Louise C. Walter

Age Affects Outcomes in Chronic Kidney Disease

Chronic kidney disease (CKD) is common among the elderly. However, little is known about how the clinical implications of CKD vary with age. We examined the age-specific incidence of death, treated end-stage renal disease (ESRD), and change in estimated glomerular filtration rate (eGFR) among 209,622 US veterans with CKD stages 3 to 5 followed for a mean of 3.2 years. Patients aged 75 years or older at baseline comprised 47% of the overall cohort and accounted for 28% of the 9227 cases of ESRD that occurred during follow-up. Among patients of all ages, rates of both death and ESRD were inversely related to eGFR at baseline. However, among those with comparable levels of eGFR, older patients had higher rates of death and lower rates of ESRD than younger patients. Consequently, the level of eGFR below which the risk of ESRD exceeded the risk of death varied by age, ranging from 45 ml/min per 1.73 m(2) for 18 to 44 year old patients to 15 ml/min per 1.73 m(2) for 65 to 84 year old patients. Among those 85 years or older, the risk of death always exceeded the risk of ESRD in this cohort. Among patients with eGFR levels <45 ml/min per 1.73 m(2) at baseline, older patients were less likely than their younger counterparts to experience an annual decline in eGFR of >3 ml/min per 1.73 m(2). In conclusion, age is a major effect modifier among patients with an eGFR of <60 ml/min per 1.73 m(2), challenging us to move beyond a uniform stage-based approach to managing CKD.

American Cancer Society lung cancer screening guidelines

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Development and Validation of a Functional Morbidity Index to Predict Mortality in Community-dwelling Elders

AbstractOBJECTIVE: Functional measures have a great appeal for prognostic instruments because they are associated with mortality, they represent the end-impact of disease on the patient, and information about them can be obtained directly from the patient. However, there are no prognostic indices that have been developed for community-dwelling elders based primarily on functional measures. Our objective in this study was to develop and validate a prognostic index for 2-year mortality in community-dwelling elders, based on self-reported functional status, age, and gender. DESIGN: Population-based cohort study from 1993 to 1995. SETTING: Community-dwelling elders within the United States. PARTICIPANTS: Subjects, age ≥70 (N=7,393), from the Asset and Health Dynamics Among the Oldest Old study. We developed the index in 4,516 participants (mean age 78, 84% white, 61% female), and validated it in 2,877 different participants (mean age 78, 73% white, 61% female). MAIN OUTCOME MEASURES: Prediction of 2-year mortality using risk factors such as activities of daily living, instrumental activities of daily living, additional measures of physical function, age, and gender. RESULTS: Overall mortality was 10% in the development cohort and 12% in the validation cohort. In the development cohort, 6 independent predictors of mortality were identified and weighted, using logistic regression models, to create a point scale: male gender, 2 points; age (76 to 80, 1 point;>80, 2 points); dependence in bathing, 1 point; dependence in shopping, 2 points; difficulty walking several blocks, 2 points; and difficulty pulling or pushing heavy objects, 1 point. We calculated risk scores for each patient by adding the points of each independent risk factor present. In the development cohort, 2-year mortality was 3% in the lowest risk group (0 to 2 points), 11% in the middle risk group (3 to 6 points), and 34% in the highest risk group (>7 points). In the validation cohort, 2-year mortality was 5% in the lowest risk group, 12% in the middle risk group, and 36% in the highest risk group. The c-statistics for the point system were 0.76 and 0.74 in the development and validation cohorts, respectively. CONCLUSIONS: This prognostic index, which relies solely on self-reported functional status, age, and gender, provides a simple and accurate method of stratifying community-dwelling elders into groups at varying risk of mortality.

Prediction of Mortality in Community‐Living Frail Elderly People with Long‐Term Care Needs

OBJECTIVES: To develop and validate a prognostic index for mortality in community‐living, frail elderly people.

