Variation in prostate-specific antigen screening in men aged 80 and older in fee-for-service Medicare

State-Level Variation In Low-Value Care For Commercially Insured And Medicare Advantage Populations

Low-value care is a major source of health care inefficiency in the US. Our analysis of 2009-19 administrative claims data from OptumLabs Data Warehouse found that low-value care and associated spending remain prevalent among commercially insured and Medicare Advantage enrollees. The aggregated prevalence of twenty-three low-value services was 1,920 per 100,000 eligible enrollees, which amounted to $3.7 billion in wasteful expenditures during the study period. State-level variation in spending was greater than variation in utilization, and much of the variation in spending was driven by differences in average procedure prices. If the average price for twenty-three low-value services among the top ten states in spending were set to the national average, their spending would decrease by 19.8 percent (from $735,000 to $590,000 per 100,000 eligible enrollees). State-level actions to improve the routine measurement and reporting of low-value care could identify sources of variation and help design state-specific policies that lead to better patient-centered outcomes, enhanced equity, and more efficient spending.

Association Between Receipt of Cancer Screening and All-Cause Mortality in Older Adults

IMPORTANCE

Guidelines recommend against routine breast and prostate cancer screenings in older adults with less than 10 years' life expectancy. One study using a claims-based prognostic index showed that receipt of cancer screening itself was associated with lower mortality, suggesting that the index may misclassify individuals when used to inform cancer screening, but this finding was attributed to residual confounding because the index did not account for functional status.

OBJECTIVE

To examine whether cancer screening remains significantly associated with all-cause mortality in older adults after accounting for both comorbidities and functional status.

DESIGN, SETTING, AND PARTICIPANTS

This cohort study included individuals older than 65 years who were eligible for breast or prostate cancer screening and who participated in the 2004 Health and Retirement Study. Data were linked to Medicare claims from 2001 to 2015. Data analysis was conducted from January to November 2020.

MAIN OUTCOMES AND MEASURES

A Cox model was used to estimate the association between all-cause mortality over 10 years and receipt of screening mammogram or prostate-specific antigen (PSA) test, adjusting for variables in a prognostic index that included age, sex, comorbidities, and functional status. Potential confounders (ie, education, income, marital status, geographic region, cognition, self-reported health, self-care, and self-perceived mortality risk) of the association between cancer screening and mortality were also tested.

RESULTS

The breast cancer screening cohort included 3257 women (mean [SD] age, 77.8 [7.5] years); the prostate cancer screening cohort included 2085 men (mean [SD] age, 76.1 [6.8] years). Receipt of screening mammogram was associated with lower hazard of all-cause mortality after accounting for all index variables (adjusted hazard ratio [aHR], 0.67; 95% CI, 0.60-0.74). A weaker, but still statistically significant, association was found for screening PSA (aHR 0.88; 95% CI, 0.78-0.99). None of the potential confounders attenuated the association between screening and mortality except for cognition, which attenuated the aHR for mammogram from 0.67 (95% CI, 0.60-0.74) to 0.73 (95% CI, 0.64-0.82) and the aHR for PSA from 0.88 (95% CI, 0.78-0.99) to 0.92 (95% CI, 0.80-1.05), making PSA screening no longer statistically significant.

CONCLUSIONS AND RELEVANCE

In this study, cognition attenuated the observed association between cancer screening and mortality among older adults. These findings suggest that existing mortality prediction algorithms may be missing important variables that are associated with receipt of cancer screening and long-term mortality. Relying solely on algorithms to determine cancer screening may misclassify individuals as having limited life expectancy and stop screening prematurely. Screening decisions need to be individualized and not solely dependent on life expectancy prediction.

Prostate-specific antigen testing among young men: an opportunity to improve value

Introduction

Prostate cancer screening using prostate‐specific antigen (PSA) testing remains widespread. The prevalence of PSA testing in young men is unknown and may be an appropriate target for improving health care by decreasing low‐value testing in this age group. The purpose of this study was to determine PSA testing rates in men younger than current guidelines support.

Materials and Methods

Health Informational National Trends Surveys (HINTS) from 2011 to 2014 and 2017 were analyzed to establish the prevalence of PSA testing in young men and to evaluate the differences in testing rates based on race.

Results

The combined survey data included 5178 men, with 2393 reporting previous PSA screening. Of men ages 18–39, 7% recalled receipt of PSA testing. Twenty‐two percent of men between the ages of 40 and 44 had been tested. Among men under age 40, PSA testing was more common among black men (14%) compared to white men (7%), Hispanics (6%), and men of Asian descent (8%). Logistic regression modeling demonstrates that black men under the age of 40 were more likely to undergo PSA testing than other racial or ethnic groups (odds ratio 2.14; 95% CI 1.17, 3.93).

Conclusions

Current guidelines do not recommend routine PSA testing in average‐risk men under the age of 40. This study found that a significant number of young men are exposed to testing, with the greatest risk among black men. This suggests that there is an opportunity to improve the value of PSA testing by decreasing testing in young men.

Temporal trends and regional disparities in cancer screening utilization: an observational Swiss claims-based study

Background

We examined colorectal, breast, and prostate cancer screening utilization in eligible populations within three data cross-sections, and identified factors potentially modifying cancer screening utilization in Swiss adults.

