ||||||
| None | 45.3 | 51.3 | 46.1 | 42.3 | 39.5 | 40.6 | |
| 1-2 | 49.1 | 43.8 | 47.0 | 51.7 | 54.9 | 55.5 | |
| 3+ | 5.6 | 4.9 | 6.9 | 6.0 | 5.6 | 3.9 | |
| Functional dependency (4682) | <.0001 | ||||||
| None | 86.5 | 93.7 | 90.3 | 86.2 | 80.8 | 66.0 | |
| IADL only | 7.0 | 3.6 | 4.4 | 7.6 | 10.3 | 16.4 | |
| ADL | 6.5 | 2.7 | 5.3 | 6.3 | 8.9 | 17.6 | |
| Perceived health (4682) | <.0001 | ||||||
| Very good/excellent | 38.0 | 42.9 | 41.5 | 35.7 | 31.4 | 29.4 | |
| Good | 35.2 | 34.8 | 33.6 | 33.6 | 37.9 | 38.9 | |
| Fair | 19.3 | 16.8 | 17.8 | 22.0 | 21.0 | 22.5 | |
| Poor | 7.6 | 5.5 | 7.2 | 8.7 | 9.7 | 9.3 | |
| Health status‡ | <.0001 | ||||||
| Above average | 21.3 | 26.8 | 24.1 | 18.8 | 15.2 | 12.9 | |
| Average | 58.3 | 60.5 | 58.0 | 59.3 | 59.0 | 49.7 | |
| Below average | 20.4 | 12.7 | 18.0 | 21.9 | 25.8 | 37.5 |
⁎All proportions were weighted to reflect national estimates. |
†Significant diseases included heart disease, diabetes, cancer (excluding nonmelanomatous skin cancer), chronic obstructive pulmonary disease, liver disease, and kidney failure. |
‡Perceived health, functional limitations, and a comorbidity count were used to classify women as either above average, average, or below average in health. |
Cancer Screening
Reported receipt of mammography screening decreased with age (Figure 1). Above-average health status was a significant predictor of receipt of mammography screening among women aged 65-79 years. Although there were no significant associations between health status and receipt of mammography screening among women aged 80 years and older, women aged 80-84 years in above-average health tended to be more likely to be screened than those in below-average health. There were no trends in receipt of mammography screening by health status among women aged 85 years and older. Overall, 18.8% of women aged 65-79 years in above-average health did not report being screened, while 48.9% of women aged 80 years and older in below-average health reported being screened.
Figure 1.
Reported receipt of cancer screening tests by age and health status for women aged 65 years and older (n
=4683).*†‡§*Below each age category (65-69, 70-74, 75-79, 80-84, and 85+ years) is the P value for the test of trend for the influence of health on receipt of preventive health measures within each age group. In parentheses next to age is the P value for the test of trend for the influence of age across all age groups.
†Perceived health, functional limitations, and a comorbidity count were used to classify women as either above average, average, or below average in health (page 7).
‡Excluded 310 women with a history of breast cancer, 81 who had a recent mammogram for reasons besides screening, 281 who were missing data on their last mammogram, and 752 who were missing completely from the cancer control module.
§Excluded 92 women with a history of colon cancer, 328 missing whether or not they ever had a sigmoidoscopy or colonoscopy or home blood stool test, 600 who had a recent sigmoidoscopy/colonscopy or home blood stool test for reasons besides screening, and 43 who were missing completely from the cancer control module.
In the case of colon cancer screening, we found that 44.7% of women aged 65 years and older reported receiving colon cancer screening in the past 10 years; the majority with colonoscopy (78.5%) and in the past 5 years (91.6%). Reported receipt of colon cancer screening decreased with increasing age. Above-average health status was a significant predictor of receipt of colon cancer screening for women aged 65-69 years, and similar trends were evident for women aged 75-84 years. However, health status was not associated significantly with reported receipt of colon cancer screening among women aged 70-74 years and 85 years and older. Nearly half (49.0%) of women aged 65-79 years in above-average health did not report receiving any form of colon cancer screening.
Pap smears were common but decreased with advancing age; 68.3% of women aged 65-79 years and 45.6% of women aged 80 years and older reported being screened. Reported receipt of Pap smear screening was significantly associated with above-average health among women aged 75-79 years (P <.01). There were no other significant associations between health status and receipt of Pap smear screening (data not shown).
Exercise Counseling
Overall, 33.7% of women reported receiving exercise counseling (Figure 2). Exercise counseling decreased with advancing age and tended to be more common among women in below-average health status. Exercise counseling was significantly more common among women aged 80-84 years in below-average health than for those in above-average health. Only 17.9% of women aged 80 years and older in above-average health status reported receiving exercise counseling.
Figure 2.
Reported receipt of exercise counseling by age and health status for women aged 65 years and older (n
=4683).*†‡*Below each age category (65-69, 70-74, 75-79, 80-84, and 85+ years) is the P value for the test of trend for the influence of health on receipt of preventive health measures within each age group. In parentheses next to age is the P value for the test of trend for the influence of age across all age groups.
