The Gerontologist 48:245-250 (2008)
© 2008 The Gerontological Society of America
The Value Older Women in an Academic Primary Care Practice Place on Preventive Health Care Services: Implications for Counseling
Mara A. Schonberg, MD, MPH1,
Meghan York, MD1,
Roger B. Davis, ScD1 and
Edward R. Marcantonio, MD, SM1
Correspondence: Address correspondence to Mara A. Schonberg, MD, MPH, Division of General Medicine and Primary Care, Department of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center, 1309 Beacon, Office 202, Brookline, MA 02446. E-mail: mschonbe{at}bidmc.harvard.edu
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Abstract
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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.
Key Words: Mammography • Preferences • Preventive health • Women
Many preventive health measures are available to elderly women, including screening tests, counseling about a healthy lifestyle (e.g., exercise) and geriatric health issues (e.g., fall prevention), immunizations, and over-the-counter preventive medications (e.g., calcium; see Amin, Kuhle, & Fitzpatrick, 2003; Nicastri & Fields, 2004; Weyer, 2004). Variable degrees of evidence support the use of these measures among elderly women, and guidelines regarding their use often vary (Walter & Covinsky, 2001). Experts encourage clinicians to consider patient life expectancy and preferences when counseling older women about preventive health (Walter & Covinsky, 2001). Despite these recommendations, studies have found that many elderly women receive screening tests from which they are unlikely to benefit as a result of poor health, whereas others in good health do not receive potentially beneficial measures (Schonberg, McCarthy, Davis, Phillips, & Hamel, 2004; Walter, Lindquist, & Covinsky, 2004).
Physician discomfort with discussing the stopping of screening may be one reason elderly women in poor health receive cancer screening tests from which they are unlikely to benefit (Schonberg, Ramanan, McCarthy, & Marcantonio, 2006). Patient preferences may also lead clinicians to order preventive measures that are unlikely to be effective. To understand how older women value and prioritize different preventive health measures, we surveyed women at one large academic primary care practice in Boston; we compared the responses of women aged 80 years and older with the responses of women aged 65 to 79.
The conceptual framework for this study was based on previous qualitative work in which we examined the factors that influence the mammography screening decisions of women aged 80 and older (Schonberg et al., 2006). We envisaged that habit, public health messages, desire for reassurance, nonreimbursed costs, hassle or difficulty, and whether the measure addressed an actual concern for the patient would influence how older women valued different preventive health measures. Considering these factors, we hypothesized that all women regardless of age would highly value mammography screening but that the oldest women would value counseling on geriatric health issues more highly than younger women. Our goal is to use these data to help clinicians improve their discussions about preventive health care with older women.
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Methods
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Study Sample
We performed a telephone survey of English-speaking women aged 65 or older who received their primary care at a hospital-based general internal medicine practice in Boston to learn about their preventive health priorities. The practice consists of approximately 50 faculty internists, over 100 internal medicine residents, and 10 nurse practitioners who provide care to approximately 34,000 patients. We excluded patients who had a history of dementia, had significant hearing loss, or were terminally ill (as determined by chart review, patients' physicians, or the patients themselves), as well as patients for whom answering survey questions would be too psychologically disturbing. Our initial electronic search identified 716 women aged 80 and older and 1,962 women aged 65 to 79 who had one billing record in the clinic in the past year.
Because we anticipated greater exclusion criteria among women aged 80 and older, we randomly identified 400 women aged 80 and older and 275 women aged 65 to 79 from these lists to reach a targeted sample of 200 women (100 per age group). We obtained consent from each patient's primary care physician, and we sent women deemed eligible a letter informing them of the study with an opt-out card. Of the 166 women aged 80 and older and 171 women aged 65 to 79 ultimately deemed eligible for our study, 102 women aged 80 and older and 98 women aged 65 to 79 agreed to be interviewed, resulting in a combined response rate of 59%. Five women initially identified in the age group from 65 to 79 years had turned 80 years by the time they were interviewed, and we included their responses with those of women aged 80 and older. The 30-minute survey was administered by one of two study investigators (M. Schonberg or M. York) or by one research assistant. The institutional review board at the Beth Israel Deaconess Medical Center approved our study.
Data Collection
We reviewed the literature to develop a comprehensive list of preventive services available to older women (Amin et al., 2003; Nicastri & Fields, 2004; Weyer, 2004; see Table 1). Our telephone questionnaire assessed how women valued each of the 30 different preventive health measures identified on a 4-point scale (essential, very important, somewhat important, and not at all important). After evaluating each measure individually, we then asked women to rank from 1 to 4 the preventive health measures most important to them. We read the list of preventive health measures as many times as necessary, changing the order each time. In addition, we obtained data on patient sociodemographic characteristics (race or ethnicity, education, income, and marital status), functional status (instrumental activities of daily living and basic activities of daily living), and perceived health.
From patients' medical records we obtained data on patients' insurance, race or ethnicity, and illness burden. We used illness burden to calculate a Charlson Comorbidity Index (CCI) for each patient (Charlson, Pompei, Ales, & MacKenzie, 1987).