Methods

The study is based on health insurance claims data of the Helsana Group. The Helsana Group is one of the largest health insurers in Switzerland, insuring approximately 15% of the entire Swiss population across all regions and age groups. We assessed proportions of the eligible populations receiving colonoscopy/fecal occult blood testing (FOBT), mammography, or prostate-specific antigen (PSA) testing in the years 2014, 2016, and 2018, and calculated average marginal effects of individual, temporal, regional, insurance-, supply-, and system-related variables on testing utilization using logistic regression.

Results

Overall, 8.3% of the eligible population received colonoscopy/FOBT in 2014, 8.9% in 2016, and 9.2% in 2018. In these years, 20.9, 21.2, and 20.4% of the eligible female population received mammography, and 30.5, 31.1, and 31.8% of the eligible male population had PSA testing. Adjusted testing utilization varied little between 2014 and 2018; there was an increasing trend of 0.8% (0.6–1.0%) for colonoscopy/FOBT and of 0.5% (0.2–0.8%) for PSA testing, while mammography use decreased by 1.5% (1.2–1.7%). Generally, testing utilization was higher in French-speaking and Italian-speaking compared to German-speaking region for all screening types. Cantonal programs for breast cancer screening were associated with an increase of 7.1% in mammography utilization. In contrast, a high density of relevant specialist physicians showed null or even negative associations with screening utilization.

Conclusions

Variation in cancer screening utilization was modest over time, but considerable between regions. Regional variation was highest for mammography use where recommendations are debated most controversially, and the implementation of programs differed the most.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-020-10079-8.

A Retrospective Observational Analysis of Overall Survival with Sipuleucel-T in Medicare Beneficiaries Treated for Advanced Prostate Cancer

INTRODUCTION

Since sipuleucel-T approval in 2010, the treatment landscape for metastatic castration-resistant prostate cancer (mCRPC) now includes the androgen-receptor signaling pathway inhibitors (ASPIs) abiraterone acetate or enzalutamide. In 2013 and 2014, these oral agents were approved for use in men with metastatic prostate cancer who had minimal to no symptoms. We compared overall survival (OS) in men who received their first mCRPC treatment using the Medicare Fee-for-Service 100% administrative claims research dataset with patient-level linkage to the National Death Index.

METHODS

This retrospective cohort analysis (January 2013 to December 2017) included men who were chemo-naïve at treatment start in 2014 and who had continuous Medicare Parts A, B, and D eligibility during the 3-year observation period. We compared: first-line sipuleucel-T vs. first-line ASPIs and any-line sipuleucel-T vs. any-line ASPIs (without sipuleucel-T). We used a multivariable regression model to help control for potentially confounding factors while assessing survival outcomes.

RESULTS

The model included 6044 eligible men (average age 75-78 years) with similar disease severity; > 80% were white. Median OS, presented as sipuleucel-T vs. ASPI, was 35.2 vs. 20.7 months (n, 906 vs. 5092; any-line cohort) and 34.9 vs. 21.0 months (n, 647 vs. 4810; first-line cohort). Model outcomes indicated sipuleucel-T was associated with significantly prolonged OS compared with ASPIs: adjusted hazard ratio, 0.59 (95% CI 0.527-0.651) and 0.56 (0.494-0.627) for the any-line and first-line cohorts, respectively.

CONCLUSION

This analysis suggests use of sipuleucel-T at any time was associated with improved OS compared with ASPI use alone. Of note, these analyses are intended as descriptive rather than definitive as this dataset contains limited data on key clinical factors. While selection bias is a risk in secondary claims data, this research provides important insight into real-world treatment outcomes.

Characteristics of Physicians Participating in Medicare's Oncology Care Model Bundled Payment Program

PURPOSE

The Oncology Care Model (OCM) is Medicare's first bundled payment program for patients with cancer. We examined baseline characteristics of OCM physician participants and markets with high OCM physician participation to inform generalizability and complement the ongoing practice-level evaluation of the OCM.

METHODS

In this cross-sectional study, we identified characteristics of US medical oncologists practicing in 2016, using a national telephone-verified physician database. We linked these data with Dartmouth Atlas and Medicare claims data from 2011 through 2016 to identify characteristics of markets with high OCM participation. We used logistic regression to examine relationships between market characteristics and OCM participation.

RESULTS

Of 10,428 US medical oncologists, 2,605 (24.9%) were listed in an OCM practice. There were no differences in sex or medical training between OCM participants and nonparticipants, although OCM participants were slightly younger. OCM participants practiced in larger (median daily patient volume, 80 v 55 patients) and urban practices (95.2% v 90.7%) and were less likely to be part of a health system (41.0% v 60.4%) or solo practice (45.5% v 67.4%; all P < .001). Participation was higher in southern and mid-Atlantic markets. Markets with high OCM physician participation had higher specialist density, hospital care intensity, and acute care use at the end of life (all P < .001). Market-level penetration of Accountable Care Organizations (adjusted odds ratio, 4.65; 95% CI 3.31 to 6.56; P < .001) and Medicare Advantage (adjusted odds ratio 2.82; 95% CI, 1.97 to 4.06; P < .001) were associated with higher OCM participation.

CONCLUSION

In the first description of oncologists participating in the OCM, we found differences in practice demographics, care intensity, and exposure to nontraditional payment models between OCM-participating and nonparticipating physicians. Such provider-level differences may not be captured in Medicare's practice-level analysis.

