Donna L Washington

Donna L Washington
VA Greater Los Angeles Healthcare System · Medicine

MD, MPH

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177
Publications
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Introduction
Skills and Expertise

Publications

Publications (177)
Article
Background Hypertension control and related cardiovascular outcomes among Americans remain suboptimal, and differ by race, ethnicity, and geography. Healthcare access is one of multiple critical factors in hypertension control. Understanding the degree to which healthcare access, versus other factors, produce these outcomes can inform policies and...
Article
Background Atrial fibrillation (AF) is the most common arrhythmia globally and is associated with increased risks of cardiovascular mortality and ischemic stroke. Prior research has demonstrated racial/ethnic disparities in AF outcomes yet this work has been limited to small cohorts and did not adjust for anticoagulant therapy. Purpose We compared...
Article
Failing to consider disparities in quality measures, such as by race and ethnicity, may obscure inequities in care, which could exist in facilities with overall high-quality ratings. We examined the relationship between overall quality and racial and ethnic disparities in diabetes care quality by health care facility–level performance on a diabetes...
Article
Importance Racial and ethnic disparities exist in anticoagulation therapy for atrial fibrillation (AF). Whether medical center racial and ethnic composition is associated with these disparities is unclear. Objective To determine whether medical center racial and ethnic composition is associated with overall anticoagulation and disparities in antic...
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Objective To evaluate racial and ethnic differences in patient experience among VA primary care users at the Veterans Integrated Service Network (VISN) level. Data Source and Study Setting We performed a secondary analysis of the VA Survey of Healthcare Experiences of Patients‐Patient Centered Medical Home for fiscal years 2016–2019. Study Design...
Article
Oral anticoagulation reduces stroke risk for patients with atrial fibrillation (AF). Prior research demonstrates lower anticoagulant prescribing in Black than in White individuals but few studies have examined racial differences in facility-level anticoagulant prescribing for AF. To assess variation in anticoagulant initiation by race within Vetera...
Article
Insomnia and pain disorders are among the most common conditions affecting United States adults and veterans, and their comorbidity can cause detrimental effects to quality of life among other factors. Cognitive behavioural therapy for insomnia and related behavioural therapies are recommended treatments for insomnia, but chronic pain may hinder tr...
Article
Background Hypoglycaemia from diabetes treatment causes morbidity and lower quality of life, and prevention should be routinely addressed in clinical visits. Methods This mixed methods study evaluated how primary care providers (PCPs) assess for and prevent hypoglycaemia by analyzing audio-recorded visits from five Veterans Affairs medical centres...
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Objective To examine the role of patient‐perceived access to primary care in mediating and moderating racial and ethnic disparities in hypertension control and diabetes control among Veterans Health Administration (VA) users. Data Source and Study Setting We performed a secondary analysis of national VA user administrative data for fiscal years 20...
Article
Introduction: Anticoagulation reduces stroke risk in atrial fibrillation (AF). Patient-level studies show significant Black-White disparities in any anticoagulant and direct oral anticoagulant (DOAC) prescribing. Little is known about whether such disparities exist at the hospital level, thus we examined the association of hospital racial compositi...
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Introduction We tested the hypotheses that depression diagnoses influence racial and ethnic disparities in diabetes control and that mental health treatment moderates that relationship. Research design and methods We created a national cohort of Veterans Health Administration (VHA) patients with diabetes using administrative data (n=815 067). Cros...
Article
Introduction: Black women with uterine fibroids experience greater symptom severity and worse treatment outcomes compared with their White counterparts. Black veterans who use the Veteran's Health Administration (VA) health care experience similar disparities. This study investigated the experiences of Black veterans receiving care for uterine fib...
Article
Background: The burden of heart failure is growing. Guideline-directed medical therapies (GDMT) reduce adverse outcomes in heart failure with reduced ejection fraction (HFrEF). Whether there is geographic variation in HFrEF quality of care is not well described. Objectives: This study evaluated variation nationally for prescription of GDMT withi...