†Perceived health, functional limitations, and a comorbidity count were used to classify women as either above average, average, or below average in health (page 7).
‡Excluded 178 women who were missing whether or not they received exercise counseling.
Immunizations
Many women aged 65 years and older did not report ever receiving pneumonia (42.7%) or flu (40.2%) immunizations in the past year (Figure 3). Reported receipt of immunizations generally increased with age until 85. Women aged 65-74 years in below-average health status were significantly more likely to receive pneumococcal immunizations than those in above-average health status. Otherwise, there were no significant associations between health status and receipt of pneumococcal immunizations. There were no significant associations between health status and receipt of influenza vaccinations, except that women aged 85 years and older in below-average health were less likely to receive influenza vaccinations than women aged 85 years and older in better health.
Figure 3.
Reported receipt of immunizations by age and health status for women aged 65 years and older (n
=4683).*†‡§*Below each age category (65-69, 70-74, 75-79, 80-84, and 85+) is the P value for the test of trend for the influence of health on receipt of preventive health measures within each age group. In parentheses next to age is the P value for the test of trend for the influence of age across all age groups.
†Perceived health, functional limitations, and a comorbidity count were used to classify women as either above average, average, or below average in health (page 7).
‡Excluded 103 women who were missing whether or not they ever received a pneumonia vaccination.
§Excluded 29 women who were missing whether or not they had a flu shot in the past year.
In multivariable analyses, reported receipt of mammography, Pap smears, and exercise counseling decreased significantly with age, while reported receipt of immunizations increased with age until 85 years (Table 2). Those in worse health status were less likely to report receiving mammography and colon cancer screening, and were more likely to report receiving immunizations. The health trends in the adjusted models approximate trends among women in younger age groups. No interactions between age and health status were significant in any of the models.
Table 2. Adjusted Receipt of Preventive Health Measures by Age and Health Status⁎
| Mammography | Colon Cancer | Pap Smears | Exercise | Pneumonia Vaccine | Flu Shot | |
|---|---|---|---|---|---|---|
| aOR (95% CI) | aOR (95% CI) | aOR (95% CI) | aOR (95% CI) | aOR (95% CI) | aOR (95% CI) | |
| Age, years | ||||||
| 65-69 | 1.00 | 1.00 | 1.00 | 1.00 | 1.00 | 1.00 |
| 70-74 | 0.62(0.45-0.87) | 0.98(0.75-1.28) | 0.42(0.27-0.65) | 0.84(0.65-1.08) | 1.58(1.26-1.98) | 1.24(0.97-1.59) |
| 75-79 | 0.54(0.39-0.74) | 1.0(0.76-1.31) | 0.32(0.21-0.49) | 0.71(0.56-0.91) | 1.51(1.18-1.92) | 1.38(1.07-1.78) |
| 80-84 | 0.42(0.29-0.60) | 0.75(0.56-1.01) | 0.27(0.18-0.43) | 0.65(0.48-0.88) | 1.92(1.46-2.53) | 1.65(1.23-2.21) |
| 85+ | 0.27(0.19-0.39) | 0.87(0.62-1.22) | 0.19(0.12-0.30) | 0.52(0.38-0.72) | 1.03(0.76-1.39) | 1.41(1.04-1.91) |
| Health status† | ||||||
| Above average | 1.00 | 1.00 | 1.00 | 1.00 | 1.00 | 1.00 |
| Average | 0.74(0.57-0.96) | 0.87(0.70-1.09) | 1.08(0.77-1.52) | 1.16(0.94-1.44) | 1.31(1.06-1.62) | 1.33(1.08-1.64) |
| Below average | 0.51(0.37-0.70) | 0.80(0.52-0.95) | 0.88(0.54-1.25) | 1.27(0.96-1.66) | 1.51(1.13-2.02) | 1.17(0.90-1.51) |
⁎We compared receipt of the preventive health measures above by age and health status after adjusting for sociodemographic factors (race, education, income level, insurance status, and geographical region) and access to care (having a usual provider and number of clinic visits in the past year). |
†Perceived health, functional limitations, and a comorbidity count were used to classify women as either above average, average, or below average in health. |
When we examined the effect of the other covariates on receipt of the preventive health measures in the models, we found that higher education, frequent office visits, and having a primary care doctor generally were associated with receipt of preventive health measures. Higher income levels were associated with receipt of cancer screening tests, and non-Hispanic whites were more likely than other racial groups to receive immunizations. There was no consistent relationship between receipt of preventive health measures and region and insurance (data not shown).
Less than 1 percent (0.4%) of women aged 70-79 years in above-average health received all 6 preventive health measures appropriately (yes to mammography, colon cancer screening, immunizations, and exercise counseling, but no to Pap smear screening), and only 2.4% of women aged 80 years and older in below-average health received all 6 measures appropriately (no to cancer screening but yes to immunizations and exercise counseling).