Impact of Age and Comorbidity on Colorectal Cancer Screening Among Older Veterans

Context Guidelines increasingly state that screening for cancer should be targeted to people who will live long enough to benefit from it. Content The investigators studied receipt of colorectal cancer screening in 27068 screen-eligible VA patients 70 years or older. Only 47% of patients with no comorbidity (5-year mortality rate, 19%) were screened, whereas 41% with severe comorbidity (5-year mortality rate, 55%) were screened. Rates were somewhat lower for older men but varied only slightly by life expectancy. Caution Some tests may have been done for diagnosis rather than screening. Implication In this population of elderly men, screening did not target healthier patients. The Editors Colorectal cancer screening guidelines recommend screening older adults who have substantial life expectancies according to age and comorbid conditions (1). For example, the U.S. Preventive Services Task Force recommends routine screening until age 75 years, whereas the Veterans Health Administration, the American Cancer Society, and the American Geriatrics Society (25) recommend colorectal cancer screening for older adults unless they are unlikely to live 5 years or have significant comorbid conditions that would preclude treatment. Targeting screening to healthy persons who are likely to live at least 5 years is recommended because randomized trials of fecal occult blood testing (FOBT) suggest that a difference in colorectal cancer mortality between screened and unscreened persons does not become noticeable until at least 5 years after screening (68). Therefore, persons with a life expectancy of 5 years or less are not likely to benefit from screening but remain at risk for harms that may occur immediately, such as complications from procedures and the treatment of clinically unimportant disease (9, 10). However, it remains unclear whether screening is being targeted to healthy older persons with substantial life expectancies and avoided in older persons with significant comorbidity, for whom the risks of screening outweigh the benefits. Previous studies of associations among age, comorbidity, and receipt of cancer screening have found that age is a stronger determinant of screening than comorbidity. For example, whereas advancing age is consistently associated with lower screening rates, worsening comorbidity has had little effect on the use of screening mammography, Papanicolaou smears, or prostate-specific antigen screening (1113). Previous studies of the relationship between colorectal cancer screening and comorbidity have been limited by small sample size, short follow-up times, and focus on FOBT rather than all types of colorectal cancer screening tests (14, 15). In addition, previous Veterans Affairs (VA) studies have not measured colorectal cancer screening performed outside the VA health care system by means of Medicare (1517). Having a better understanding of how comorbidity and age affect overall screening use is particularly important for colorectal cancer screening because the tests and follow-up procedures are often more invasive than those for other types of cancer and may result in substantial harms, such as major bleeding events, colon perforation, or strokeespecially in elderly persons with limited life expectancies (9, 18, 19). To characterize the use of colorectal cancer screening across a prognostic spectrum of advancing age and comorbidity, we examined VA data and Medicare claims for patients 70 years of age or older who were seen at 4 geographically diverse VA facilities. Specifically, we determined 2-year screening incidence and 5-year mortality rate for subgroups of older patients without significant comorbidity for whom guidelines recommend screening, as well as for subgroups of older patients with severe comorbidity for whom most guidelines agree that the risks of screening outweigh the benefits. Methods Data Sources and Patients We identified a cohort of screen-eligible patients on 1 January 2001 and followed them for 2 years for the performance of colorectal cancer screening. We obtained data for this cohort study from National VA Data Systems, clinical data extracted from the electronic record system (Veterans Health Information Systems and Technology Architectures) of 4 VA medical centers (Minneapolis, Minnesota; Durham, North Carolina; Portland, Oregon; and West Los Angeles, California), and Medicare claims. National VA data included the National Patient Care Database (which captures all inpatient and outpatient claims within the VA), Fee Basis Files (which capture claims for non-VA services paid for by the VA), and the Vital Status File (which captures mortality data for veterans) (20). Clinical data extracted from the 4 VA centers included text entered by clinicians in response to computerized clinical reminders about colorectal cancer screening (21). We used linked Medicare claims from the VA Information Resource Center to capture services provided