Low-Value Prostate Cancer Screening Among Older Men Within the Veterans Health Administration

Care cascades following low-value cervical cancer screening in dually enrolled Veterans

BACKGROUND

Veterans dually enrolled in the Veterans Health Administration (VA) and Medicare commonly experience downstream services as part of a care cascade after an initial low-value service. Our objective was to characterize the frequency and cost of low-value cervical cancer screening and subsequent care cascades among Veterans dually enrolled in VA and Medicare.

METHODS

This retrospective cohort study used VA and Medicare administrative data from fiscal years 2015 to 2019. The study cohort was comprised of female Veterans aged >65 years and at low risk of cervical cancer who were dually enrolled in VA and Medicare. Within this cohort, we compared differences in the rates and costs of cascade services related to low-value cervical cancer screening for Veterans who received and did not receive screening in FY2018, adjusting for baseline patient- and facility-level covariates using inverse probability of treatment weighting.

RESULTS

Among 20,972 cohort-eligible Veterans, 494 (2.4%) underwent low-value cervical cancer screening with 301 (60.9%) initial screens occurring in VA and 193 (39%) occurring in Medicare. Veterans who were screened experienced an additional 26.7 (95% CI, 16.4-37.0) cascade services per 100 Veterans compared to those who were not screened, contributing to $2919.4 (95% CI, -265 to 6104.7) per 100 Veterans in excess costs. Care cascades consisted predominantly of subsequent cervical cancer screening procedures and related outpatient visits with low rates of invasive procedures and occurred in both VA and Medicare.

CONCLUSIONS

Veterans dually enrolled in VA and Medicare commonly receive related downstream tests and visits as part of care cascades following low-value cervical cancer screening. Our findings demonstrate that to fully capture the extent to which individuals are subject to low-value care, it is important to examine downstream care stemming from initial low-value services across all systems from which individuals receive care.

Qualitative Study on Internet Use and Care Impact for Black Men With Prostate Cancer

Black men have a greater risk of prostate cancer as well as worse quality of life and more decisional regret after prostate cancer treatment compared to non-Hispanic White men. Furthermore, patients with prostate cancer who primarily obtain information on the internet have significantly more decisional regret compared to other information sources. Our objective was to explore the perspectives of Black patients on the use and impact of the internet for their prostate cancer care. In 2022-2023, we conducted seven virtual focus groups with Black patients with prostate cancer (n = 22). Transcripts were independently analyzed by two experienced researchers using a constant comparative method. Online sources were commonly used by participants throughout their cancer journey, although informational needs varied over time. Patient factors affected use (e.g., physical health and experience with the internet), and family members played an active role in online information-seeking. The internet was used before and after visits to the doctor. Key topics that participants searched for online included nutrition and lifestyle, treatment options, and prostate cancer in Black men. Men reported many downstream benefits with internet use including feeling more empowered in decision-making, reducing anxiety about treatment and providing greater accountability for research. However, they also reported negative impacts such as feeling overwhelmed or discouraged sorting through the information to identify high-quality content that is personally relevant, as well as increased anxiety or loss of sleep from overuse. In summary, online sources have the potential to positively impact the cancer journey by reinforcing or supplementing information from health care providers, but can be harmful if the information is poor quality, not representative, or the internet is overused.

Variation in Low-Value Service Use Across Veterans Affairs Facilities

BACKGROUND

It is unclear whether extensive variation in the use of low-value services exists even within a national integrated delivery system like the Veterans Health Administration (VA).

OBJECTIVE

To quantify variation in the use of low-value services across VA facilities and examine associations between facility characteristics and low-value service use.

DESIGN

In this retrospective cross-sectional study of VA administrative data, we constructed facility-level rates of low-value service use as the mean count of 29 low-value services per 100 Veterans per year. Adjusted rates were calculated via ordinary least squares regression including covariates for Veteran sociodemographic and clinical characteristics. We quantified the association between adjusted facility-level rates and facility geographic/operational characteristics.

PARTICIPANTS

5,242,301 patients across 139 VA facilities.

MAIN MEASURES

Use of 29 low-value services within six domains: cancer screening, diagnostic/preventive testing, preoperative testing, imaging, cardiovascular testing and procedures, and surgery.

KEY RESULTS

The mean rate of low-value service use was 20.0 services per 100 patients per year (S.D. 6.1). Rates ranged from 13.9 at the 10th percentile to 27.6 at the 90th percentile (90th/10th percentile ratio 2.0, 95% CI 1.8‒2.3). With adjustment for patient covariates, variation across facilities narrowed (S.D. 5.2, 90th/10th percentile ratio 1.8, 95% CI 1.6‒1.9). Only one facility characteristic was positively associated with low-value service use percent of patients seeing non-VA clinicians via VA Community Care, p < 0.05); none was associated with total low-value service use after adjustment for other facility characteristics. There was extensive variation in low-value service use within categories of facility operational characteristics.

CONCLUSIONS

Despite extensive variation in the use of low-value services across VA facilities, we observed substantial use of these services across facility operational characteristics and at facilities with lower rates of low-value service use. Thus, system-wide interventions to address low-value services may be more effective than interventions targeted to specific facilities or facility types.

Prevalence and Cost of Care Cascades Following Low-Value Preoperative Electrocardiogram and Chest Radiograph Within the Veterans Health Administration

BACKGROUND

Low-value care cascades, defined as the receipt of downstream health services potentially related to a low-value service, can result in harm to patients and wasteful healthcare spending, yet have not been characterized within the Veterans Health Administration (VHA).

OBJECTIVE

To examine if the receipt of low-value preoperative testing is associated with greater utilization and costs of potentially related downstream health services in Veterans undergoing low or intermediate-risk surgery.

