A Survey of Obstetrician-Gynecologists Regarding their Care of Women 65 Years or Older

Background: To survey a representative group of obstetriciangynecologists (ob-gyns) regarding the frequency of care provided to women 65 years or older and the nature of health concerns in this high-need population. Methods: This descriptive survey included fellows and junior fellows of the American College of Obstetricians and Gynecologists (ACOG) in clinical practice. A survey was mailed to 1,000 ACOG members, with an overall response rate of 42.7%. The survey included questions about physician demographics and care to women 65 or older, and health needs of respondents’ patients. Responses were compared between those who did or did not provide care for women 65 or older. Results: Of the 427 responders, 86.4% reported that they cared for older women. A higher proportion of female rather than maleobgyns cared for older patients. Approximately half (54.8%) of all physicians reported adequate or comprehensive training in the overall treatment of older patients, and the majority expressed adequate or comprehensive training in counseling or treatment for issues relating to obesity, sexuality, fitness and nutrition, cardiovascular health, bone health, breast disorders, osteoporosis, and urinary conditions. Few saw only older women, and few reported adequate training for conditions involving other systems including mental disorders. Conclusion: Most of the surveyed ob-gyns are engaged in the care of women 65 years and older, especially for preventive care, disease screening and early detection, and urogenital conditions. Most felt comfortable in the context of multi-dimensional collaborative care for older women with major medical or mental health concerns.

concern.Several factors such as diversity of the population, distinguishing between normal aging and disease, and the impact of socioeconomic concerns on physical and mental health are important for developing preventive and treatment strategies.
Older women die of the same disorders that affect menheart disease, cancer, and vascular disease -but are more likely to be afflicted with other chronic conditions that can also limit their lifestyles (e.g., diabetes, hypertension, arthritis) [3].Cardiovascular disease, cancer, fractures, and infections are among the most common risk factors for older women, and are more prevalent among this population than in younger women [3][4][5][6].Many factors that change with aging can be compounded by illness and chronic medical conditions.These factors include nutritional requirements, cognitive changes, mobility, social support, socioeconomic changes, pain management, and disease vulnerability.In addition, psychiatric co-morbidities and cognitive conditions such as depression, Alzheimer's disease, and dementia emerge frequently in older age and may play important roles in the presentation and reporting of medical conditions.While family physicians, general internists, and geriatricians have been the historic point of care for older patients, obstetriciangynecologists (ob-gyns) can play important roles.This is due to their training to understand preventive care, morbidity, and mortality of women of all ages, including those well beyond their reproductive years, as well as relationships that ob-gyns build with their patients over time [7,8].This more inclusive concept may be particularly relevant with the ongoing shortage of primary care providers throughout the United States.

Introduction
The population of older Americans is expected to represent 20 percent of the total U.S. population in the next 50 years, and older women will comprise the majority of that group [1,2].Thus, health care needs of this group are and will continue to be an increasing

Survey
A survey was developed by the research department at the American College of Obstetricians and Gynecologists (ACOG).Questions were developed in consultation with ACOG fellows and junior fellows in practice, and pilot-tested on a sample of practicing ob-gyns with adjustments made before distribution.Physicians were asked questions about their age, gender, practice location, and practice characteristics, as well as whether they deliver care to patients age 65 and older.
Participants were surveyed about the frequency with which they provided a number of services to older patients.These services included evaluating acute problems, counseling about certain conditions, and recommending various treatments using Likert scale questions.Ob-gyns were also asked Likert-type questions regarding their interest in caring for older patients, whether they believe obgyns should treat such patients, and what sources of information they use in caring for older patients.Physicians were asked in an open response format about their own top health concerns for their older patients, as well as what health concerns were most important to their older patients.This survey was declared exempt by the University of New Mexico Human Research Review Committee (HRRC#13329).

Participants
We sought to obtain complete surveys from at least 350 respondents in order to ensure that the 95% confidence interval for frequency data was 5% or less.The survey was sent to 1,000 ACOG fellows and junior fellows in practice, 500 of whom were members of the collaborative ambulatory research network (CARN) and 500 were randomly chosen fellows who were not surveyed in the prior year.CARN members are ACOG fellows and junior fellows who are typically recruited through advertising or outreach through random selection from ACOG's membership rolls.Each agreed to participate in several survey studies throughout the year without receiving any compensation.CARN is representative of practicing ACOG members, and was established to improve the response rate on published ACOG research department survey studies [9,10].Previous CARN studies achieved a 40-55% response rate which, given the current combined sample, would provide the desired minimum sample size for analyses [9,10].
A total of 1,000 physicians were sent a paper mailing that included a cover letter, survey, and stamped return envelope.Those who did not respond to the paper mailing were sent up to five letter reminders containing the same information.Following the final reminder mailing, participants were sent a brief, one-page letter containing selected questions and an invitation to complete and return the previously mailed survey.