to our cohort outside the VA by Medicare (22). On the basis of these data sources, we identified a cohort of 60933 patients 70 years of age or older who had at least 1 outpatient visit within the VA health care system or Medicare between 1 January 2000 and 31 December 2000 (the period during which we measured comorbidity) and at least 1 outpatient visit at 1 of the 4 VA centers between 1 January 2001 and 31 December 2002 (the period during which we measured the performance of colorectal cancer screening) (Figure 1). We selected the 4 VA centers for geographic diversity. We excluded 11817 (19%) patients who were enrolled in Medicare managed care at any point from 1 January 2000 to 31 December 2002, because they lacked Medicare claims. In addition, patients had to be eligible for screening to be included in our cohort. Therefore, we used VA and Medicare inpatient and outpatient claims from the 8-year period before the start of 2001 (dating back to 1 October 1992 for VA claims and 1 January 1999 for Medicare claims) to exclude 11200 (18%) patients with a history of colorectal cancer, colitis, colorectal polyps, colectomy, or colostomy and 8153 (13%) patients who had any history of a colonoscopy or had had a sigmoidoscopy or barium enema within 5 years and were therefore not due for screening at the start of 2001. We also used claims from the 6 months before their index test to exclude 2695 (4%) of patients who had signs or symptoms that would justify the performance of a test for nonscreening purposes (Figure 1). This left a final screen-eligible cohort of 27068 patients on 1 January 2001. Figure 1. Study flow diagram. Eligibility criteria included having been seen in an outpatient clinic at 1 of 4 Veterans Affairs (VA) centers between 1 January 2001 and 31 December 2002, which indicated that the VA was at least partially responsible for medical care, but data on colorectal cancer screening were gathered during the entire 2-year screening interval from both national VA and Medicare claims. Additional eligibility criteria included having at least 1 outpatient visit between 1 January and 31 December 2000 to define comorbidity as of 1 January 2001. *Defined by searching VA and Medicare inpatient and outpatient claims before 1 January 2001, dating as far back as 1 October 1992 for VA claims and 1 January 1999 for Medicare claims. Data Collection and Measurement Outcome Variables We assessed receipt of colorectal cancer screening between 1 January 2001 and 31 December 2002 for our cohort across the VA health care system and Medicare, because many elderly veterans use more than 1 VA center and most are enrolled in Medicare (23). We identified colorectal cancer screening in National VA Data Systems and linked Medicare payment data (hospital outpatient and physician/supplier files) by using International Classification of Disease, Ninth Revision (ICD-9), codes; Current Procedural Terminology (CPT) codes; and Level II Healthcare Common Procedure Coding System (HCPCS) codes for FOBT (CPT codes 82270, 82273, and 82274 and HCPCS code G0107), colonoscopy (ICD-9 codes 45.22, 45.23, 45.25, 45.41, 45.42, and 45.43; CPT codes 44388 to 44394, 45355, and 45378 to 45385; and HCPCS codes G0105, G0121), sigmoidoscopy (ICD-9 codes 45.24, 48.22 to 48.24, 48.26, 48.35, and 48.36; CPT codes 45300, 45303, 45305, 45308, 45309, 45315, 45320, 45330 to 45334, and 45337 to 45339; and HCPCS code G0104), or barium enema (ICD-9 code 87.64; CPT codes 74270 and 74280; and HCPCS codes G0106, G0120, and G0122) (2427). We assigned patients to 1 of the 4 screening procedures on the basis of their first test during 2001 through 2002. We chose a 2-year screening period to allow sufficient time for screening tests to be scheduled and performed; this is also the screening interval used in randomized trials of FOBT (6, 7). We obtained vital status through 31 December 2005 from the VA Vital Status File to determine 5-year mortality rates. The VA Vital Status File is similar to the National Death Index in terms of accuracy and completeness (28). We used 5-year mortality rates descriptively to identify conditions associated with having a life expectancy less than 5 years (5-year mortality rate >50%). Predictor Variables We assigned patients to 1 of 3 categories on the basis of their age on 1 January 2001: 70 to 74 years, 75 to 79 years, or 80 years or older. We defined the burden of comorbidity by using the Deyo adaptation of the Charlson Comorbidity Index (2931), a summary measure of 19 chronic disease diagnoses from administrative data that are selected and weighted according to their association with mortality. We calculated CharlsonDeyo scores from VA and Medicare inpatient and outpatient claims during the 12 months before the start of 2001 (3234). We categorized patients as having no significant comorbidity if they had a CharlsonDeyo score of 0, average comorbidity if they had a CharlsonDeyo score of 1 to 3, and severe comorbidity if they had a CharlsonDeyo score of 4 or greater. We chose th