Article
Background: The COVID-19 pandemic in the U.S. has disproportionately impacted communities deemed vulnerable to disease outbreaks. Our objectives were to test 1) whether infection and mortality decreased in counties in the most vulnerable (highest) tercile of the Social Vulnerability Index (SVI), and 2) whether disparities between terciles of SVI w...
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Introduction While positive airway pressure (PAP) therapy is the most efficacious and widely used treatment for sleep disordered breathing (SDB), the initial discomfort associated with PAP use and the poor sleep experienced by patients with SDB contribute to treatment non-adherence. Women with SDB report poorer sleep quality and have lower PAP adhe...
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Introduction Black identified women and veterans consistently experience disproportionately higher rates of insomnia. Cognitive behavioral therapy for insomnia (CBT-I) improves sleep outcomes, although higher rates of attrition and sub-optimal adherence in these groups can limit symptom improvement. Few studies have examined CBT-I treatment adheren...
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Introduction Sleep disordered breathing (SDB) is associated with poor mental health and lower overall quality of life (QOL); however, research examining these outcomes after positive airway pressure (PAP) therapy for SDB in women is limited. We studied a 6-session PAP adherence program that included behavioral sleep improvement strategies plus conc...
Article
Objective: Limited population-based data examines racial disparities among pregnant and postpartum veterans. Our objective was to determine whether Black/white racial disparities in health care access, use, and veteran and infant outcomes are present among pregnant and postpartum veterans and their infants using Veterans Health Administration (VA)...
Article
Objective: Persons with serious mental illness (SMI: schizophrenia-spectrum disorders, bipolar disorder) experience increased risk of mortality after contracting COVID-19 based on the results of several international evaluations. However, information about COVID-19 mortality risk among patients with SMI in the Veterans Health Administration (VHA)...
Article
Context: Surges in the ongoing coronavirus-19 (COVID-19) pandemic and accompanying increases in hospitalizations continue to strain hospital systems. Identifying hospital-level characteristics associated with COVID-19 hospitalization rates and clusters of hospitalization "hot spots" can help with hospital system planning and resource allocation....
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Objective Evaluate self-reported electronic screening (eScreening) in a VA Transition Care Management Program (TCM) to improve the accuracy and completeness of administrative ethnicity and race data. Materials and Methods We compared missing, declined, and complete (neither missing nor declined) rates between (1) TCM-eScreening (ethnicity and race...
Article
Background and objectives: Substance use disorder (SUD) represents a substantial health burden to US Veterans. We aimed to quantify recent time trends in Veterans' substance-specific disorders using Veterans Health Administration (VA) data. Methods: We identified Veteran VA patients for fiscal years (FY) 2010-2019 (October 1, 2009-September 9, 2...
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Importance: Despite complexities of racial and ethnic residential segregation (hereinafter referred to as segregation) and neighborhood socioeconomic deprivation, public health studies, including those on COVID-19 racial and ethnic disparities, often rely on composite neighborhood indices that do not account for residential segregation. Objective...
Article
PurposeSleep-disordered breathing (SDB) is a common sleep disorder in veterans; however, limited research exists in women veterans. We sought to estimate patterns of care in terms of evaluation, diagnosis, and treatment among women veterans with factors associated with elevated SDB risk.Methods Within one VA healthcare system, women identified thro...
Article
Introduction: In patients with heart failure with reduced ejection fraction (HFrEF), use of guideline directed medical therapies (GDMT) reduces mortality. Whether there is geographic variation in GDMT prescribing is not well-characterized. Hypothesis: We assessed the hypothesis that there is wide geographic variation nationally within the Veterans...
Article
Introduction Few studies have focused on determinants of women's ratings of care experiences in primary care. We assessed associations between availability of women's health services and women veterans' ratings of care experiences. Methods In a cross-sectional analysis, we linked Fiscal Year 2017 (October 1, 2016, to September 30, 2017) survey dat...