Because greater functional dependency, poor perceived health, and higher CCI scores have all been found to predict mortality, we dichotomized women into two groups based on health to learn whether preventive health priorities changed with health (Carey, Walter, Lindquist, & Covinsky, 2004; Charlson et al., 1987; Welch, Albertsem, Nease, Bubolz, & Wasson, 1996). We defined women to be in poor condition if they perceived themselves to be in poor health, had a CCI of 2 or more, or had at least one functional limitation; otherwise, we considered the women to be in good condition.
Statistical Analyses
We used bivariable statistics to compare patients' race or ethnicity, education, insurance coverage, income, perceived health status, CCI, and functional status by age. We also used bivariable statistics to compare age, race or ethnicity, insurance coverage, CCI, and number of clinic visits between respondents and nonrespondents. We compared the value placed on each preventive health measure by women's age (65–79, 80–84, and 85 and older) by using bivariable statistics. We divided women into these age groups because we were particularly interested in the preferences of women aged 80 and older, because screening recommendations are most uncertain for these women. In order to create a "top 10" list of preventive health measures for each age group of women, we weighted whether a woman ranked a preventive health measure as 1, 2, 3, or 4 and we averaged the score given to each measure within each age group (the measure ranked "1" was given a weight of 4 and the measure ranked "4" was given a weight of 1). We also explored the ranked importance of preventive health measures for each age group of women by health. We performed all statistical analyses using SAS statistical software, version 9.1 (SAS Institute, Cary, NC).
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Results
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Of the 200 women who participated in the survey, 46.5% were aged 65 to 79 with a mean age of 71.5 years, 28.5% were aged 80 to 84 with a mean age of 82.6 years, and 25.0% were aged 85 and older with a mean age of 88.3 years. The majority of the women in the sample were non-Hispanic White (65.5%), had private insurance (82.0%), and were in good health condition (52.0%). Women aged 80 and older were more likely than women aged 65 to 79 to report a household income less than $20,000 per year (55.7% vs 28.8%) and to have a functional dependency (47.7% vs 14.0%; see Table 2). The 137 nonrespondents did not differ from respondents in regard to age, race or ethnicity, insurance, CCI, and number of clinic visits in the past year.
Figures 1 through 4<--CO?1--> demonstrate the proportion of women by age that considered each preventive health measure essential or very important to maintaining their health. Women aged 80 and older were significantly less likely than women aged 65 to 79 to consider screening tests such as bone densitometry, mammograms, colonoscopy, Papanicolaou smears, cholesterol testing, clinical breast exams, and skin screenings, as well as exercise counseling, essential or very important. For most other services there was little change or no consistent pattern on the value placed on preventive health measures by age. However, there was a trend for women aged 80 and older to be more likely than women aged 65 to 79 to consider counseling on fall prevention essential or very important (p =.08).
Figure 5 demonstrates the top 10 preventive health measures valued by older women by age. Women aged 65 to 79 ranked mammography and colonoscopy highest, with 5 of 6 of their top measures being screening tests. Women aged 80 and older prioritized flu shots, recommendations for aspirin, or asking about chronic pain or incontinence. Although screening colonoscopy was less highly valued among the oldest women, mammography screening was highly valued among all older women. Counseling about several geriatric health syndromes (vision, falls, memory loss) made it into the top 10 list of preventive health measures for women aged 80 and older.
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Figure 5. Rankings of how elderly women value preventative health measures by age. To create the "top 10" lists for each age group, we weighted whether a woman ranked a preventive health measure as 1, 2, 3, or 4 and we averaged the score given to each measure within each age group
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When we examined preventive health rankings of elderly women by age and health, we found similar results as when we did not include health except for exercise counseling. Women aged 80 and older in good health ranked exercise counseling as one of their top 5 preventive health measures, although it did not make the top 10 list for women aged 80 and older in poor health. Regardless of age or health, flu shots and mammography screening were 2 of the most highly ranked preventive health measures among all.
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Discussion
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We found that women aged 80 and older value screening tests and exercise counseling less than do younger women. We also found some shift in rankings of preventive health measures from radiological or laboratory screening tests (e.g., colonoscopy, cholesterol) to counseling about geriatric health issues (e.g., pain, incontinence) with age. Nevertheless, we were surprised that women aged 80 and older were not more likely than younger women to consider counseling on geriatric health issues essential or very important to their health. This may be due to a strong disease focus or a lack of knowledge about the value of preventive health care among the very old. Our data suggest that women over the age of 80 years need additional education on which preventive health measures are likely to be effective. The benefits of some screening tests may not be achieved in the oldest women as a result of limited life expectancy (Walter et al., 2001). To improve the quality of preventive health care delivered to elderly women, system changes may be necessary to facilitate shifts in preventive services from diagnostic tests (mammography, cholesterol) toward counseling, which is less resource intensive but more time intensive for clinicians.