Time lag to benefit after screening for breast and colorectal cancer: meta-analysis of survival data from the United States, Sweden, United Kingdom, and Denmark

Objectives To determine a pooled, quantitative estimate of the length of time needed after breast or colorectal cancer screening before a survival benefit is observed. Design Meta-analysis of survival data from population based, randomized controlled trials comparing populations screened and not screened for breast or colorectal cancer. Trials were identified as high quality by reviews from the Cochrane Collaboration and United States Preventive Services Task Force. Setting Trials undertaken in the United States, Denmark, United Kingdom, and Sweden. Population Screened patients older than 40 years. Primary outcome measures Time to death from breast or colorectal cancer in screened and control populations. Interventions Fecal occult blood testing for colorectal cancer screening, mammography for breast cancer screening. Results Our study included five and four eligible trials of breast and colorectal cancer screening, respectively. For breast cancer screening, 3.0 years (95% confidence interval 1.1 to 6.3) passed before one death from breast cancer was prevented for every 5000 women screened. On average across included studies, it took 10.7 years (4.4 to 21.6) before one death from breast cancer was prevented for 1000 women screened. For colorectal cancer screening, 4.8 years (2.0 to 9.7) passed before one death from colorectal cancer was prevented for 5000 patients screened. On average across included studies, it took 10.3 years (6.0 to 16.4) before one death from colorectal cancer was prevented for 1000 patients screened. Conclusions Our results suggest that screening for breast and colorectal cancer is most appropriate for patients with a life expectancy greater than 10 years. Incorporating time lag estimates into screening guidelines would encourage a more explicit consideration of the risks and benefits of screening for breast and colorectal cancer.

Adverse events in older patients undergoing colonoscopy: a systematic review and meta-analysis

BACKGROUND Studies suggest that advancing age is an independent risk factor for experiencing adverse events during colonoscopy. Yet many of these studies are limited by small sample sizes and/or marked variation in reported outcomes. OBJECTIVE To determine the incidence rates for specific adverse events in elderly patients undergoing colonoscopy and calculate incidence rate ratios for selected comparison groups. SETTING AND PATIENTS Elderly patients undergoing colonoscopy. DESIGN Systematic review and meta-analysis. MAIN OUTCOME MEASUREMENTS Perforation, bleeding, cardiovascular (CV)/pulmonary complications, and mortality. RESULTS Our literature search yielded 3328 articles, of which 20 studies met our inclusion criteria. Pooled incidence rates for adverse events (per 1000 colonoscopies) in patients 65 years of age and older were 26.0 (95% CI, 25.0-27.0) for cumulative GI adverse events, 1.0 (95% CI, 0.9-1.5) for perforation, 6.3 (95% CI, 5.7-7.0) for GI bleeding, 19.1 (95% CI, 18.0-20.3) for CV/pulmonary complications, and 1.0 (95% CI, 0.7-2.2) for mortality. Among octogenarians, adverse events (per 1000 colonoscopies) were as follows: cumulative GI adverse event rate of 34.9 (95% CI, 31.9-38.0), perforation rate of 1.5 (95% CI, 1.1-1.9), GI bleeding rate of 2.4 (95% CI, 1.1-4.6), CV/pulmonary complication rate of 28.9 (95% CI, 26.2-31.8), and mortality rate of 0.5 (95% CI, 0.06-1.9). Patients 80 years of age and older experienced higher rates of cumulative GI adverse events (incidence rate ratio 1.7; 95% CI, 1.5-1.9) and had a greater risk of perforation (incidence rate ratio 1.6, 95% CI, 1.2-2.1) compared with younger patients (younger than 80 years of age). There was an increased trend toward higher rates of GI bleeding and CV/pulmonary complications in octogenarians but neither was statistically significant. LIMITATIONS Heterogeneity of studies included and not all complications related to colonoscopy were captured. CONCLUSIONS Elderly patients, especially octogenarians, appear to have a higher risk of complications during and after colonoscopy. These data should inform clinical decision making, the consent process, public health policy, and comparative effectiveness analyses.