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Background The Veterans Health Administration (VA) refers patients to community providers for specialty services not available on-site. However, community-level specialist shortages may impede access to care. Objective Compare gynecologist supply in veterans’ county of residence versus at their VA site. Design We identified women veteran VA patie...
Article
Objective: To examine by age, the veterans' report on whether components of age-friendly health systems were discussed during primary care visits. Data sources and study setting: Veterans Affairs (VA) Survey of Healthcare Experience of Patients from October 2015 to September 2019. Study design: Cross-sectional survey of VA users by age group (...
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This cohort study examines whether exposure to environmental toxins mediates the association of racial and ethnic disparities with hospitalizations among US veterans with COVID-19.
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Importance: Substance use disorders (SUDs) are major contributors to morbidity and mortality globally, but they are often underrecognized and underdiagnosed, particularly in some sociodemographic subgroups. Understanding the extent to which clinical diagnoses underestimate these conditions within subgroups is imperative to achieving equitable trea...
Article
Introduction Structural inequalities perpetuate poor health outcomes. Sleep inequality, which is the disproportionate burden of sleep problems among marginalized groups compared to historically advantaged groups, is poorly understood. While racial discrimination is associated with chronic health outcomes, few studies have examined the health impact...
Article
Introduction Despite increasing evidence that sleep disordered breathing (SDB) is common in women veterans, little is known of how to screen for SDB in this population. Some evidence suggests there are sex-related differences in SDB presentation, where women may be more likely to present with fatigue or depression, compared to men who may present w...
Article
Introduction Maintaining accurate race and ethnicity data among patients of the Veterans Affairs (VA) healthcare system has historically been a challenge. This work expands on previous efforts to optimize race and ethnicity values by combining multiple VA data sources and exploring race- and ethnicity-specific collation algorithms. Materials and M...
Article
Background Prior research has found that 25% of women veterans who are new to the Department of Veterans Affairs (VA) health care system discontinue services within 3 years of initial use. Although it has been suggested that providing more gender-sensitive care might improve women veterans' health care experiences, no study has yet documented an em...
Article
Purpose Patient attrition from the Veterans Health Administration (VA) healthcare system could undercut its mission to ensure care for eligible veterans. Attrition of women veterans could exacerbate their minority status and impede systemic efforts to provide high-quality care. We obtained women veterans’ perspectives on why they left or continued...
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Objective This study compared the benefits of cognitive–behavioral therapy for insomnia for sleep, mental health symptoms, and quality of life (QoL) in a sample of women veterans with and without probable post-traumatic stress disorder (PTSD) comorbid with insomnia disorder. Methods Seventy-three women veterans (30 with probable PTSD) received a m...
Article
Purpose Racial/ethnic minoritized groups, women, and economically disadvantaged groups are disproportionately affected by the COVID-19 pandemic. We investigated racial/ethnic differences by gender in correlates of COVID-19 infection among veterans seeking health care services at the Veterans Health Administration (VHA). Little is known about gender...
Article
Introduction: Equitable COVID-19 vaccine access is imperative to mitigating negative COVID-19 impacts among racial/ethnic minorities. U.S. racial/ethnic minorities have lower COVID-19 vaccination rates than Whites despite higher COVID-19 death/case rates. The Veterans Health Administration provides the unique context of a managed care system with...
Article
Objectives American Indian and Alaska Native (AI/AN) communities have been disproportionately affected by the coronavirus disease 2019 (COVID-19) pandemic. This study examines whether neighborhood characteristics mediate AI/AN versus White-non-Hispanic Veteran COVID-19 infection disparities, and whether mediation differs based on proximity to reser...
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Racial/ethnic disparities in coronavirus disease 2019 (COVID-19) hospitalization and mortality have emerged in the United States, but less is known about whether similar differences exist in testing, and how this changed as COVID-19 knowledge and policies evolved. We examined racial/ethnic variations in COVID-19 testing over time among veterans who...
