Low-Value Prostate Cancer Screenings Common in VA; Low-Value Breast, Cervical, Colorectal Screening Rare
Healthcare without benefit – or in which the potential harm outweighs the benefit – is considered low value. For example, cancer screening can become low value with increasing age, greater illness burden, or lower life expectancy. In these scenarios, short-term risks (i.e., procedural complications or testing burden) outweigh the expected benefits from detecting slow-growing cancers. VA uses a multidisciplinary patient-centered medical home (PCMH) model in more than 900 clinics, and while PCMH models have been associated with improved preventative care delivery, connections to low-value cancer screenings have not been examined. This study sought to describe the prevalence and association of multilevel factors, including key PCMH domains, with four common low-value cancer screenings (breast, cervical, colorectal, and prostate) within the VA healthcare system. Using VA data, investigators identified 5,993,010 Veterans who had at least one primary care visit in FY2017 – and who were at average risk for cancer. Factors evaluated in multivariable regression models included patient (i.e., demographics, comorbidities), clinician (i.e., demographics, physician or other advanced degree), and clinic characteristics (i.e., community or hospital-based, urban or rural).
- Low-value prostate cancer screenings were common, although low-value breast, cervical, and colorectal testing was rare. Of the nearly 6 million Veterans in the cohort, less than 3% received a low-value test for breast, cervical, or colorectal cancer; however, 39% of men screened for prostate cancer received a low-value test.
- Patient race and ethnicity, sociodemographic factors, and illness burden were significantly associated with the likelihood of receiving low-value tests among screened patients, but the direction of the association differed by cancer type.
- No single factor explained receipt of a low-value test across cancer screening cohort There was also no clear association between select domains of the PCMH model and low-value test receipt.
- While low-value cancer screenings may pose greater risk than benefit, testing outside established recommendations must be individualized, as algorithmic decisions may misclassify patients otherwise appropriate for screening. Individualized recommendations for cancer screening may help to advance care quality, particularly for patients with advanced age or poor health status.
- This study examined factors associated with low-value tests only among those screened, rather than in all eligible patients, which may make findings more difficult to interpret. Investigators did not include all cancer screening factors, such as encounter time, individual attitudes, or patient request.
This study was supported by VA’s Office of Primary Care. Drs. Schuttner and Maynard are part of HSR&D’s Center of Innovation for Veteran-Centered and Value-Drive Care, Seattle, WA.
Schuttner L, Haraldsson B, Maynard C, et al. Factors Associated with Low-Value Cancer Screenings in the Veterans Health Administration. JAMA Network Open. October 22, 2021;4(10):e2130581.