Impact of Age and Comorbidity on Non–Small-Cell Lung Cancer Treatment in Older Veterans

PURPOSE Because comorbidity affects cancer treatment outcomes, guidelines recommend considering comorbidity when making treatment decisions in older patients with lung cancer. Yet, it is unclear whether treatment is targeted to healthier older adults who might reasonably benefit. PATIENTS AND METHODS Receipt of first-line guideline-recommended treatment was assessed for 20,511 veterans age ≥ 65 years with non-small-cell lung cancer (NSCLC) in the Veterans Affairs (VA) Central Cancer Registry from 2003 to 2008. Patients were stratified by age (65 to 74, 75 to 84, ≥ 85 years), Charlson comorbidity index score (0, 1 to 3, ≥ 4), and American Joint Committee on Cancer stage (I to II, IIIA to IIIB, IIIB with malignant effusion to IV). Comorbidity and patient characteristics were obtained from VA claims and registry data. Multivariate analysis identified predictors of receipt of guideline-recommended treatment. RESULTS In all, 51% of patients with local, 35% with regional, and 27% with metastatic disease received guideline-recommended treatment. Treatment rates decreased more with advancing age than with worsening comorbidity for all stages, such that older patients with no comorbidity had lower rates than younger patients with severe comorbidity. For example, 50% of patients with local disease age 75 to 84 years with no comorbidity received surgery compared with 57% of patients age 65 to 74 years with severe comorbidity (P < .001). In multivariate analysis, age and histology remained strong negative predictors of treatment for all stages, whereas comorbidity and nonclinical factors had a minor effect. CONCLUSION Advancing age is a much stronger negative predictor of treatment receipt among older veterans with NSCLC than comorbidity. Individualized decisions that go beyond age and include comorbidity are needed to better target NSCLC treatments to older patients who may reasonably benefit.

Screening Mammography in Older Women: A Review

IMPORTANCE Guidelines recommend individualizing screening mammography decisions for women aged 75 years and older. However, little pragmatic guidance is available to help counsel patients. OBJECTIVE To provide an evidence-based approach for individualizing decision-making about screening mammography in older women. EVIDENCE ACQUISITION We searched PubMed for English-language studies in peer-reviewed journals published from January 1, 1990, to February 1, 2014, to identify risk factors for late-life breast cancer in women aged 65 years and older and to quantify the benefits and harms of screening mammography for women aged 75 years and older. FINDINGS Age is the major risk factor for developing and dying from breast cancer. Breast cancer risk factors that reflect hormonal exposures in the distant past, such as age at first birth or age at menarche, are less predictive of late-life breast cancer than factors indicating recent hormonal exposures such as high bone mass or obesity. Randomized trials of the benefits of screening mammography did not include women older than 74 years. Thus it is not known if screening mammography benefits older women. Observational studies favor extending screening mammography to older women who have a life expectancy of more than 10 years. Modeling studies estimate 2 fewer breast cancer deaths/1000 women who in their 70s continue biennial screening for 10 years instead of stopping screening at age 69. Potential harms of continued screening over 10 years include false-positive mammograms in approximately 200/1000 women screened and overdiagnosis (ie, finding breast cancer that would not have clinically surfaced otherwise) in approximately 13/1000 women screened. Providing information about life expectancy along with potential benefits and harms of screening may help older womens decision-making about screening mammography. CONCLUSIONS AND RELEVANCE For women with less than a 10-year life expectancy, recommendations to stop screening mammography should emphasize increased potential harms from screening and highlight health promotion measures likely to be beneficial over the short term. For women with a life expectancy of more than 10 years, deciding whether potential benefits of screening outweigh harms becomes a value judgment for patients, requiring a realistic understanding of screening outcomes.