Article
Introduction In our recent national survey study, 13% of women Veterans reported a diagnosis of Sleep Disordered Breathing (SDB), of whom 65% used positive airway pressure (PAP) treatment. We also found many women Veterans at high risk for SDB were undiagnosed (43%). The current study builds upon this survey research to identify rates of evaluation...
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Studies documenting coronavirus disease 2019 (COVID-19) racial/ethnic disparities in the United States were limited to data from the initial few months of the pandemic, did not account for changes over time, and focused primarily on Black and Hispanic minority groups. To fill these gaps, we examined time trends in racial/ethnic disparities in COVID...
Article
Background Substance use and related disorders are common among US Veterans, but the population burden of has never been directly assessed among Veterans Health Administration (VA) patients. We surveyed VA patients to measure substance use and related disorders in the largest US integrated healthcare system. Methods We surveyed N = 6000 outpatient...
Article
Background: Veteran family homelessness is a significant issue, yet little is known about the needs and barriers to services of veteran families experiencing homelessness. This qualitative study examined the experiences, needs, and barriers to services among homeless-experienced veteran families to inform providers for this important population....
Article
Objective To assess associations between body mass index (BMI) and severe COVID‐19 outcomes: hospitalization, intensive care unit (ICU) admission, and mortality. A secondary aim was to investigate whether associations varied by age. Methods The cohort comprised COVID‐19 positive Veterans Health Administration (VHA) patients (N=9,347). For each out...
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Objective/Background: The current study describes insomnia precipitating events reported by women Veterans and examines differences in sleep and psychological distress variables in those who endorsed traumatic, nontraumatic, or no insomnia precipitating events. Participants: Baseline data were collected from 347 women Veterans enrolled in a behavio...
Article
Posttraumatic stress disorder (PTSD) is associated with coronavirus disease 2019 (COVID-19) risk factors, such as hypertension and obesity. Associations between PTSD and COVID-19 outcomes may affect Veterans Health Administration (VA) services, as PTSD occurs at higher rates among veterans than the general population. While previous research has id...
Article
Study objectives: The goals of this study were to estimate rates of undiagnosed, diagnosed and treated sleep apnea in women Veterans and to identify factors associated with diagnosis and treatment of sleep apnea in this population. Methods: A large nationwide postal survey was sent to a random sample of 4,000 women Veterans who had received heal...
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Patient-centered medical homes (PCMH) are primary care delivery models that improve care access and population-level health outcomes, yet they have not been observed to narrow racial-ethnic disparities in the Veteran Health Administration (VHA) or other health systems. We aimed to identify and compare underlying drivers of persistent hypertension a...
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Objective To examine mediation and moderation of racial/ethnic all‐cause mortality disparities among Veteran Health Administration (VHA)‐users by neighborhood deprivation and residential segregation. Data sources Electronic medical records for 10/2008‐9/2009 VHA‐users linked to National Death Index, 2000 Area Deprivation Index, and 2006‐2009 US Ce...
Article
Research Objective Research suggests that about 80% of women veterans receiving care at the Department of Veterans Affairs (VA) have experienced at least one trauma in their lifetimes, including military sexual trauma or combat‐related trauma. Trauma‐sensitive communication reflects an understanding of the impact of trauma and the needs of trauma s...
Poster
Introduction A quarter of women Veterans (WVs) receiving VA healthcare meet diagnostic criteria for both insomnia disorder and posttraumatic stress disorder (PTSD). Cognitive Behavioral Therapy for Insomnia (CBT-I) is effective at improving sleep among individuals with comorbid psychiatric conditions; however, no studies have examined the impact of...
Poster
Introduction Sleep apnea (SA) is the most commonly diagnosed sleep disorder among patients in the US Veterans Administration (VA). The dramatic rise in women receiving VA care makes it essential to understand the presentation and treatment of SA in women Veterans. We performed a nationwide survey about sleep among US women Veterans and compared cha...
