Providing Quality Primary Care to Older Adults

Abstract

trend for older adults to seek care from non-primary care specialists at a higher rate than in the recent past. In 2005, 43% of ambulatory care visits by patients aged 65 and over were to primary care physicians and 57% were to non-primary care specialists. In 1980, 62% of ambulatory care visits by patients aged 65 and over were to primary care physicians and 38% were to non-primary care specialists. 2 The expanded use of subspecialists by the Medicare population is particularly striking among older adults with multiple chronic illnesses. During 1999, older adults with 5 or more chronic illnesses received medical services from a mean of 13.8 unique physicians. 3 This trend away from the traditional role of the primary care physician in the care of older adults places these patients at risk for poor continuity of care, adverse drug events, and the iatrogenic consequences of the over-utilization of diagnostic and therapeutic interventions. To improve the quality and control the costs of medical care for older adults, primary care physicians, and especially family physicians, must reassert their central role in the care of older adults. This issue of the Journal of the American Board of Family Medicine includes several articles that provide specific new findings that can help inform the care of older patients in the family physician’s office. These articles also illustrate some key principles that can lead to improved primary care for older patients. Two articles address the vexing problems of when and how to screen for prostate cancer in older men and what is the best treatment approach for localized prostate cancer. Prostate cancer is the second leading cause of cancer deaths among men in the United States. The incidence increases with age and is rare in men younger than 40. In autopsy studies in which the entire prostate is examined, incidental histologic evidence of prostate cancer is found in 80% of men older than 80. 4 Using practice-based research networks in the Northeast, Hudson and colleagues 5 studied the use of the prostate-specific antigen (PSA) screening test among middle-aged and older men. This study found that men aged 75 years and older are receiving PSA testing at a rate of 74.6%, which is comparable to the screening rates for men aged 50 to 74 years. The authors point out that this high rate of screening among older men is not consistent with evidence-based practice guidelines. Of most interest, the authors conclude that PSA screening rates were lower in offices with more effective intraoffice communication among office staff and between staff and patients. No direct evidence exists to show that early