Statistical analysis
The data were analyzed using a personal computer-based software package (IBM SPSS Statistics ® 20.0,IBM Corp © , Armonk, NY).Descriptive statistics were computed for the measures used in the analyses.Pearson correlations were used on continuous variables.One-way ANOVA was used to compare group means of continuous measures.Differences on dichotomous and categorical variables were assessed using chi-square tests.Analyses were tested for statistical significance using an alpha of 0.05.

Respondent demographics
A total of 427 participants completed the survey for a response rate of 42.7%.The response rates were higher among the CARN members than non-CARN members (52.8% vs. 32.6%;χ 2 = 6.27, p < .01).There were no significant differences in sex or age between the two groups, but CARN responders were more likely to report being white than non-CARN participants (χ 2 = 8.62, p = .01).Of those who completed the survey, 367 respondents formed the study group because they characterized themselves as being either ob-gyns or gynecologists only.The remaining 60 were excluded because their practices focused solely on a younger patient population (i.e., maternal fetal medicine, pediatric and adolescent gynecology, infertility, hospitalists, family planning and reproductive health, or maternity and infant care).
Three hundred seventeen respondents (86.4%) reported caring for older patients.A higher proportion of those ob-gyns were female compared with those who did not treat older patients (58.0% vs. 40.0%;χ 2 = 5.96, p = .02).Otherwise, there were no differences in age, race, practice setting, or practice location between those who did or did not report treating older patients.An approximately equal proportion of responders described themselves as either "a specialist" or "both a specialist and a generalist," regardless whether they cared for older patients.Respondents who reported caring for older patients represented Puerto Rico, the District of Columbia, and all 50 U.S. states (excluding Maine, North Dakota, Iowa, and Nevada).Additional demographic information about respondents who treat women 65 years or older is shown in table 1.

Narrative responses
Respondents were asked narrative questions about their patients' top five health concerns.The top health concerns that participants perceived from their patients (accounting for 43.7% of the total responses) were: cancer (risk, prevention, screening, detection); cardiovascular disease; weight management; urinary concerns (incontinence, frequency); and dementia (Alzheimer's disease, memory loss).Physicians reported similar concerns for their patients, as recorded by 62.3% of all respondents.These concerns included cardiovascular disease; weight management; cancer (risk, prevention, screening, detection); bone health and osteoporosis; and primary or preventive care.Other concerns cited for both physicians and their over 65 patients were aging and social concerns, sexual functioning, diabetes, mental health (psychiatric co-morbidities), and pelvic prolapse.

Discussion
Women who are 65 years or older are forecast to be the most rapidly growing population in the United States in the next 30 years [1,2].Anticipating this shift in population, this survey was conducted to better define the current level of care provided by ob-gyns for older women given the lack of information in this area.Most respondents practicing general obstetrics and gynecology or gynecology only reported that they cared for older patients in some capacity, though older patients made up a relatively small proportion of their overall patient populations on average.The vast majority of participants also stated that they wanted to treat older patients, and that they believed that ob-gyns should treat older patients.
Most of this cohort expressed adequate training and current knowledge on sexuality, fitness and nutrition, cardiovascular health, bone health, breast health, and diabetes in older patients.Only a scant majority (54.8%) reported adequate or comprehensive training and knowledge in the overall treatment of older patients, however, indicating an important knowledge gap.Additionally, few reported adequate knowledge regarding psychosocial and cognitive decline.This is important to highlight given the prevalence of those disorders among older adults, and the impact that these conditions can have on overall wellness and lifespan [11][12][13].Results of this survey indicate a possible area of improvement in the training programs of ob-gyns who may not receive an appropriate level of education regarding mental health in an aging population.average of 15.6% (SD = 10.9%) of the respondents' patient load.Physicians reporting that more of their patients were uninsured were less likely to report treating older patients (F (1, 290) = 10.24,p < .01).Those seeing more patients with private health insurance or Medicare, were more likely to treat older patients [F (1, 290) = 4.08, p < .05 and F (1, 290) = 10.93,p < .01respectively].Physicians seeing more White patients were also more likely to report treating older patients [F (1, 290) = 11.33,p < .01],whereas those seeing a higher proportion of Hispanic/Latina patients were less likely to treat older patients (F (1, 290) = 11.6,p < .01).

Practice patterns
Only 54.8% of physicians who provide care for older patients reported adequate or comprehensive training in the overall treatment of older patients.Most of these respondents reported that their training and current knowledge were adequate or comprehensive about such issues as breast health (95.2%), bone health (88.9%), sexuality (74.1%), fitness and nutrition (65.6%), cardiovascular health (56.3%), and diabetes (53.0%).Less than 50%, however, reported adequate training and current knowledge regarding psychosocial issues and cognitive decline in older patients, corresponding with the finding that only 46.5% of respondents reported routinely evaluating patients for psychosocial issues.

