INTRODUCTION
Korea is one of the fastest-aging countries worldwide. Korea has become an aging society, with 7% of the population reaching ≥65 years in 2000.1) However, the aging speed of the Korean society is much faster than expected. It became an aged society in 2017, with 14% of the population aged ≥65 years.2) Although experts in Korea originally expected it to become an aged society in 2018 or 2020, Korea made this transition from an aging society in only 17 years, which is more rapid than that of any other country.
Most older Korean adults have chronic diseases. Nearly 90% of Korean older adults reported one or more chronic diseases, with approximately half of them having three or more chronic diseases.3) The mean number of diagnosed chronic diseases was 2.6. An increase in the number of older adults indicates an increase in the chronic disease burden in Korean society. The national medical expenses for older adults are increasing as the population increases. The expense was 32.4% of the total expense in 2010, which was already one-third of the total expense for 10% of the population and reached 43.1% in 2019.4)
Many older adults also have specific age-related health problems; thus, they experience both geriatric problems and chronic diseases. Many developed countries have official geriatric specialties or subspecialties to address geriatric problems.5,6) Geriatric training is offered as official residency or fellowship training in each country.
However, South Korea has no official geriatric specialties or sub-specialties. Most geriatric health problems are addressed by specialists, and each specialist usually deals with only a subset of geriatric problems in older adults. Therefore, there is a high chance of unmet needs regarding geriatric health problems among older Korean adults. To our knowledge, data on the unmet needs related to geriatric health problems in older Korean adults are scarce. Therefore, the Korean Geriatrics Society performed a field survey on the health-related unmet needs of Korean older adults using a representative sample.
MATERIALS AND METHODS
Study Participants
This descriptive study aimed to elucidate the perceived necessity for geriatricians among older Korean adults. The study participants were men and women aged ≥70 years. The nationwide proportional quota sampling method was used for representativeness, except on Jeju Island. Computer-assisted personal interviews were conducted, and a pre-constructed questionnaire was administered to participants by Gallup Korea. In total, 411 men and women responded to the survey.
Measurement
Questionnaire development
We constructed a questionnaire for the field survey of 21 items. First, a literature review was conducted to collect the items. The review included a total of 74 items. Most of the items were collected from nationwide surveys or validated questionnaires. Additionally, we created two items that asked about the geriatric problems of the participants and the necessity for geriatric physicians to resolve the participants’ health problems. Seventy-six items were included in the next step.
We selected items for inclusion in the final questionnaire through expert consensus using the Delphi technique. Thirty-nine geriatric experts participated as panelists in the process. We asked the panelists score each item regarding how much they agreed with the inclusion of the item in the final questionnaires. The iteration was stopped in the second round because most of the panelists reached an agreement on the selected items. Finally, we selected 21 items for inclusion in the final questionnaire.
Items included in the questionnaire and field survey
The final questionnaire included the following items: (1) demographic variables (age, sex, education, marital status, previous occupation, and residential region); (2) subjective health; (3) chronic diseases; (4) need for assistance in daily living; (5) having a regular physician; (6) experiences in regular physician encounters; (7) medications; (8) physician understanding of the geriatric problems; (9) necessity for geriatric physicians to resolve their health problems; and (10) physical function according to the K-FRAIL scale.7) The language and order of items were trimmed to enhance participant understanding. Polypharmacy was defined as the taking of ≥4 medications. The participants were asked to answer the following question: “Do you need help from family or others to perform your daily activities?” Individuals who answered “yes” to this question were defined as having dependencies in activities of daily living (ADL).
Field survey
A field survey was conducted by a trained interviewer in Gallup, Korea, through computer-assisted personal interviews between November 17 and December 7, 2021. The questionnaire was administered to preselected respondents by an interviewer. After completing the interviews, the responses to the questionnaire were reviewed by the interviewer and the respondents were asked not to skip any items. Confidentiality was assured.
The study protocol was approved by the Institutional Review Board of the Asan Medical Center (IRB No. 2022-0262). Written informed consents were obtained from participants before interview.
Also, this study complied the ethical guidelines for authorship and publishing in the Annals of Geriatric Medicine and Research.8)
Statistical Analysis
All subsequent analyses were performed according to sex. Continuous variables were analyzed using the general linear model and are presented as mean±standard deviation. Categorical variables are presented as unweighted numbers (weighted percentages) and were analyzed using chi-square tests. The statistical analyses were performed using Stata version 15.1 (StataCorp LLC, College Station, TX, USA). Statistical significance was set at p<0.05.
RESULTS
Baseline Participant Characteristics
Table 1 presents the general characteristics of the study participants. The study included a total of 411 men and women. The mean age was 77.6±5.9 years. Two hundred forty-four (59.4%) participants were women. In addition, 184 (44.8%) participants lived in the Seoul metropolitan area. Most participants (83.7%) reported <9 years of education. Most men (82.9%) were married, whereas half the women (53.1%) were widowed.
The mean number of medications was 2.13±1.17, and 74 of participants (18.0%) took ≥4 medications. Sixty-seven participants reported needing assistance in their daily living; half of the participants (50.1%) reported that they could not climb 10 steps and one-third (34.8%) reported that they could not walk 300 m. Most participants (86.4%) reported feeling fatigued, and 44 (10.7%) had lost 5% or more of their body weight in the previous year.
Most participants (88.6%) had one or more chronic diseases, and the mean number of chronic diseases was 1.97±1.33. Hypertension was the most common chronic disease (65.9%), followed by diabetes mellitus, osteoarthritis, dyslipidemia, and musculoskeletal pain.
