MORTALITY IN BARIATRIC SURGERY
Case series demonstrate that bariatric surgery can be performed with a low rate of perioperative mortality (0.5%), but the rate among high-risk patients and the community at large is unknown. The authors sought to evaluate the risk of early mortality among Medicare beneficiaries and to determine the relative risk of death among older patients. This retrospective cohort study encompassed all fee-for-service Medicare beneficiaries from 1997 to 2002. Outcome measures were 30-day, 90-day, and 1-year postsurgical all-cause mortality among patients undergoing bariatric procedures. A total of 16,155 patients underwent bariatric procedures (mean age, 47.7 years [SD, 11.3 years]; 75.8% women). The rates of 30-day, 90-day, and 1-year mortality were 2.0%, 2.8%, and 4.6%, respectively. Men had higher rates of early death than women (3.7% vs 1.5%, 4.8% vs 2.1%, and 7.5% vs 3.7% at 30 days, 90 days, and 1 year, respectively; P <.001). Mortality rates were greater for those aged 65 years or older compared with younger patients (4.8% vs 1.7% at 30 days, 6.9% vs 2.3% at 90 days, and 11.1% vs 3.9% at 1 year; P <.001). After adjustment for sex and comorbidity index, the odds of death within 90 days were 5-fold greater for older Medicare beneficiaries (aged 75 years; n = 136) than for those aged 65 to 74 years (n = 1381; odds ratio, 5.0; 95% confidence interval, 3.1-8.0). The odds of death at 90 days were 1.6 times higher (95% confidence interval, 1.3-2.0) for patients of surgeons with less than the median surgical volume of bariatric procedures (among Medicare beneficiaries during the study period) after adjusting for age, sex, and comorbidity index. The authors concluded that among Medicare beneficiaries, the risk of early death after bariatric surgery is considerably higher than previously suggested and is associated with advancing age, male sex, and lower surgeon volume of bariatric procedures. Patients age 65 years or older had a substantially higher risk of death within the early postoperative period than younger patients.

Flum DR, Salem L, Elrod JAB, et al. Early mortality among Medicare beneficiaries undergoing bariatric surgical procedures. JAMA 2005; 294:1903-1908.

AGE, RACE, AND HEALTH STATUS IN MAMMOGRAPHY
Screening mammography is controversial for elderly women because of an absence of efficacy data. Decisions to screen are based on individualized assessment of risks and benefits. Our objective was to determine how screening mammography varies by age and race when adjusted for propensity to die. In a retrospective cohort study, rates of screening mammogram performed in 2000-2001 based on claims, adjusted for propensity to die in 2000, were determined for a nationally representative 5% random sample of female fee-for-service Medicare beneficiaries 65 years and older in (N = 722,310).

Results showed that the overall rate of screening was 39%. When stratified into quintiles by propensity to die, 2-year rates ranged from 61% in the lowest-risk group to 5% in the highest-risk group. In analyses stratified by age and adjusted for propensity to die, 42% of women age 65-69 years were screened, declining to 26% of women 85 years and older (P <.001). Adjusted screening rates for white women, black women, and women of other races were 40%, 30%, and 25%, respectively (P <.001). Thus, among women with similar health status, the youngest women were 1.61 times more likely to be screened compared with the oldest; compared with black women and women of other races, white women were 1.38 and 1.60 times, respectively, more likely to be screened. The authors concluded that the decisions to screen for breast cancer are related not only to health status but also to age and race. Underuse and overuse of screening mammography likely occurs owing to age- and race-associated decision making. Assessment of life expectancy may more accurately identify women who could benefit from screening.

Bynum JPW, Braunstein JB, Sharkey P, et al. The influence of health status, age, and race on screening mammography in elderly women. Arch Intern Med 2005; 165:2083-2088.

DISPARITIES IN COLORECTAL CANCER SCREENING
Despite its effectiveness in reducing mortality, colorectal cancer (CRC) screening rates are low, especially among low-income and minority groups; however, physician recommendation can increase screening rates. The investigators performed a multilevel analysis of the Medicare Current Beneficiary Survey data linked to Medicare claims and the Area Resource File to identify determinants of racial and socioeconomic disparities in CRC screening among 9985 Medicare Parts A and B beneficiaries with a usual physician. Recent CRC screening was defined as receipt of either a home fecal occult blood test, flexible sigmoidoscopy, or colonoscopy at recommended intervals. Results showed that unadjusted rates of screening were 48% for white and 39% for black beneficiaries (P <.001). Racial differences in CRC screening receipt were eliminated after adjustment for socioeconomic status as measured by income and education. Socioeconomic status disparities decreased but remained significant after adjustment for personal and health system factors. Awareness of CRC (adjusted odds ratio, 2.76; 95% confidence interval, 2.29-3.33) and having a primary care generalist (vs another specialist) as one’s usual physician (adjusted odds ratio, 1.31; 95% confidence interval, 1.12-1.53) were associated with higher odds of screening, controlling for other factors. The odds of screening were also higher among those whose usual physician was rated more highly on information-giving skills. The authors concluded that racial differences in CRC screening rates among Medicare beneficiaries with a usual physician are explained by differences in socioeconomic status. Beneficiaries with a primary care generalist as their usual physician had higher rates of CRC screening receipt. Increased efforts to make Medicare beneficiaries aware of the benefits of CRC screening may capitalize on the associations found in this study between CRC knowledge, physician information giving, and timely screening.

O’Malley AS, Forrest CB, Feng S, Mandelblatt J. Disparities despite coverage: Gaps in colorectal cancer screening among Medicare beneficiaries. Arch Intern Med 2005; 165:2129-2135.

CEREBRAL WHITE MATTER LESIONS AND THE RISK OF DEMENTIA
The objective of this trial was to study the association between white matter lesions (WML) in specific locations and the risk of dementia. The Rotterdam Scan Study, a prospective population-based cohort study, scored periventricular and subcortical WML on magnetic resonance imaging and observed participants until January 2002 for incident dementia. The general population included 1077 people aged 60 to 90 years who did not have dementia at baseline. The main outcome measure was incident dementia by Diagnostic and Statistical Manual of Mental Disorders, Third Edition (DSM III-R) criteria. During a mean follow-up of 5.2 years, 45 participants developed dementia. Higher severity of periventricular WML increased the risk of dementia, whereas the association between subcortical WML and dementia was less prominent. The adjusted hazard ratio of dementia for each standard deviation increase in periventricular WML severity was 1.67 (95% confidence interval, 1.25-2.24). This increased risk was independent of other risk factors for dementia and partly independent of other structural brain changes on magnetic resonance imaging. The authors concluded that white matter lesions, especially in the periventricular region, increase the risk of dementia in elderly people.

Prins ND, van Dijk EJ, den Heijer T, et al. Cerebral white matter lesions and the risk of dementia. Arch Neurol 2004;61: 1531-1534.