Desire to treat older patients
Of those who reported treating older patients, 89.5% expressed this desire, and 92.0% of these favored that all ob-gyns provide some treatment to this population.Physicians who wanted to treat older patients reported encountering arthritis, diabetes, and obesity more frequently in their patients (χ 2 = 10.40,p < .01;χ 2 = 5.7, p = .02;and χ 2 = 5.32, p = .02respectively).They were also more likely to counsel about exercise and alcohol (χ 2 = 11.58,p < .01;and χ 2 = 5.77, p = .02respectively), but did not differ from those who reported not wanting a "Frequently seen" is defined by 40% or more of respondents who care for older women report seeing these conditions frequently or very frequently.
b "Infrequently seen "is defined by fewer than 40% of respondents who care for older women report seeing these conditions frequently or very frequently.
• as a small part of their practice.While findings in the current study indicated adequate training and screening practices for most common medical conditions, ob-gyns may feel inadequately trained in dealing with older women having several chronic health conditions including dementia and mental health disorders.Increased awareness in these areas, as well as in the importance of providing supportive care for older patients may improve ob-gyns' confidence in working with this population, as well as in improving the overall quality of care.While it is unreasonable to expect ob-gyns to become specialists in many areas of care for the elderly, by increasing screening practices and comfort in treating older women, ob-gyns will continue to be an important part of a multidisciplinary, team to care for older patients.This survey, as the first of its kind, can act as a springboard for future studies to examine the effect of the changing demographics of patient populations and what this means for the provision of comprehensive women's health care.
While this cohort reported regularly seeing in older patients such conditions as urinary incontinence and obesity, few respondents frequently saw other common conditions among older women such as Alzheimer's disease, mental disorders, and musculoskeletal disorders.This may indicate that ob-gyns are less likely to screen for these conditions, and may spend more time evaluating patients for conditions within their specialty.While very well trained in evaluating for specialty care, they may be less equipped to recognize patients who present with conditions outside of the scope of their expertise.
The current results clearly indicate that many ob-gyns are motivated to care for older patients.Furthermore, participants who believe that ob-gyns should treat older patients rated their training and current knowledge in caring for older women more highly.They were also more likely to screen for, recognize, and counsel patients regarding a variety of health conditions.It is possible that stressing the importance of care for this population increases physicians' interest in and focus on treating these particular patients, which may lead to improved care.
Physicians' reported concerns about cardiovascular disease, weight management, and cancer in older patients when asked for narrative responses.Respondents indicated the belief that these concerns were also shared by their patients.Ob-gyns in this cohort also stressed the importance of primary or preventive care in working with older patients, something that will play an increasing role in obgyn ambulatory practices for all patients.
Ob-gyns continue to be engaged in the delivery of women's health services across all ages and, over time, may begin to see an increase in older women in their practices [8].The scope of nonillness care provided to older women is affected by a variety of factors including the growing older population, strong relationships with obgyn providers, an improved ease of access to ob-gyn offices compared with family physicians or general internists, or preference toward doctors focused on women's health care [8].Thus, it is important to understand both the strengths and areas of growth for ob-gyns' provision of care to this important and growing patient population.
Certain limitations of this survey require discussion.The response rate of ACOG fellows and junior fellows in active practice was 42.7% in the current study.The subgroup from the CARN network was selected, because it was representative of ob-gyns' demographics, practice settings, and practice locations.As anticipated, their response rate was higher than the non-CARN respondents [9,10].Another limitation was response bias from self-reporting that could affect its generalizability to ob-gyns overall.The number of respondents was adequate, however, based on the overall power of our analyses requiring at least 350 participants.
This study focused on ob-gyns' treatment of patients whose levels of functioning and health could have varied from the general older population women.The survey listed many health conditions but was not specific such as the extent of any obesity, psychiatric comorbidities, or pain affliction requiring chronic treatment.Because this survey was largely exploratory in nature, results represent a snapshot of ob-gyns' perceptions regarding providing ambulatory care today rather than a comprehensive examination of all ob-gyns' practice patterns, and may miss important elements of the care provided to older women.
Future studies examining the differences in treatment of older women 65 years or older may provide insight into how care changes as a person's age progresses.Many geriatricians consider patients under 75 as being the "young old" who may be better suited for gynecologists.Geriatrics is not only about age but also function.Disease specific treatment may be less of a concern than overall functional decline and frailty, which becomes more apparent among patients in their 80s and 90s.

Conclusion
A growing proportion of the U.S. population will be women 65 years or older.We report that most ob-gyns see older women

Table 1 :
Demographics Of Respondents (Acog fellows and junior fellows in Active Practice) Who Treat Women ≥ 65 (317 Respondents).

Table 2 :
Respondent-Estimated Patient demographics (317 Respondents).patients in terms of regularity of other counseling or evaluation practices surveyed (e.g., sexuality, fitness and nutrition, health risk behaviors, etc.), immunization practices, or the frequency with which they saw patients with other conditions.Those who believed that ob-gyns should treat older patients were more likely to counsel about chemoprophylaxis for breast cancer (for high risk women) (χ 2 = 4.06, p < .05),and to evaluate for cardiovascular disease (χ 2 = 4.89, p < .05).They did not differ from those who reported that ob-gyns should not treat older patients on any questions regarding counseling or evaluation for non gynecologic conditions, frequency of encountering various medical conditions, or vaccinations provided.

Table 3 :
Reported Health Conditions of Older Women Seen By Respondents.