Article
Background: Gender sensitivity of providers and staff has assumed increasing importance in closing historical gender disparities in health care quality and outcomes. The Department of Veterans Affairs (VA) has implemented several initiatives intended to improve gender sensitivity of its health care workforce. The current study examines practice- a...
Article
Objective: The goal was to examine psychiatric diagnosis rates among a national cohort of primary care patients with and without obesity. Methods: The cohort was derived from national Veterans Health Administration data (women, N=342,262; men, N=4,524,787). Sex-stratified descriptive statistics characterized psychiatric diagnosis rates. Chi-squa...
Article
Background: Minimally invasive hysterectomy for fibroids decreases recovery time and risk of postoperative complications compared with abdominal hysterectomy. Within Veterans Affair (VA), black women with uterine fibroids are less likely to receive a minimally invasive hysterectomy than white women. Objective: To quantify the contributions of pa...
Article
Objectives: Sleep complaints, such as insomnia and sleep disturbances caused by posttraumatic stress disorder (PTSD), are more common among women veterans than nonveteran women. Alcohol use among some women may be partially motivated by the desire to improve sleep. This study evaluated rates of alcohol use as a sleep aid among women veterans and e...
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Introduction: Colorectal cancer (CRC) is a common but largely preventable malignancy. Screening is recommended for all adults aged 50-75 years; however, screening rates are low nationally and vary by patient factors and across health care systems. It is currently unknown whether there are inequities in CRC screening rates by patient sociodemograph...
Article
Background: Obesity is highly stigmatized, especially for women, and therefore may negatively affect health care experiences. Past findings on the relationship between obesity and health care experiences are mixed, perhaps because few studies examine relationships by gender and obesity class. Our objective was to evaluate whether women and men wit...
Article
Background: The Veterans Administration (VA) is transforming its historically male-dominated health care system to better serve women veterans, few of whom, nevertheless, use VA health care. We describe the factors affecting women veterans' use of VA-provided health care. Methods: We conducted in-person interviews with 22 women veterans in Los Ange...
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Purpose: To assess disparities in primary care experiences for patients with a substance use disorder (SUD) diagnosis. Methods: We assessed differences in Veterans Health Administration (VA) primary care patients' experiences using data from the 2014 outpatient VA Patient-Centered Medical Home Survey of Healthcare Experiences of Patients (SHEP; N=2...
Article
Objective To examine the relationship between care fragmentation and patient ratings of care quality and identify potentially actionable mediators. Data Sources/Study Setting 2015 telephone survey of 1395 women Veterans with three or more visits in primary care and/or women's health care in the prior year at 12 Veterans Affairs (VA) medical center...
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Purpose: Equal-access health care systems such as the Veterans Health Administration (VHA) reduce financial and nonfinancial barriers to care. It is unknown if such systems mitigate racial/ethnic mortality disparities, such as those well documented in the broader U.S. population. We examined racial/ethnic mortality disparities among VHA health care...
Article
Background: Systemic hormone therapy (HT) is effective for treating menopausal symptoms but also confers risks. Therefore, experts have developed clinical guidelines for its use. Purpose: We assessed primary care guideline adherence in prescribing systemic HT, and associations between adherence and provider characteristics, in four Veterans Heal...
Article
Background Abnormal uterine bleeding (AUB) is common among primary care patients. We assessed the extent to which Veterans Health Administration (VA) primary care patients with AUB are receiving guideline-adherent primary care. Methods We identified women with AUB presenting to primary care providers across four VA health care systems from June 20...
Article
Background Abnormal uterine bleeding (AUB) is a common women's health complaint. However, the quality of primary care (PC) management of AUB is unknown. Our objective was to develop quality indicators for Veterans Health Administration (VA) PC assessment and management of AUB. Methods We drafted candidate indicators based on comprehensive review o...
Article
Background: Several cardiotoxic substances impact heart failure incidence. The burden of comorbid tobacco or substance use disorders among heart failure patients is under-characterized. We describe the burden of tobacco and substance use disorders among hospitalized heart failure patients in the United States. Methods: We calculated the proporti...