Relationship between Health Status and Use of Screening Mammography and Papanicolaou Smears among Women Older Than 70 Years of Age

Context Some worry that clinicians will screen for breast and cervical cancer even when the probability of benefit is very low because of the patients age and comorbid disease. Contribution Over 75% of women age 70 years or older reported recent mammography and Papanicolaou smear in a 20002001 health survey. Rates decreased with age but not with worsening self-reported health status. Implications Decisions to screen for breast and cervical cancer may not appropriately consider an individual womans health. Cautions The researchers used self-reported health, which correlates with life expectancy in populations but may not be accurate enough to use in individual patients. The Editors One of the most striking features of the elderly population is its heterogeneity (1). While many individuals remain quite healthy with advancing age, others develop worsening health and functional impairments that can significantly decrease life expectancy and the benefit-to-harm ratio of cancer screening tests (2-4). Many cancer screening guidelines now recognize this heterogeneity, recommending that screening decisions should be based not on age alone but should also take into account an older persons health status (5-7). Life expectancy is better predicted by health status than by age alone, and older women with life expectancies less than 5 years are unlikely to benefit from cancer screening tests (8, 9). However, it is unclear to what extent cancer screening tests are actually targeted to healthy older women who might reasonably benefit and are avoided in older women with limited life expectancies. Previous studies evaluating associations among age, health status, and recent receipt of cancer screening have found that rates of screening mammography and Papanicolaou (Pap) smears decrease with advancing age (10-14). However, results have been mixed regarding associations between screening use and health status. Several studies using the 1992 National Health Interview Survey found that self-rated health and physical function were not associated with recent screening mammography (10, 11). More comorbid conditions have been associated with both higher and lower rates of screening mammography and Pap smears (12, 15, 16). A study using the 1991 Medicare Current Beneficiary Survey and Medicare claims data found that functional and cognitive impairments were associated with decreased mammography use (13), while a cohort study in Connecticut found that screening mammography was underused among healthy older women (14). All of these studies were done during the early 1990s, when screening rates were low among older women; Medicare coverage of mammography and Pap smears began only in 1991. Since that time, mammography and Pap smear rates have steadily increased (17-19), but we do not know of any recent studies that evaluate how age and health status currently affect receipt of screening mammography or Pap smears in the elderly population. To determine whether screening mammography and Pap smears are currently targeted to healthy older women and avoided in older women who are unlikely to benefit, we examined data from the 2001 California Health Interview Survey (CHIS). We evaluated recent screening mammography and Pap smear use by older California women stratified into distinct health quartiles on the basis of a validated measure of health status. Methods Data Source and Participants Data used in this population-based cross-sectional study came from the public-use files of the 2001 CHIS, which is the largest state health survey in the United States (20). The CHIS is a 2-stage, geographically stratified random-digitdial telephone survey that collected health and demographic information from adults residing in California households between November 2000 and October 2001. At the first stage, California telephone numbers were randomly generated by a computer, and a random sample of these numbers was then dialed for each of 41 predefined geographic areas. At the second stage, 1 adult was randomly selected to be interviewed from among all adults living in the contacted household. Trained staff administered the interviews in 6 languages using a computer-assisted telephone interviewing system. These interviews had a response rate of 63.7%, resulting in a total sample size of 55 428 adults. The potential analytic cohort for this study included the 5103 women who were 70 years of age or older. We excluded 311 women (6%) who were missing data on the Medical Outcomes Study 12-item Short Form (SF-12), leaving 4792 women. In addition, women were excluded if data on their most recent mammography or Pap smear were missing, if they reported a history of breast or cervical cancer, or if they reported that the test was obtained for symptoms or work-up of abnormal examination results. Participants were excluded separately for mammography and Pap smears, resulting in slightly different sample