Despite Guidelines to the Contrary, High Rates of PSA Screening Found among Older Veterans with Limited Life Expectancy
Guidelines from the U.S. Preventive Services Task Force, American Cancer Society, and American Urologic Association all recommend against prostate-specific antigen (PSA) screening in elderly men with limited life expectancy. This prospective study sought to identify medical center characteristics associated with screening among men with limited life expectancy. Using VA data, as well as Medicare claims data, investigators examined patient and medical center characteristics for 622,262 Veterans ages 70 and older who were eligible for PSA screening at 104 VAMCs in 2003. Men were stratified into life expectancy groups ranging from favorable (age 70-79 with Charlson comorbidity score = 0) to limited (age 85+ with Charlson score = 1 or age 70+ with Charlson score = 4) and the percent of men who received PSA screening in 2003 in the VA system or under Medicare was calculated for each medical center. VA medical center characteristics hypothesized to influence PSA screening were obtained from the 1999-2000 VA Survey of Primary Care Practices, completed by VA primary care directors, in addition to publically available VA data. Center characteristics that were assessed included: academic affiliation, clinic appointment length, ratio of mid-level providers (e.g., nurse practitioners, physician assistants) to physicians, incentives to achieve performance measures (e.g., certificates, monetary), medical center size, and region. Patient characteristics that were assessed included demographics and comorbidities.
- High rates of PSA screening were found among older Veterans with life expectancy of less than 10 years, with substantial variation across VAMCs.
- Among Veterans with limited life expectancy (n=123,223), 45% received PSA screening in 2003. Across 104 VAMCs, the PSA screening rate for this population ranged from 25-79%.
- VA medical center characteristics associated with higher PSA screening rates included: no academic affiliation, a ratio of mid-level providers to physicians >3:4, and location in the South. Use of incentives and high scores on performance measures did not significantly affect screening practices.
- The percentages of men screened with limited and favorable life expectancies were highly correlated, indicating that screening is being poorly targeted.
- Data were from 2003 and may not reflect current PSA screening practices. But a recent study suggests that annual screening among men ages 75-79 remains high at 57% in 2005 and 2008.
- Rates reflect PSA screening both in the community and VA; however, sensitivity analyses were performed including only PSA tests within VA, and all associations remained the same.
- As a result of this and other studies, VHA’s National Center for Health Promotion and Disease Prevention has developed a set of goals to reduce overscreening in older adults starting in FY12.
Dr. Yano was supported by an HSR&D Research Career Development Award, and she is part of HSR&D’s Center for the Study of Healthcare Provider Behavior, Sepulveda, CA. Dr. Powell is part of HSR&D’s Center for Chronic Disease Outcomes Research, Minneapolis, MN and Dr. Walter is part of HSR&D’s Program to Improve Care for Veterans with Complex Comorbid Conditions, San Francisco.
So C, Kirby K, Mehta K, Hoffman R, Powell A, Freedland S, Sirovich B, Yano E, and Walter L. Medical Center Characteristics Associated with PSA Screening in Elderly Veterans with Limited Life Expectancy. Journal of General Internal Medicine December 17, 2011;e-pub ahead of print.