Exnovation of Low Value Care: A Decade of Prostate-Specific Antigen Screening Practices

OBJECTIVES

To examine prostate-specific antigen (PSA) screening practice change in subgroups of men defined in guidelines and in various regions and to identify factors associated with change in screening practices.

DESIGN

Observational study using serial cross-sections, 2003 to 2013.

SETTING

National fee-for-service Medicare.

PARTICIPANTS

Men aged 68 and older eligible for prostate cancer screening.

MEASUREMENTS

National PSA screening practices in men aged 68 and older from 2003 to 2013 and change in regional screening rates in men aged 75 and older.

RESULTS

The PSA screening rate in men aged 68 and older was 17.2% in 2003, 22.3% in 2008, and 18.6% in 2013 (p < .001 for all differences); rates ended slightly lower than rates in 2003 only in men 80 and older. Racial disparities in screening became less pronounced over this period. In men aged 75 and older, change in regional screening rates varied widely, with absolute rates growing by 15 per 100 enrollees in some areas and declining by the same amount in others. Areas with high social capital, a measure associated with diffusion of new ideas, were more likely to decline; malpractice intensity and managed care penetration had no effect.

CONCLUSION

Studying Medicare enrollees over time, we found little reduction in PSA screening and even increases according to race and in some regions. The heterogeneous changes across regions suggest that consistent reduction in the use of low-value care may require change strategies that go beyond evidence and guidelines to include monitoring and feedback on performance. J Am Geriatr Soc 67:29-36, 2019.

Are there regional tendencies toward controversial screening practices? A study of prostate and breast cancer screening in a Medicare population

INTRODUCTION

Prostate and breast cancer screening in older patients continue to be controversial. Balancing the desire for early detection with avoidance of over-diagnosis has led to competing and contradictory guidelines for both practices. Despite similarities, it is not known how these screening practices are related at the regional level. In this study, we examined how screening PSA and mammography are related within healthcare regions, and, to better understand what may be driving these practices, whether they are associated with local intensity of care.

METHODS

We performed a retrospective cross-sectional study of fee-for-service Medicare beneficiaries in 2012. For each of 306 hospital referral regions (HRRs), we calculated rates of PSA screening for men aged ≥68 years, as well as rates of screening mammography for women aged ≥75 years, adjusted for age and race. Additionally, we determined regional rates of "healthcare intensity", including spending on tests and procedures, and intensity of end-of-life care. Pearson correlations of adjusted rates were calculated within HRRs.

RESULTS

The mean adjusted rate of PSA screening was 22%. The mean age of screened and unscreened patients was 75.0 and 77.4 years, respectively (p<0.0001). The mean adjusted rate of screening mammography was 23%; mean ages of screened and non-screened women were 79.95 and 83.67, respectively (p<0.0001). HRR-level PSA screening rates were independent of screening mammography rates (r=0.06, p=0.31). PSA screening rates were associated with spending on testing and procedures (r=0.42, p<0.0001) and various measures of intensity of EOL care (e.g. r=0.40, p<0.0001 for mechanical ventilator use). Screening mammography had low correlation with both health care spending and EOL care intensity measures (all r-values <0.3).

CONCLUSIONS

Regional rates of PSA screening rates were independent of screening mammography, thus these practices appear to be driven by different factors. Unlike mammography, PSA screening was associated with local enthusiasm for testing and treatment. Efforts to reduce over-testing should contemplate these practices differently, and future research should examine the factors motivating these screening practices.

Knowledge, attitudes, and practices towards prostate cancer screening amongst men living in the southern Italian peninsula: the Prevention and Research in Oncology (PRO) non-profit Foundation experience

PURPOSE

We aimed to explore the knowledge, attitudes, and practices towards prostate cancer (PCa) risk factors and prevention amongst men living in the southern Italian peninsula.

METHODS

We retrospectively reviewed data collected during free preventive visits carried out by the Prevention and Research in Oncology (PRO) non-profit Foundation between July 2013 and July 2016. The following data were collected: demographic and clinical features, knowledge about PCa prevention and sources of knowledge, knowledge about PCa risk factors, previous prostate-specific antigen (PSA) test, previous digital rectal examination (DRE), previous prostate ultrasound, and general attitudes towards DRE.

RESULTS

The study population consisted of 2144 Caucasian men living in four regions in the south of Italy (Campania, Calabria, Molise, Puglia). Median age was 59 years. One thousand six hundred and ninety-nine (79.2%) subjects reported knowing the existence of PCa prevention programs. Most of them received information from the media while only 17.1% declared that the information on PCa prevention that they received was from their family physicians. One thousand two hundred seventy-five (59.5%) subjects declared knowing of the existence of PCa risk factors and 41.3% was aware of the existence of both genetic and exogenous factors. The percentage of subjects who reported having had at least one PSA test in their life was 77.8 and 55.4% reported having had a DRE.

CONCLUSIONS

Knowledge about PCa screening amongst male subjects living in southern peninsular Italy is quite high. Knowledge of PCa risk factors is suboptimal and the practice of DRE is underutilized.

What is the best way not to treat prostate cancer?

