TY - JOUR T1 - Skin Cancer in U.S. Elderly Adults: Does Life Expectancy Play a Role in Treatment Decisions? JF - J Am Geriatr Soc Y1 - 2016 A1 - Linos, Eleni A1 - Chren, Mary-Margaret A1 - Irena Cenzer A1 - Kenneth E Covinsky KW - Activities of Daily Living KW - Aged KW - Aged, 80 and over KW - Carcinoma, Basal Cell KW - Carcinoma, Squamous Cell KW - Comorbidity KW - Cost-Benefit Analysis KW - Cross-Sectional Studies KW - Curettage KW - Decision Support Techniques KW - Disability Evaluation KW - Electrosurgery KW - Female KW - Humans KW - Keratinocytes KW - Life Expectancy KW - Male KW - Mohs Surgery KW - Prognosis KW - Skin Neoplasms AB -

OBJECTIVES: To examine whether life expectancy influences treatment pattern of nonmelanoma skin cancer, or keratinocyte carcinoma (KC), the most common malignancy and the fifth most costly cancer to Medicare.

DESIGN: Nationally representative cross-sectional study.

SETTING: Nationally representative Health and Retirement Study linked to Medicare claims.

PARTICIPANTS: Treatments (N = 9,653) from individuals aged 65 and older treated for basal or squamous cell carcinoma between 1992 and 2012 (N = 2,702) were included.

MEASUREMENTS: Limited life expectancy defined according to aged 85 and older, medical comorbidities, Charlson Comorbidity Index score of 3 or greater, difficulty in at least one activity of daily living (ADL), and a Lee index of 13 or greater. Treatment type (Mohs micrographic surgery (MMS) (most intensive, highest cost), excision, or electrodesiccation and curettage (ED&C) (least intensive, lowest cost)), according to procedure code.

RESULTS: Most KCs (61%) were treated surgically. Rates of MMS (19%), excision (42%), and ED&C (39%) were no different in participants with limited life expectancy and those with normal life expectancy. For example, 19% of participants with difficulty or dependence in ADLs, 20% of those with a Charlson comorbidity score greater than 3, and 15% of those in their last year of life underwent MMS; participants who died within 1 year of diagnosis were treated in the same way as those who lived longer.

CONCLUSION: A one-size-fits-all approach in which advanced age, health status, functional status, and prognosis are not associated with intensiveness of treatment appears to guide treatment for KC, a generally nonfatal condition. Although intensive treatment of skin cancer when it causes symptoms may be indicated regardless of life expectancy, persons with limited life expectancy should be given choices to ensure that the treatment matches their goals and preferences.

VL - 64 UR - http://www.ncbi.nlm.nih.gov/pubmed/27303932 IS - 8 U1 - http://www.ncbi.nlm.nih.gov/pubmed/27303932?dopt=Abstract ER - TY - JOUR T1 - Subjective social status and functional decline in older adults. JF - J Gen Intern Med Y1 - 2012 A1 - Bonnie Chen A1 - Kenneth E Covinsky A1 - Irena Cenzer A1 - Nancy E Adler A1 - Brie A Williams KW - Activities of Daily Living KW - Aged KW - Aging KW - Female KW - Health Status Disparities KW - Humans KW - Longitudinal Studies KW - Male KW - Middle Aged KW - Mobility Limitation KW - Risk Factors KW - Self Report KW - Social Class AB -

BACKGROUND: It is unknown whether subjective assessment of social status predicts health outcomes in older adults.

OBJECTIVE: To describe the relationship between subjective social status and functional decline in older adults.

DESIGN: Longitudinal cohort study.

SETTING: The Health and Retirement Study, a nationally representative survey of community-dwelling older adults (2004-2008).

PARTICIPANTS: Two thousand five hundred and twenty-three community-dwelling older adults.