Prevalence and Satisfaction of the Participants with their Regular Physicians
A total of 83.1% (n=359) of participants reported having a regular physician. Moreover, 86.8% (n=375) of the participants answered that they did not have difficulty meeting their physicians when needed. A total of 82.4% (n=356) of the participants responded that they could comfortably ask questions to their physicians.
Table 2 shows that the participants’ satisfaction with their physician required sufficient time for consultation based on the characteristics of the participants. Of these, 67.2% (n=275) felt that their physicians spent sufficient time seeing them during consultations. Half of the highly educated participants felt that their physicians spent enough time seeing them during their consultations. Approximately 60.7% of the participants bereaved their partners and felt that their physicians spent enough time consulting with them.
Physicians’ Understanding of Geriatric Problems
Table 3 shows the participants’ responses regarding physician understanding of geriatric problems. In this study, 24.3% (n=106) of participants reported that their physician understood geriatric problems well, including 16.5% (n=18) of women aged ≥80 years. Only 13.8% of men taking four or more medications felt that their physician understood their geriatric problems well. Approximately 37.3% of participants educated 9–12 years reported that their physician understood their geriatric problems well.
Necessity for Geriatric Physicians
Table 4 shows the need for geriatric physicians to resolve the participants’ health problems. Of the participants, 76.2% (n=313) answered that a geriatrician would be necessary to manage geriatric problems. In particular, 84.4% of participants who needed assistance in their daily living (84.6% of men and 84.2% of women) responded that they would need a geriatrician for geriatric problems. All participants with >12 years of education thought that a geriatrician was needed for geriatric problems.
DISCUSSION
Of the participants, 85% reported having one or more chronic diseases and 90% had one or two regular physicians. Most of the participants could see a physician when needed and felt comfortable asking questions about their health to their physicians. However, one-third of the participants said that their physicians did not spend sufficient time addressing their problems and only 25% felt that their physicians understood geriatric problems well. Three-quarters said that geriatricians need to fulfill their unmet healthcare needs. They claimed that help from a geriatrician was needed, although most had regular physicians to consult about their health problems.
Owing to older adults’ functional decline, physical illness, and psychological needs, they have more complicated needs compared with younger adults.9) Most older adults aged >85 years have complex multimorbidity, frailty, disability, dementia, and palliative care needs.10) In addition, older adults have an increased prevalence of polypharmacy and probability of the inappropriate prescription of medication. Polypharmacy leads to an increased risk of geriatric syndrome, morbidity, and mortality in older adults.11) In addition, independence in daily life determines the quality of life of older adults.12) Older adults need geriatricians because they can provide a full range of geriatric care.13) Hence, facing aging society, physicians should recognize and care for geriatric syndrome.14) However, as shown in the results of our study, most Korean primary care physicians do not understand the complicated geriatric problems in older patients. This leads to unmet healthcare needs, which is a problem with inadequate solutions.15) These unmet healthcare needs increase disease severity, complications, and risk of mortality16) and decrease the quality of life17) of older adults in Korea.
Geriatricians are physicians certified in geriatric medicine who are specifically trained to care for aging and medically complex older adults. Owing to their characteristics, older patients must be systematically assessed using geriatric assessment tools.18) Geriatrics collaborate with primary care providers, a distinct specialty of older adult care medicine,19) or nursing home medicine.20) The position of geriatrics, organization of older adults’ care, and geriatricians’ training and contents of work vary widely between countries.13) In one study of 22 countries, geriatrics was considered a medical specialty in 11 European countries and a subspecialty in nine countries. However, geriatrics in Greece and Portugal is not considered a specialty or subspecialty.13) As mentioned earlier, Korea has no official geriatric specialty or subspecialty; thus, there is an unmet need for older adults with complicated geriatric conditions.
In some countries, geriatric subspecialty training is an advanced fellowship program after the completion of the basic residency program. The advanced courses are divided into intradepartment and interdepartment subspecialty programs.21,22) Interdepartment geriatric subspecialties are implemented in the United States and Taiwan, and the curriculum includes a fellowship course in geriatric medicine after a certain period of residency. In this type of subspecialty, candidates from various specialties such as internal medicine, family medicine, and rehabilitation medicine can apply to the same geriatrics fellowship program and receive the same certificate after program completion, regardless of their specialty in the residency program. Intradepartment geriatric subspecialties are implemented in Australia and Canada, in which the geriatric fellowship programs are run by each specialty, and candidates can apply to the subspecialty program according to their specialty of the residency program.21,22) However, geriatrics in the UK is the largest medical specialty. Postgraduate medical training programs include basic medical education for 2 years and 3–7 years for geriatric subspecialties.23) The period for specialization also varies from 3 to 6 years in different countries.13)
Although the number of older adults is increasing worldwide, geriatricians are insufficient. Approximately 30% of patients aged ≥65 years are expected to require care by a geriatrician, while each geriatrician can care for 700 older adults in the United States.24) Thus, 1,500 geriatricians per year are required over the next years to fulfill the need for certified geriatricians.25) The number of older people aged ≥80 years per geriatrician varies from 450 in Austria to 25,000 in Turkey.18) The results of this study suggested the need to double the number of geriatricians.13)
Our study had several limitations. First, the sample size was small (n=411). Therefore, further studies with larger sample sizes are required. Second, our study was based on a self-reported survey and may have had recall or measurement biases. Finally, the health status of the participants and their functional capacities, such as their ability to walk, should be considered when interpreting the results. Despite these limitations, our study identified health-related unmet needs in a representative sample of Korean older adults.
In conclusion, many Korean older adults required geriatricians to fulfill their unmet healthcare needs. Unmet healthcare needs could lead to adverse events and a lack of geriatric knowledge could decrease the quality of healthcare for older adults. Therefore, geriatricians must improve health services for older adults. Korean policymakers need to determine directions by referring to health programs for older adults.
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