INTRODUCTION

Selective treatment approaches for prostate cancer (PCa) are warranted given the highly varied nature of the disease and the consequences associated with definitive therapy.

MATERIALS AND METHODS

We present a stepwise overview of strategies optimized to not treat PCa, ranging from improved screening practices that seek to maximize the yield at initial diagnosis, as well as refinements to clinical risk prediction and the performance of active surveillance.

RESULTS

Improved adherence to screening guidelines offering simplistic, rational practice recommendations are poised to improve the performance of early detection strategies. In addition, measures to improve the quality of PCa screening would include greater integration of novel markers with higher specificity for clinically significant disease, in an effort to stem the tide of over-diagnosis and consequential overtreatment of low-grade tumors. For men diagnosed with PCa, the use of validated, multi-variable risk stratification stands to offer greater certainty in initial management choices: consideration of active surveillance for those with low-risk status, and definitive therapy for men with intermediate and high-risk features. We review the efficacy and nature of active surveillance protocols, and offer a context for refinements that may be anticipated with future study.

CONCLUSIONS

The question of how best to not treat prostate cancer is often more complex than policies of universal treatment, yet is integral to minimize morbidity of over-treatment in patients with low-risk tumors. An array of refined risk stratification instruments, biomarkers, and genomic assays seek to improve the confidence both prior to, and following diagnosis.

Why Do Health Economists Promote Technology Adoption Rather Than the Search for Efficiency? A Proposal for a Change in Our Approach to Economic Evaluation in Health Care

At a time of intense pressure on health care budgets, the technology management challenge is for disinvestment in low-value technologies and reinvestment in higher value alternatives. The aim of this article is to explore ways in which health economists might begin to redress the observed imbalance between the evaluation of new and existing in-use technologies. The argument is not against evaluating new technologies but in favor of the “search for efficiency,” where the ultimate objective is to identify reallocations that improve population health in the face of resource scarcity. We explore why in-use technologies may be of low value and consider how economic evaluation analysts might embrace a broader efficiency lens, first through “technology management” (a process of analysis and evidence-informed decision making throughout a technology’s life cycle) and progressing through “pathway management” (the search for efficiency gains across entire clinical care pathways). A number of model-based examples are used to illustrate the approaches.

Real-world comparative risks of herpes virus infections in tofacitinib and biologic-treated patients with rheumatoid arthritis

OBJECTIVE

To evaluate the risks of herpes zoster (HZ) and herpes simplex virus (HSV) infection associated with tofacitinib compared with biologic agents among patients with rheumatoid arthritis (RA).

METHODS

Using health plan data from 2010 to 2014, patients with RA initiating tofacitinib or biologics with no history of HZ or HSV were identified, as were incident cases of HZ or HSV. Crude incidence rates were calculated by drug exposure. Cox proportional hazards models evaluated the adjusted association between tofacitinib and HZ, and a composite outcome of HZ or HSV.

RESULTS

A total of 2526 patients initiating tofacitinib were compared with initiations of other biologics: anti-tumour necrosis factor (TNF) (n=42 850), abatacept (n=12 305), rituximab (n=5078) and tocilizumab (n=6967). Patients receiving tofacitinib were somewhat younger (mean age 55 years) versus those on other biologics, and somewhat less likely to use concomitant methotrexate (MTX) (39% vs 43%-56%, depending on drug). Crude incidence of HZ associated with tofacitinib was 3.87/100 patient-years (py). After multivariable adjustment, HZ risk was significantly elevated, HR 2.01 (95% CI 1.40 to 2.88) compared with abatacept. Rates and adjusted HRs for all other RA biologics were comparable with each other and abatacept. Older age, female sex, prednisone >7.5 mg/day, prior outpatient infection and greater number of hospitalisations were also associated with increased HZ risk. Incidence rates for the combined outcome were greatest for tofacitinib (7.61/100 py) and also significantly elevated after adjustment (HR=1.40, 95% CI 1.09 to 1.81).

CONCLUSIONS

The rate of zoster associated with tofacitinib was approximately double that observed in patients using biologics.

Downstream tests, treatments, and annual direct payments in older men cared for by primary care providers with high or low prostate-specific antigen screening rates using 100 percent Texas U.S. Medicare public insurance claims data: a retrospective cohort study

BACKGROUND

All authorities recommend against prostate specific antigen (PSA) screening in men 75 years and older. However, some primary care physicians (PCPs) continue to have high rates of PSA, with large variation in testing. We assessed the tests, treatments, and payments for prostate cancer care in men aged 75 or older who have PCPs with high or low PSA testing rates.

METHODS

We performed a retrospective cohort study using the 2010 Medicare beneficiaries aged 75 or older in Texas, United States who had no prostate cancer in 2007-2009 and had an identifiable PCP. We first identified high vs. low PSA testing PCPs, and then grouped older men in the two PCP groups. We determined health care visits to any provider and to urologists in office and outpatient settings. We estimated the direct medical payments for prostate cancer care for diagnostics, treatments and visits to providers in 2010-2011 using the generalized gamma model with log link function.