MAIN MEASURES: Self-report of social status (SSS), categorized into three groups, reported by participants who marked a 10-rung ladder to represent where they stand in society. Four-year functional decline (new difficulty in any of five activities of daily living, mobility decline and/or death)

KEY RESULTS: Mean age was 64; 46% were male, 85% were white. At baseline, lower SSS was associated with being younger, unmarried, of nonwhite race/ethnicity, higher rates of chronic medical conditions and ADL impairment (P < 0.01). Over 4 years, 50% in the lowest SSS group declined in function, compared to the middle and highest groups (28% and 26%), P-trend <0.001. Those in the lowest rungs of SSS were at increased risk of 4-year functional decline (unadjusted RR = 1.91, CI 1.-9-2.46). The relationship between a subjective belief that one is worse off than others and functional decline persisted after serial adjustment for demographics, objective SES measures, and baseline health and functional status (RR 1.36, CI 1.08-1.73).

CONCLUSIONS: In older adults, the belief that one is in the lowest rungs of social status is a measure of socioeconomic distress and of significant risk for functional decline. These findings suggest that self-report of low subjective social status may give clinicians additional information about which older adults are at high risk for future functional decline.

VL - 27 IS - 6 U1 - http://www.ncbi.nlm.nih.gov/pubmed/22215272?dopt=Abstract U2 - PMC3358399 U4 - health outcomes/socioeconomic Differences/social status/social status/functional decline/functional decline/ADL and IADL Impairments ER - TY - JOUR T1 - Spouse-rated vs self-rated health as predictors of mortality. JF - Arch Intern Med Y1 - 2009 A1 - Liat Ayalon A1 - Kenneth E Covinsky KW - Aged KW - Cross-Sectional Studies KW - Female KW - Health Status KW - Humans KW - Longitudinal Studies KW - Male KW - Middle Aged KW - Self-Assessment KW - Spouses AB -

BACKGROUND: The Health and Retirement Study is a national sample of Americans older than 50 years and their spouses. The present study evaluated cross-sectional and longitudinal data from January 2000 through December 2006. The objective of the study was to evaluate the roles of spouse-rated vs self-rated health as predictors of all-cause mortality among adults older than 50 years.

METHODS: A total of 673 dyads of married couples were randomly selected to participate in a Health and Retirement Study module examining spouse-rated health. For each couple, one member was asked to rate his or her overall health status, and his or her spouse was asked to report the partner's overall health status. Mortality data were available through 2006.

RESULTS: Our findings demonstrate that spouse-rated health (area under the curve, 0.75) is as strong a predictor of mortality as self-rated health (area under the curve, 0.73) (chi(2)(1) = 0.36, P = .54). Combining spouse-rated and self-rated health predicts mortality better than using self-rated health alone (area under the curve, 0.77) (chi(2)(1) = 6.72, P = .009).

CONCLUSIONS: Spouse ratings of health are at least as strongly predictive of mortality as self-rated health. This suggests that, when self-rated health is elicited as a prognostic indicator, spouse ratings can be used when self-ratings are unavailable. Both measures together may be more informative than either measure alone.

PB - 169 VL - 169 IS - 22 U1 - http://www.ncbi.nlm.nih.gov/pubmed/20008702?dopt=Abstract U2 - PMC2920055 U4 - Cross-Sectional Studies/Health Status/SELF-RATED HEALTH/Longitudinal Studies/Middle Aged/Self Assessment/Spouses/MORTALITY ER - TY - JOUR T1 - Screening mammography in older women. Effect of wealth and prognosis. JF - Arch Intern Med Y1 - 2008 A1 - Brie A Williams A1 - Lindquist, Karla A1 - Rebecca L. Sudore A1 - Kenneth E Covinsky A1 - Louise C Walter KW - Aged KW - Breast Neoplasms KW - Chi-Square Distribution KW - Female KW - Humans KW - Longitudinal Studies KW - Mammography KW - Mass Screening KW - Prognosis KW - Risk Factors KW - Social Class AB -

BACKGROUND: Wealthy women have higher rates of screening mammography than poor women do. Screening mammography is beneficial for women with substantial life expectancies, but women with limited life expectancies are unlikely to benefit. It is unknown whether higher screening rates in wealthy women are due to increased screening in women with substantial life expectancies, limited life expectancies, or both. This study examines the relationship between wealth and screening mammography use in older women according to life expectancy.

METHODS: A cohort study was performed of 4222 women 65 years or older with Medicare participating in the 2002 and 2004 Health and Retirement Survey. Women were categorized according to wealth and life expectancy (based on 5-year prognosis from a validated prognostic index). The outcome was self-reported receipt of screening mammography within 2 years.