Discussion
Our findings indicate that older women are not receiving the preventive health measures most likely to be effective based on their age and health status. Cancer screening was not targeted to women aged 80 years and older in above-average health even though many of these women have more than 5 years of life expectancy.3 Meanwhile, many women (49%) aged 80 years and older in below-average health were screened with mammography. We also found that many older women did not receive recommended immunizations. Notably, women aged 85 years and older in below-average health were less likely to get influenza vaccinations than women aged 85 and older in better health even though the oldest women in poor health are at the greatest risk of mortality from influenza.17 In addition, despite a growing and robust literature demonstrating that exercise can delay disability and help maintain independence, we found that older women, especially those in good health, infrequently reported receiving exercise counseling.7 Higher exercise counseling among older women in poor health may reflect disease-specific guidelines, however, exercise recommendations also are important for those in good health. Finally, very few older women simultaneously receive all preventive health measures appropriately. Interventions are necessary to improve the delivery and targeting of preventive health measures to older women.
Targeting of preventive health services to elderly women by health status may be poor for several reasons. Clinicians may use age rather than health status when deciding whether or not to screen women in their 80s and 90s for cancer. Also, elderly women, regardless of their health status, may perceive limited life expectancy for themselves and be reluctant to accept preventive health measures. Although increasing age significantly impacts life expectancy, older women's health also can strongly affect life expectancy.3 Cancer screening in older women in poor health is concerning because it places women at risk for complications and anxiety related to diagnosis and treatment even though the cancer would be unlikely to become clinically significant in their lifetime.3 Denying or forgoing a screening test to elderly women in good health is equally inappropriate because these women may live long enough to benefit.
We wondered if the greater number of clinic visits among the oldest women in poor health accounted for some of the poor targeting of preventive health services because additional clinic visits could be associated with more opportunities for physicians to recommend preventive services. However, in post hoc analyses we found that those in poor health status did not have significantly more clinic visits than those in good health status. Furthermore, physicians may need to use more clinic time to address active issues among older women in poor health.
We also found that many women aged 65-79 years in good health did not report receiving breast (19%) or colon cancer screening (45%). Other studies that have examined receipt of colon cancer screening among US older adults also have found low rates.18 Interventions are necessary to increase breast and colon cancer screening among older women in good health. Ideally, these interventions would focus on older women with life expectancies >10 years. Interventions also might be necessary to reduce breast cancer screening among elderly women in poor health, especially because we found that 49% of women aged 80 years and older in below-average health were screened and these women likely have life expectancies of <5 years.
Interventions discussed in the medical literature designed to increase cancer screening among older women include physician education seminars,19 preventive health check lists,20 computer reminders,21 and support from nonphysician staff.22 We are unaware of interventions to reduce cancer screening among elderly women in poor health, but such an intervention would likely require clinician counseling. Although discussing stopping screening may be uncomfortable, we recommend that clinicians discuss potential risks of screening and that there are few data showing any benefit of cancer screening among women aged 80 years and older with multiple comorbidities.23, 24 We also recommend that clinicians focus discussions on preventive measures whose benefits may be achieved in a short time (eg, exercise or immunizations) so that elderly women do not feel like they are being “given-up on.”25 This may be particularly important because we found that many older women do not receive exercise counseling or immunizations. Finally, interventions designed to improve preventive health care delivery to older women may need to be comprehensive rather than focused on a specific service, because we found that so few older women receive all preventive health measures appropriately.
There are several limitations to this study. First, we relied on self-report, which can lead to recall bias and misclassification. Second, our measure of health status has not been validated, and the survey asks about only a limited number of diseases and lacks information on severity and duration of disease. Third, the NHIS releases only an overall response rate to the survey, however, sample weights are adjusted for nonresponse. Finally, the health of older women in our study may have changed since they underwent colonoscopy; however, 92% reported being screened for colon cancer in the past 5 years. Despite these limitations, this study represents a significant contribution to the literature by examining receipt of a wide range of preventive health measures simultaneously among a nationally representative sample of older US women stratified by health status.
In summary, we found evidence of poor targeting and inappropriate use of screening and preventive health measures among older women. Many older women in above-average health were not screened for breast or colon cancer, while many of the oldest women in below-average health were screened. Regardless of health status, many older women did not receive immunizations from which they may benefit, and many received Pap smears from which they are unlikely to benefit. Exercise counseling was uncommon and was least common among the oldest women in good health. Interventions are necessary to improve the quality and targeting of preventive health care delivered to older women.
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This research was conducted while Dr. Mara Schonberg was supported by a Hartford Geriatrics Health Outcomes Research Scholars Award from the AGS Foundation for Health in Aging.
PII: S0002-9343(08)00666-9
doi:10.1016/j.amjmed.2008.05.042
© 2008 Elsevier Inc. All rights reserved.