RESULTS

In multilevel, multivariable analyses, 25.4% (n = 550) of PCPs had PSA testing rates in men aged 75 or older that were significantly higher than the mean rate of all 2,169 Texas PCPs; 29.4% (n = 638) had rates that were significantly lower. In all, 22,853 vs. 23,929 older men were cared for by PCPs with high vs. low testing rates. Older men cared for by high PSA rate PCPs were more likely to receive a PSA test (OR 3.64, 95% CI 3.48-3.80), a biopsy (OR 1.16, 95% CI 1.02-1.31), an ultrasound (OR 1.19, 95% CI 1.07-1.32) or any radiation treatment (OR 1.31, 95% CI 1.03-1.66) than men cared for by low PSA rate PCPs. Men with high PSA rate PCPs were 1.21 (95% CI 1.05-1.39) times more likely to have such outpatient visits. The average annual adjusted Medicare payments for prostate cancer care was $25.60 higher for patients cared for by PCPs with high PSA test rates.

CONCLUSIONS

Older men seeing PCPs with high rates of PSA testing undergo more testing and treatments for prostate cancer, with higher Medicare insurance payments. Future studies are needed to delineate whether men seeing PCPs with low testing rates likely received PSA tests from other providers.

U.S. Internal Medicine Residents' Knowledge and Practice of High-Value Care: A National Survey

PURPOSE

To determine U.S. internal medicine (IM) residents' knowledge of, attitudes toward, and self-reported practice of high-value care (HVC), or care that balances the benefits, harms, and costs of tests and treatments.

METHOD

The authors conducted a cross-sectional survey of U.S. IM residents who took the Internal Medicine In-Training Examination in October 2012. They used multivariable mixed-effects models to examine the relationships between self-reported knowledge and practice of HVC and both exposure to HVC teaching and the care intensity of the training hospital (based on a composite age-sex-race-illness standardized measure of hospital days and inpatient physician visits by Medicare recipients).

RESULTS

Of 21,617 residents who received the survey, 18,102 (83.7%) completed it. Self-reported HVC practices varied: 4,187 of 17,633 respondents (23.7%) agreed that they "share estimated costs of tests and treatments with patients"; 15,549 of 17,626 (88.2%) agreed that they "incorporate patients' values and concerns into clinical decisions." Discussions about balancing the benefits, harms, and costs of treatments with faculty during patient care at least a few times a week were reported by 7,103 of 17,704 respondents (40.1%) and were associated with all self-reported HVC practices. The training hospital's care intensity was inversely associated with self-reported incorporation of costs and patient values into clinical decisions but not with other self-reported behaviors.

CONCLUSIONS

U.S. IM residents reported varying HVC knowledge and practice. Faculty discussions of HVC during patient care correlated with such knowledge and practice and may represent an opportunity to improve residents' competency in providing value-based care.

Regional-Level Correlations in Inappropriate Imaging Rates for Prostate and Breast Cancers: Potential Implications for the Choosing Wisely Campaign

IMPORTANCE

The association between regional norms of clinical practice and appropriateness of care is incompletely understood. Understanding regional patterns of care across diseases might optimize implementation of programs like Choosing Wisely, an ongoing campaign to decrease wasteful medical expenditures.

OBJECTIVE

To determine whether regional rates of inappropriate prostate and breast cancer imaging were associated.

DESIGN, SETTING, AND PARTICIPANTS

Retrospective cohort study using the the Surveillance, Epidemiology, and End Results-Medicare linked database. We identified patients diagnosed from 2004 to 2007 with low-risk prostate (clinical stage T1c/T2a; Gleason score, ≤6; and prostate-specific antigen level, <10 ng/mL) or breast cancer (in situ, stage I, or stage II disease), based on Choosing Wisely definitions.

MAIN OUTCOMES AND MEASURES

In a hospital referral region (HRR)-level analysis, our dependent variable was HRR-level imaging rate among patients with low-risk prostate cancer. Our independent variable was HRR-level imaging rate among patients with low-risk breast cancer. In a subsequent patient-level analysis we used multivariable logistic regression to model prostate cancer imaging as a function of regional breast cancer imaging and vice versa.

RESULTS

We identified 9219 men with prostate cancer and 30,398 women with breast cancer residing in 84 HRRs. We found high rates of inappropriate imaging for both prostate cancer (44.4%) and breast cancer (41.8%). In the first, second, third, and fourth quartiles of breast cancer imaging, inappropriate prostate cancer imaging was 34.2%, 44.6%, 41.1%, and 56.4%, respectively. In the first, second, third, and fourth quartiles of prostate cancer imaging, inappropriate breast cancer imaging was 38.1%, 38.4%, 43.8%, and 45.7%, respectively. At the HRR level, inappropriate prostate cancer imaging rates were associated with inappropriate breast cancer imaging rates (ρ = 0.35; P < .01). At the patient level, a man with low-risk prostate cancer had odds ratios (95% CIs) of 1.72 (1.12-2.65), 1.19 (0.78-1.81), or 1.76 (1.15-2.70) for undergoing inappropriate prostate imaging if he lived in an HRR in the fourth, third, or second quartiles, respectively, of inappropriate breast cancer imaging, compared with the lowest quartile.

CONCLUSIONS AND RELEVANCE

At a regional level, there is an association between inappropriate prostate and breast cancer imaging rates. This finding suggests the existence of a regional-level propensity for inappropriate imaging utilization, which may be considered by policymakers seeking to improve quality of care and reduce health care spending in high-utilization areas.