For instance, we found that all older women, including women aged 85 and older, ranked mammography screening as highly valued whereas exercise counseling was not highly valued. Meanwhile, data are lacking that demonstrate a benefit to mammography screening among women aged 85 and older, yet there is a significant and growing literature on the benefits of exercise among older adults (Christmas & Andersen, 2000). Clinicians may need to transfer the focus of preventive health care discussions from measures whose benefits may take years to achieve (e.g., mammography) to measures whose benefits may be achieved in a short time frame (e.g., exercise; see Christmas & Andersen; Walter & Covinsky, 2001).
There are several limitations to this study. We interviewed only English-speaking women at one academic primary care practice in Boston, and our results may not be generalizable to other women. Not all women eligible for the study chose to participate, although respondents did not differ from nonrespondents in terms of age, race or ethnicity, or illness burden. Because our data are cross-sectional, our findings may represent cohort effects rather than true age differences. As a result of small sample size, we were unable to control for the absence or presence of disease in our analyses. Despite these limitations, this is the first study to our knowledge to examine older women's preferences about preventive health care and how older women value one preventive health measure compared with another.
As women aged 80 and older are the fastest growing segment of the U.S. population, identifying and delivering effective preventive health care to these women is becoming increasingly important. Despite this, we found that the oldest women prioritize some preventive health measures (e.g., mammography) over others that are more likely to be effective (e.g., exercise counseling). Clinicians should consider how older women value different preventive health measures when they are providing counseling to ensure that older women are made aware of and are encouraged to engage in the preventive health activities most likely to prolong or preserve their health.
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Figure 2. Proportion of women who considered physician counseling about geriatric syndromes essential or very important by age
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Figure 3. Proportion of women who considered immunizations and recommendations for preventive medications essential or very important by age
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Figure 4. Proportion of women who considered healthy lifestyle counseling essential or very important by age (asterisk indicates significant difference: p <.05)
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Footnotes
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This work was funded by an Older Americans Independence Center Grant Pilot Project, a Harvard/Hartford Foundation Junior Faculty Development Grant, a National Research Service Award from the National Cancer Institute (1 F32 CA110424-01), and a 2006 Hartford Geriatrics Health Outcomes Research Scholars Award. 
We thank Mary Beth Hamel, MD, MPH, from the Division of General Medicine and Primary Care, Beth Israel Deaconess Medical Center, for her help in reviewing this manuscript.
1 Department of Medicine, Harvard Medical School, Brookline, MA.
Decision Editor: William J. McAuley, PhD
Received for publication March 15, 2007.
Accepted for publication June 25, 2007.
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References
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- Amin, S. H., Kuhle, C. L., & Fitzpatrick, L. A., (2003). Comprehensive evaluation of the older woman. Mayo Clinic Proceedings, 78, 1157-1185.[Abstract/Free Full Text]
- Carey, E. C., Walter, L. C., Lindquist, K., & Covinsky, K. E., (2004). Development and validation of a functional morbidity index to predict mortality in community-dwelling elders. Journal of General Internal Medicine, 19, 1027-1033.[Medline]
- Charlson, M. E., Pompei, P., Ales, K. L., & MacKenzie, C. R., (1987). A new method of classifying prognostic comorbidity in longitudinal studies: Development and validation. Journal of Chronic Diseases, 40, 373-383.[Medline]
- Christmas, C., & ersen, R. A., (2000). Exercise and older patients: Guidelines for the clinician. Journal of the American Geriatrics Society, 48, 318-324.[Medline]
- Nicastri, C., & Fields, S., (2004). Health promotion/disease prevention in older adults—An evidence-based update. Clinical Geriatrics, 12, 17-25.
- Schonberg, M. A., McCarthy, E. P., Davis, R. B., Phillips, R. S., & Hamel, M. B., (2004). Breast cancer screening in women aged 80 and older: Results from a national survey. Journal of the American Geriatrics Society, 52, 1688-1695.[Medline]
- Schonberg, M. A., Ramanan, R. A., McCarthy, E. P., & Marcantonio, E. R., (2006). Decision-making and counseling around mammography screening for women aged 80 or older. Journal of General Internal Medicine, 21, 979-985.[Medline]
- Walter, L. C., & Covinsky, K. E., (2001). Cancer screening in elderly patients: A framework for individualized decision making. Journal of the American Medical Association, 285, 2750-2756.[Abstract/Free Full Text]
- Walter, L. C., Lindquist, K., & Covinsky, K. E., (2004). Relationship between health status and use of screening mammography and Papanicolaou smears among women older than 70 years of age. Annals of Internal Medicine, 140, 681-688.[Abstract/Free Full Text]
- Welch, H. G., Albertsem, P. C., Nease, R. F., Bubolz, T. A., & Wasson, J. H., (1996). Estimating treatment benefits for the elderly: The effect of competing risks. Annals of Internal Medicine, 124, 577-584.[Abstract/Free Full Text]
- Weyer, S. M., (2004). Health screening guidelines for the elderly: A clinical approach. Resident & Staff Physician, 50, 10-15.[Medline]
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