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Pilot Study to Assess Gaps in Follow-Up for Suspicious PSA Tests
Steven B. Zeliadt, PhD MPH
VA Puget Sound Health Care System Seattle Division, Seattle, WA
Funding Period: June 2008 - September 2009
Timely follow up of suspicious screening tests for cancers other than prostate has been identified as an important priority in the VA. There is little information available about follow-up care for elevated PSA tests.
This study evaluated quality of care for elevated PSA results using electronic data and validated the findings with medical records abstraction. Specific study aims were:
Aim 1. Measure completeness of follow-up care among men in VISN20 with elevated PSA levels, including timeliness of follow-up and receipt of biopsy.
Aim 2. Validate database measures of follow-up care and assess non-VA care through a medical record abstraction audit.
Using the VISN20 data warehouse we identified13,591 Veterans between the ages of 40 and 74 who had an initial elevated PSA test result between the years 1998 and 2006, and examined the follow-up care they received after that elevated result. Subjects were classified as receiving complete or incomplete follow up care. Complete follow-up included receipt of biopsy, urology visit without a biopsy or repeat PSA test with a normal result (<4 ng/ml). Incomplete follow-up was defined as repeat PSA testing that remained elevated or no additional follow-up. A sample of 111 records was selected and abstracted to evaluate provider notes to determine whether patients received any additional follow-up care that was not documented in the electronic data. We compared stage at diagnosis for men who were biopsied within 2 years of the elevated test, and those who had delays of more than 2 years but were eventually diagnosed with prostate cancer over the study period, from 1998 through the end of 2008.
Within 24 months of the elevated PSA test, 33% of men underwent a biopsy, 16% were referred to urology but not biopsied, 19% had a subsequent normal PSA test, 19% had additional PSA tests that remained elevated with no subsequent referral to urology, and 14% had no follow-up. Younger age, higher PSA levels, more prior tests, urologic conditions, low body mass index, and low comorbidity scores were associated with less complete follow-up. A biopsy outside of the VA was identified in 8% of subjects in the chart audit (5 of 61) who had no biopsy recorded in the electronic database. After adjusting for covariates, men with a delayed diagnosis were more likely to have pathologically advanced-stage cancer (T2C/T3/T4) than those who were biopsied and diagnosed within 24 months of the elevated PSA test (76% vs. 61%, p<0.001).
There is considerable variation in follow-up practice for men under age 75 with elevated PSA test results within VISN20, with completeness of follow-up declining in more recent years. Clear and consistent guidelines for follow-up of elevated PSA tests is needed.
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DRA: Aging, Older Veterans' Health and Care, Health Systems
Keywords: Cancer, Prostate disease, Screening
MeSH Terms: none