Is anyone listening? Variation in PSA screening among providers for men 75+ before and after United States Preventive Services Task Force recommendations against it: a retrospective cohort study

Background

In 2008, the United States Preventive Services Task Force recommended against prostate specific antigen (PSA) testing for cancer screening in men age 75+.

Purpose

To assess PSA screening by primary care physicians (PCPs) before and after recommendations.

Methods

In 2013, this retrospective cohort study analyzed PCPs in Texas with 20+ male patients aged 75+ in both 2007 and 2010, with Parts A and B Medicare. The main outcome was percent of PCP’s male patients 75+ who received PSA testing ordered by the PCP in 2007 and 2010, with no recent symptoms suggestive of prostate cancer.

Results

In both 2007 and 2010, 1,083 PCPs cared for at least 20 men aged 75 or older. The rate of PSA screening ordered by PCPs was 33.2% in 2007 and 30.6% in 2010. In multilevel analyses controlling for patient characteristics, the variation in PSA screening attributable to the PCP (intraclass correlation coefficient) increased from 23% in 2007 to 26% in 2010, p<0.001. Men with PCPs older than age 60 had 9% lower odds (95% CI, 1–17%) in 2010 compared to 2007 of receiving a PSA test, vs. a 4% increase (95% CI, 4% decrease to 12% increase) in men with PCPs aged 50 or younger. Patients with Board Certified PCPs had a 12% lower odds (95% CI, 8% to 16%) from 2007 to 2010, vs. 2% increase (95% CI 11% decrease to 18% increase) in men with PCPs without board certification.

Conclusions

The USPSTF recommendation did not increase consensus among PCPs regarding PSA screening of older men.

Antianginal Therapy Before Percutaneous Coronary Intervention

Background—

The regional variability of percutaneous coronary intervention (PCI) rates may be explained by variations in the medical treatment of stable coronary artery disease. We sought to determine whether greater regional use of antianginal medications in PCI patients is associated with lower regional rates of PCI.

Methods and Results—

Using CathPCI Registry and Dartmouth Atlas data, we examined patients undergoing elective PCI for stable coronary artery disease from January 1, 2009, through March 31, 2011, and calculated rates of providing ≥2 antianginal medicines before PCI. We regressed the hospital referral region rates of PCI per 1000 Medicare enrollees in 2007 on the regions’ rates of providing ≥2 antianginal medications before PCI. Among 300 772 PCI procedures, 32.8%, 48.3%, 16.1%, and 2.8% of patients were on 0, 1, 2, or ≥3 antianginal medications, respectively. The median rate of providing ≥2 antianginal medications before PCI was 18.9%. Although substantial variability existed across hospital referral regions in providing ≥2 antianginal medications and in rates of PCI from the Dartmouth Atlas, there was no association between the rates of PCI in each hospital referral region and the rates of ≥2 antianginal medications before PCI (Spearman ρ, 0.0277; P =0.64).

Conclusions—

We found no association between the intensity of antianginal therapy and the use of PCI across hospital referral regions, despite the variability of both. Opportunities likely exist in many regions to increase the use of antianginal therapy before proceeding to elective PCI, and more research is needed to explain observed variations in care.

Five-year downstream outcomes following prostate-specific antigen screening in older men

IMPORTANCE

Despite ongoing controversies surrounding prostate-specific antigen (PSA) screening, many men 65 years or older undergo screening. However, few data exist that quantify the chain of events following screening in clinical practice to better inform decisions.

OBJECTIVE

To quantify 5-year downstream outcomes following a PSA screening result exceeding 4.0 ng/mL in older men.

DESIGN AND SETTING

Longitudinal cohort study in the national Veterans Affairs health care system.

PARTICIPANTS

In total, 295,645 men 65 years or older who underwent PSA screening in the Veterans Affairs health care system in 2003 and were followed up for 5 years using national Veterans Affairs and Medicare data.

MAIN OUTCOME MEASURES

Among men whose index screening PSA level exceeded 4.0 ng/mL, we determined the number who underwent prostate biopsy, were diagnosed as having prostate cancer, were treated for prostate cancer, and were treated for prostate cancer and were alive at 5 years according to baseline characteristics. Biopsy and treatment complications were also assessed.

RESULTS

In total, 25,208 men (8.5%) had an index PSA level exceeding 4.0 ng/mL. During the 5-year follow-up period, 8313 men (33.0%) underwent at least 1 prostate biopsy, and 5220 men (62.8%) who underwent prostate biopsy were diagnosed as having prostate cancer, of whom 4284 (82.1%) were treated for prostate cancer. Performance of prostate biopsy decreased with advancing age and worsening comorbidity (P < .001), whereas the percentage treated for biopsy-detected cancer exceeded 75% even among men 85 years or older, those with a Charlson-Deyo Comorbidity Index of 3 or higher, and those having low-risk cancer. Among men with biopsy-detected cancer, the risk of death from non-prostate cancer causes increased with advancing age and worsening comorbidity (P < .001). In total, 468 men (5.6%) had complications within 7 days after prostate biopsy. Complications of prostate cancer treatment included new urinary incontinence in 584 men (13.6%) and new erectile dysfunction 588 men (13.7%).