sizes for each test (Figure 1). Proxy respondents were accepted for frail or ill adults who could not answer for themselves (n = 85). Figure 1. Flow diagram of women included in analyses for each screening test. Pap Data Collection and Measurement Outcome Variables Participants were asked a series of questions about the receipt of screening mammography and Pap smears. Questions inquired about whether participants had ever had the test and, if so, when the most recent test had been performed. On the basis of established screening guidelines, participants were counted as screened for breast cancer if they reported routine screening mammography within the 2 years preceding the date of the survey (5). They were counted as screened for cervical cancer if they reported a routine screening Pap smear within the past 3 years (21, 22). Predictor Variables Age was categorized into 4 groups: 70 to 74 years, 75 to 79 years, 80 to 84 years, and 85 years or older. Health status was assessed by using the SF-12 Physical Summary Scale (PCS-12), which is a 12-item questionnaire constructed from the Medical Outcomes Study 36-item Short Form to describe functional health status (23). The PCS-12 includes questions about self-rated health and whether a persons health limits his or her physical functioning in a series of activities a lot, a little, or not at all (24). Answers to the PCS-12 questions were scored by using established norm-based methods, with higher scores indicating better health. The median score for the general U.S. population 70 years of age or older is approximately 40 (24). The number of physician visits was recorded to evaluate whether the number of screening opportunities might explain the relationships among screening rates, health status, and age. Other factors known to influence the use of cancer screening tests were also ascertained, including ethnicity, education, income, use of hormone replacement therapy, and presence of comorbid illnesses. The Committee on Human Research at the University of California, San Francisco, and the Committee for Research and Development at the San Francisco Veterans Affairs Medical Center approved the study. Statistical Analysis We used SUDAAN, version 8.0.1 (Research Triangle Institute, Research Triangle Park, North Carolina), to take the CHIS sample weights and complex survey design into account in all statistical analyses. We compared baseline characteristics across health status quartiles using chi-square tests. We also categorized women into 16 subgroups on the basis of age (4 categories) and PCS-12 quartile to evaluate the combined effect of age and health status on the use of screening mammography and Pap smears. Subgroups ranged from women 70 to 74 years of age in the best health status quartile (who are most likely to derive survival benefit from cancer screening since their estimated life expectancy is >20 years) to women 85 years of age or older in the worst health status quartile (who are least likely to benefit from cancer screening since their estimated life expectancy is <3 years) (8). Differences between percentages of women screened in each agehealth subgroup were determined according to advancing age and worsening health status by using the CochranArmitage chi-square test for trend. Population estimates were generated by SUDAAN using sample weights and the jackknife replication method (25). Multivariate logistic regression modeling was used to assess the independent associations between age or health status and cancer screening after adjustment for ethnicity, education, income, and marital status. Interaction terms between health status and ethnicity and between age and ethnicity were not statistically significant for mammography or Pap smear use. Role of the Funding Sources This study was funded through grant support from the Veterans Administration Health Services Research and Development program and the Agency for Healthcare Research and Quality. The funding agencies had no role in the design, conduct, or reporting of this study. Results Participant Characteristics Baseline characteristics of the 4792 women in this analytic cohort are presented in Table 1, according to health status. Thirty-six percent of women were at least 80 years of age. Seventy-nine percent of women were white, and 51% had more than 12 years of education. Very few women (<1%) had no health insurance, and 31% were taking hormone replacement therapy at the time of the survey. Table 1. Characteristics of California Women 70 Years of Age or Older, according to Health Status (n = 4792) The median PCS-12 score was 43.4. Scores were normally distributed, ranging from 10.6 to 66.8. The top 25th percentile of women had PCS-12 scores greater than 51.7, whereas the bottom 25th percentile had PCS-12 scores less than or equal to 31.6. Women in the worst PCS-12 quartile were less educated; had lower incomes; and had higher rates of diabetes, heart disease, and hypertension. Thirty-seven percent of women in the worst PCS-12 quartile had seen a physician more