Article
Aims: The Veterans Health Administration promotes evidence-based complementary and integrative health (CIH) therapies as nonpharmacologic approaches for chronic pain. We aimed to examine CIH use by gender among veterans with chronic musculoskeletal pain, and variations in gender differences by race/ethnicity and age. Methods: We conducted a seco...
Article
Background: Several cardiotoxic substances contribute to the development of heart failure (HF). The burden of comorbid substance use disorders (SUD) among patients with HF is under-characterized. Objectives: To describe the national burden of comorbid SUD (tobacco, alcohol, or drug use disorders) among hospitalized HF patients in the U.S. Methods:...
Article
Background: Women Veterans who use the Veterans Health Administration (VA) have high rates of substance abuse and poorer health than non-Veteran women. Less is known about the psychosocial needs of women Veterans who seek care in non-VA settings. Objectives: We provide a grounded description of factors that impact substance abuse, mental health,...
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Background: Food insecurity has been associated with worse health outcomes in the civilian population. Male veterans of the Gulf Wars have been shown to have a higher prevalence of food insecurity than similarly situated civilians. Women veterans have more risk factors for food insecurity, relative to male veterans, yet little is known about the p...
Article
Background: Primary care teams can facilitate access to care by helping patients to determine whether and when care is needed, and coordinating care across multiple clinicians and settings. Appointment availability metrics may or may not capture these contributions, but patients' own ratings of their access to care provide an important alternative...
Article
Background: Women veterans are at increased risk for cardiovascular disease (CVD), but little is known about comorbidities and healthcare preferences associated with CVD risk in this population. Methods: We describe the prevalence of CVD-relevant health behaviors, mental health symptoms, and health care use characteristics and preferences among...
Article
Introduction: Documented gaps in health professionals' training in women's health are a special concern for continuing education (CE). In the Veterans Affairs (VA) health care system, women veterans are a numerical minority, preferably assigned to designated women's health primary care providers (DWHPs). DWHPs need to maintain their knowledge and...
Article
Patient-centered medical homes are widely promoted as a primary care delivery model that achieves better patient outcomes. It is unknown if their benefits extend equally to all racial/ethnic groups. In 2010 the Veterans Health Administration, part of the Department of Veterans Affairs (VA), began implementing patient-centered medical homes nationwi...
Article
Background Little is known about contraceptive care for the growing population of women veterans who receive care in the Veterans Administration (VA) healthcare system. Objective To determine rates of contraceptive use, unmet need for prescription contraception, and unintended pregnancy among reproductive-aged women veterans. Design and Participa...
Article
Objective/background: To identify caregiving-related sleep problems and their relationship to mental health and daytime function in female Veterans. Participants: Female Veterans (N = 1,477) from cross-sectional, nationwide, postal survey data. Methods: The survey respondent characteristics included demographics, comorbidity, physical activity...
Article
Purpose: Female veterans are at high risk for sleep problems, and there is a need to provide effective treatment for this population who experience insomnia. This study's primary goal was to compare the acceptability of medication versus nonmedication treatments for insomnia among female veterans. In addition, we examined the role of patient age,...
Article
Purpose: Disparities in health and health care access between rural and urban Americans are well documented. There is evidence that these disparities are mirrored within the US veteran population. However, there are few studies assessing this issue among women veterans (WVs). Methods: Using the 2008-2009 National Survey of Women Veterans, a popu...
Article
Background: Women are a rapidly growing segment of patients who seek care in the Veterans Affairs (VA) Healthcare System, yet many questions regarding their health care experiences and outcomes remain unanswered. Racial and ethnic disparities have been well-documented in the general population and among veterans; however, prior disparities researc...
Article
Purpose of the Study: To examine whether Veteran status influences (a) women’s survival to age 80 years without disease and disability and (b) indicators of successful, effective, and optimal aging at ages 80 years and older. Design and Methods: The Women’s Health Initiative (WHI) enrolled 161,808 postmenopausal women aged 50–79 years from 1993 to...