CONCLUSIONS AND RELEVANCE

Performance of prostate biopsy is uncommon in older men with abnormal screening PSA levels and decreases with advancing age and worsening comorbidity. However, once cancer is detected on biopsy, most men undergo immediate treatment regardless of advancing age, worsening comorbidity, or low-risk cancer. Understanding downstream outcomes in clinical practice should better inform individualized decisions among older men considering PSA screening.

Older adults and forgoing cancer screening: "I think it would be strange"

IMPORTANCE

Although there is a growing recognition that older adults and those with extensive comorbid conditions undergo cancer screening too frequently, there is little information about patients' perceptions regarding cessation of cancer screening. Information on older adults' views of screening cessation would be helpful both for clinicians and for those designing interventions to reduce overscreening.

OBJECTIVE

To obtain a deeper understanding of older adults' perspectives on screening cessation and their experiences communicating with clinicians about this topic.

DESIGN

Semistructured interview study.

SETTING

Senior health center affiliated with an urban hospital.

PARTICIPANTS

We interviewed 33 older adults presenting to a senior health center. Their median age was 76 years (range, 63-91 years). Of the 33 participants, 27 were women; 15 were African American, 16 were white, 1 was Asian, and 1 was American Indian.

MAIN OUTCOME MEASURES

We transcribed audio recordings of interviews and analyzed them using methods of grounded theory to identify themes and illustrative quotes.

RESULTS

Undergoing screening tests was perceived by participants as morally obligatory. Although many saw continued screening as a habit or custom not involving any decision, cessation of screening would require a major decision. Many asserted that they had never discussed screening cessation with their physicians or considered stopping on their own; some reported being upset when their physician recommended stopping. Although some would accept a physician's strong recommendation to stop, others thought that such a physician's recommendation would threaten trust or lead them to get another opinion. Participants were skeptical about the role of statistics and the recommendations of government panels in screening decisions but were more favorable toward stopping because of the balance of risks and benefits, complications, or test burdens.

CONCLUSIONS AND RELEVANCE

For many older adults, stopping screening is a major decision, but continuing screening is not. A physician's recommendation to stop may threaten patient trust. Effective strategies to reduce nonbeneficial screening may include discussion of the balance of risks and benefits, complications, or burdens.

The influence of stress, depression, and anxiety on PSA screening rates in a nationally representative sample

BACKGROUND

Prostate-specific antigen (PSA) testing for prostate cancer is controversial, with concerning rates of both overscreening and underscreening. The reasons for the observed rates of screening are unknown, and few studies have examined the relationship of psychological health to PSA screening rates. Understanding this relationship can help guide interventions to improve informed decision-making for screening.

METHODS

A nationally representative sample of men 57-85 years old without prostate cancer (N = 1169) from the National Social life, Health and Aging Project was analyzed. The independent relationship of validated psychological health scales measuring stress, anxiety, and depression to PSA testing rates was assessed using multivariable logistic regression analyses.

RESULTS

PSA screening rates were significantly lower for men with higher perceived stress [odds ratio (OR) = 0.76, P = 0.006], but not for higher depressive symptoms (OR = 0.89, P = 0.22) when accounting for stress. Anxiety influences PSA screening through an interaction with number of doctor visits (P = 0.02). Among the men who visited the doctor once those with higher anxiety were less likely to be screened (OR = 0.65, P = 0.04). Conversely, those who visited the doctor 10+ times with higher anxiety were more likely to be screened (OR = 1.71, P = 0.04).

CONCLUSIONS

Perceived stress significantly lowers PSA screening likelihood, and it seems to partly mediate the negative relationship of depression with screening likelihood. Anxiety affects PSA screening rates differently for men with different numbers of doctor visits. Interventions to influence PSA screening rates should recognize the role of the patients' psychological state to improve their likelihood of making informed decisions and improve screening appropriateness.

Remaining Life Expectancy Measurement and PSA Screening of Older Men

BACKGROUND: Guidelines recommend informed decision-making regarding prostate specific antigen (PSA) screening for men with at least 10 years of remaining life expectancy (RLE). Comorbidity measures have been used to judge RLE in previous studies, but assessments based on other common RLE measures are unknown. We assessed whether screening rates varied based on four clinically relevant RLE measures, including comorbidities, in a nationally-representative, community-based sample. METHODS: Using the National Social Life, Health and Aging Project (NSHAP), we selected men over 65 without prostate cancer (n=709). They were stratified into three RLE categories (0-7 years, 8-12 years, and 13+ years) based on validated measures of comorbidities, self-rated health status, functional status, and physical performance. The independent relationship of each RLE measure and a combined measure to screening was determined using multivariable logistic regressions. RESULTS: Self-rated health (OR = 6.82; p < 0.01) most closely correlated with RLE-based screening, while the comorbidity index correlated the least (OR = 1.50; p = 0.09). The relationship of RLE to PSA screening significantly strengthened when controlling for the number of doctor visits, particularly for comorbidities (OR= 43.6; p < 0.001). Men who had consistent estimates of less than 7 years RLE by all four measures had an adjusted PSA screening rate of 43.3%. CONCLUSIONS: Regardless of the RLE measure used, men who were estimated to have limited RLE had significant PSA screening rates. However, different RLE measures have different correlations with PSA screening. Specific estimates of over-screening should therefore carefully consider the RLE measure used.