RESULTS: Overall, within 2 years, 68% of women (2871 of 4222) received a screening mammogram. Screening was associated with wealth (net worth, > $100 000) and good prognosis (< or = 10% probability of dying in 5 years). Screening mammography was more common among wealthy women than among poor women (net worth, < $10 000) both for women with good prognosis (82% vs 68%; P < .001) and for women with limited prognoses (> or = 50% probability of dying in 5 years) (48% vs 32%; P = .02). These associations remained after multivariate analysis accounting for age, race, education, proxy report, and rural residence.

CONCLUSIONS: Poorer older women with favorable prognoses are at risk of not receiving screening mammography when they are likely to benefit. Wealthier older women with limited prognoses are often screened when they are unlikely to benefit.

PB - 168 VL - 168 IS - 5 U1 - http://www.ncbi.nlm.nih.gov/pubmed/18332298?dopt=Abstract U3 - 18332298 U4 - Mammography/WOMEN/life Expectancy/Wealth/methodology/risk factors ER - TY - JOUR T1 - Self-restriction of medications due to cost in seniors without prescription coverage. JF - J Gen Intern Med Y1 - 2001 A1 - Michael A Steinman A1 - Laura Sands A1 - Kenneth E Covinsky KW - Aged KW - Aged, 80 and over KW - Cohort Studies KW - Cross-Sectional Studies KW - Female KW - Humans KW - Insurance, Pharmaceutical Services KW - Male KW - Prescription Fees KW - Risk Factors KW - Socioeconomic factors KW - Treatment Refusal KW - United States AB -

OBJECTIVE: Little is known about patients who skip doses or otherwise avoid using their medications because of cost. We sought to identify which elderly patients are at highest risk of restricting their medications because of cost, and how prescription coverage modifies this risk.

DESIGN AND PARTICIPANTS: Cross-sectional study from the 1995-1996 wave of the Survey of Asset and Health Dynamics Among the Oldest Old, a population-based survey of Americans age 70 years and older.

MEASUREMENTS: Subjects were asked the extent of their prescription coverage, and whether they had taken less medicine than prescribed for them because of cost over the prior 2 years. We used bivariate and multivariate analyses to identify risk factors for medication restriction in subjects who lacked prescription coverage. Among these high-risk groups, we then examined the effect of prescription coverage on rates of medication restriction.

MAIN RESULTS: Of 4,896 seniors who regularly used prescription medications, medication restriction because of cost was reported by 8% of subjects with no prescription coverage, 3% with partial coverage, and 2% with full coverage (P <.01 for trend). Among subjects with no prescription coverage, the strongest independent predictors of medication restriction were minority ethnicity (odds ratio [OR], 2.9 compared with white ethnicity; 95% confidence interval [95% CI], 2.0 to 4.2), annual income <$10,000 (OR, 3.8 compared with income > or =$20,000; 95% CI, 2.4 to 6.1), and out-of-pocket prescription drug costs >$100 per month (OR, 3.3 compared to costs < or =$20; 95% CI, 1.5 to 7.2). The prevalence of medication restriction in members of these 3 risk groups was 21%, 16%, and 13%, respectively. Almost half (43%) of subjects with all 3 risk factors and no prescription coverage reported restricting their use of medications. After multivariable adjustment, high-risk subjects with no coverage had 3 to 15 times higher odds of medication restriction than subjects with partial or full coverage (P <.01).

CONCLUSIONS: Medication restriction is common in seniors who lack prescription coverage, particularly among certain vulnerable groups. Seniors in these high-risk groups who have prescription coverage are much less likely to restrict their use of medications.

PB - 16 VL - 16 IS - 12 U1 - http://www.ncbi.nlm.nih.gov/pubmed/11903757?dopt=Abstract U4 - Aged, 80 and Over/Cohort Studies/Cross Sectional Studies/Female/Insurance, Pharmaceutical Services/Prescription Fees/Risk Factors/Socioeconomic Factors/Support, U.S. Government--non PHS/Support, U.S. Government--PHS/Treatment Refusal ER -