Medical center characteristics associated with PSA screening in elderly veterans with limited life expectancy

BACKGROUND

Although guidelines recommend against prostate-specific antigen (PSA) screening in elderly men with limited life expectancy, screening is common.

OBJECTIVE

We sought to identify medical center characteristics associated with screening in this population.

DESIGN/PARTICIPANTS

We conducted a prospective study of 622,262 screen-eligible men aged 70+ seen at 104 VA medical centers in 2003.

MAIN MEASURES

Primary outcome was the percentage of men at each center who received PSA screening in 2003, based on VA data and Medicare claims. Men were stratified into life expectancy groups ranging from favorable (age 70-79 with Charlson score = 0) to limited (age 85+ with Charlson score ≥1 or age 70+ with Charlson score ≥4). Medical center characteristics were obtained from the 1999-2000 VA Survey of Primary Care Practices and publicly available VA data sources.

KEY RESULTS

Among 123,223 (20%) men with limited life expectancy, 45% received PSA screening in 2003. Across 104 VAs, the PSA screening rate among men with limited life expectancy ranged from 25-79% (median 43%). Higher screening was associated with the following center characteristics: no academic affiliation (50% vs. 43%, adjusted RR = 1.14, 95% CI 1.04-1.25), a ratio of midlevel providers to physicians ≥3:4 (55% vs. 45%, adjusted RR = 1.20, 95% CI 1.09-1.32) and location in the South (49% vs. 39% in the West, adjusted RR = 1.25, 95% CI 1.12-1.40). Use of incentives and high scores on performance measures were not independently associated with screening. Within centers, the percentages of men screened with limited and favorable life expectancies were highly correlated (r = 0.90).

CONCLUSIONS

Substantial practice variation exists for PSA screening in older men with limited life expectancy across VAs. The high center-specific correlation of screening among men with limited and favorable life expectancies indicates that PSA screening is poorly targeted according to life expectancy.

The impact of PSA screening on prostate cancer mortality and overdiagnosis of prostate cancer in the United States

BACKGROUND

The study assessed the impact of prostate-specific antigen (PSA) testing in the United States by comparing the rates of PSA testing in U.S. counties to the rates of prostate biopsies and newly treated prostate cancer and to deaths from prostate cancer.

METHODS

We examined the association between the percentage of men aged 66-74 from a nationally representative 5% Medicare sample who received PSA testing in each U.S. county in 1997 and the percent of men who received prostate biopsies or treatment for newly diagnosed prostate cancer in 1997 as well as mortality from prostate cancer and from all other causes from 1998 to 2007.

RESULTS

Analyses of 1,067 U.S. counties showed a significant relationship between the rate of PSA testing and both the rate of men undergoing treatment for prostate cancer and prostate cancer mortality (both p < .001) but no relationship with mortality from other causes. For every 100,000 men receiving a PSA test in 1997, an additional 4,894 men underwent prostate biopsy and 1,597 additional men underwent prostate cancer treatment in 1997, and 61 fewer men died from prostate cancer during 1998-2006. Analyses stratified by age and race produced similar results.

CONCLUSIONS

PSA testing was associated with modest reductions in prostate cancer mortality and large increases in the number of men overdiagnosed with and overtreated for prostate cancer. The results are similar to those obtained by the large European randomized prospective trial of PSA testing.

Geritalk: communication skills training for geriatric and palliative medicine fellows

Expert communication is essential to high-quality care for older patients with serious illness. Although the importance of communication skills is widely recognized, formal curricula for teaching communication skills to geriatric and palliative medicine fellows is often inadequate or unavailable. The current study drew upon the educational principles and format of an evidence-based, interactive teaching method to develop an intensive communication skills training course designed specifically to address the common communication challenges that geriatric and palliative medicine fellows face. The 2-day retreat, held away from the hospital environment, included large-group overview presentations, small-group communication skills practice, and development of future skills practice commitment. Faculty received in-depth training in small-group facilitation techniques before the course. Geriatric and palliative medicine fellows were recruited to participate in the course and 100% (n = 18) enrolled. Overall satisfaction with the course was very high (mean 4.8 on a 5-point scale). After the course, fellows reported an increase in self-assessed preparedness for specific communication challenges (mean increase 1.4 on 5-point scale, P < .001). Two months after the course, fellows reported a high level of sustained skills practice (mean 4.3 on 5-point scale). In sum, the intensive communication skills program, customized for the specific needs of geriatric and palliative medicine fellows, improved fellows' self-assessed preparedness for challenging communication tasks and provided a model for ongoing deliberate practice of communication skills.

The role of community-based participatory research to inform local health policy: a case study

The community of health services researchers in general internal medicine has played an important role in affecting health policy at the national and state levels. Community-based participatory research (CBPR) offers health services researchers an opportunity to identify and address health policy questions at the local level. We present the following four mechanisms by which CBPR might increase the ability of health services researchers to impact health by informing local policy. CBPR benefits community partners by allowing them to participate directly in the research process, gives academic researchers access to local data, enhances interpretation of research findings through an understanding of local context, and provides a natural infrastructure for affecting local policy through its community partners. For each of these mechanisms, we describe one example from a CBPR project conducted by one of us (M.O.). Considering the challenges and opportunities of conducting CBPR, future efforts will help describe how this emerging research paradigm can complement traditional health services research to most effectively inform health policy at multiple levels.