DESIGN

Retrospective cohort study using VHA administrative data from fiscal years 2017-2018 comparing Veterans who underwent low-value preoperative electrocardiogram (EKG) or chest radiograph (CXR) with those who did not.

PARTICIPANTS

National cohort of Veterans at low risk of cardiopulmonary disease undergoing low- or intermediate-risk surgery.

MAIN MEASURES

Difference in rate of receipt and attributed cost of potential cascade services in Veterans who underwent low-value preoperative testing compared to those who did not KEY RESULTS: Among 635,824 Veterans undergoing low-risk procedures, 7.8% underwent preoperative EKG. Veterans who underwent a preoperative EKG experienced an additional 52.4 (95% CI 47.7-57.2) cascade services per 100 Veterans, resulting in $138.28 (95% CI 126.19-150.37) per Veteran in excess costs. Among 739,005 Veterans undergoing low- or intermediate-risk surgery, 3.9% underwent preoperative CXR. These Veterans experienced an additional 61.9 (95% CI 57.8-66.1) cascade services per 100 Veterans, resulting in $152.08 (95% CI $146.66-157.51) per Veteran in excess costs. For both cohorts, care cascades consisted largely of repeat tests, follow-up imaging, and follow-up visits, with low rates invasive services.

CONCLUSIONS

Among a national cohort of Veterans undergoing low- or intermediate-risk surgeries, low-value care cascades following two routine low-value preoperative tests are common, resulting in greater unnecessary care and costs beyond the initial low-value service. These findings may guide de-implementation policies within VHA and other integrated healthcare systems that target those services whose downstream effects are most prevalent and costly.

Discontinuing Cancer Screening for Older Adults: a Comparison of Clinician Decision-Making for Breast, Colorectal, and Prostate Cancer Screenings

BACKGROUND

While guidelines recommend against routine screening for breast, prostate, and colorectal cancers in older adults (65+ years) with <10-year life expectancy, many of these patients continue to be screened. How clinicians consider screening cessation across multiple cancer screening types is unknown.

OBJECTIVE

To compare and contrast clinicians' perspectives on discontinuing breast, prostate, and colorectal cancer screenings in older adults.

DESIGN

Qualitative, semi-structured interviews.

PARTICIPANTS

Primary care clinicians in Maryland (N=30) APPROACH: We conducted semi-structured interviews with individual clinicians. Interviews were recorded, transcribed, and analyzed using standard techniques of qualitative content analysis to identify major themes.

KEY RESULTS

Participants were mostly physicians (24/30) and women (16/30). Four major themes highlighted differences in decision-making across cancer screenings: (1) Clinicians reported more often screening beyond guideline-recommended ages for breast and prostate cancers than colorectal cancer; (2) clinicians had different priorities when considering the benefits/harms of each screening; for example, some prioritized continuing colorectal cancer screening due to the test's high efficacy while others prioritized stopping colorectal cancer screening due to high procedural risk; some prioritized continuing prostate cancer screening due to poor outcomes from advanced prostate cancer while others prioritized stopping prostate cancer screening due to high false positive test rates and harms from downstream tests; (3) clinicians discussed harms of prostate and colorectal cancer screening more readily than for breast cancer screening; (4) clinicians perceived more involvement with gastroenterologists in colonoscopy decisions and less involvement from specialists for prostate and breast cancer screening.

CONCLUSIONS

Our results highlight the need for more explicit guidance on how to weigh competing considerations in cancer screening (such as test accuracy versus ease of cancer treatment after detection). Recognizing the complexity of the benefit/harms analysis as clinicians consider multiple cancer screenings, future decision support tools, and clinician education materials can specifically address the competing considerations.

Factors Associated With Low-Value Cancer Screenings in the Veterans Health Administration

IMPORTANCE

Most clinical practice guidelines recommend stopping cancer screenings when risks exceed benefits, yet low-value screenings persist. The Veterans Health Administration focuses on improving the value and quality of care, using a patient-centered medical home model that may affect cancer screening behavior.

OBJECTIVE

To understand rates and factors associated with outpatient low-value cancer screenings.

DESIGN, SETTING, AND PARTICIPANTS

This cohort study assessed the receipt of low-value cancer screening and associated factors among 5 993 010 veterans. Four measures of low-value cancer screening defined by validated recommendations of practices to avoid were constructed using administrative data. Patients with cancer screenings in 2017 at Veterans Health Administration primary care clinics were included. Excluded patients had recent symptoms or historic high-risk diagnoses that may affect test appropriateness (eg, melena preceding colonoscopy). Data were analyzed from December 23, 2019, to June 21, 2021.

EXPOSURES

Receipt of cancer screening test.

MAIN OUTCOMES AND MEASURES

Low-value screenings were defined as occurring for average-risk patients outside of guideline-recommended ages or if the 1-year mortality risk estimated using a previously validated score was at least 50%. Factors evaluated in multivariable regression models included patient, clinician, and clinic characteristics and patient-centered medical home domain performance for team-based care, access, and continuity previously developed from administrative and survey data.

RESULTS

Of 5 993 010 veterans (mean [SD] age, 63.1 [16.8] years; 5 496 976 men [91.7%]; 1 027 836 non-Hispanic Black [17.2%] and 4 539 341 non-Hispanic White [75.7%] race and ethnicity) enrolled in primary care, 903 612 of 4 647 479 men of average risk (19.4%) underwent prostate cancer screening; 299 765 of 5 770 622 patients of average risk (5.2%) underwent colorectal cancer screening; 21 930 of 469 045 women of average risk (4.7%) underwent breast cancer screening; and 65 511 of 458 086 women of average risk (14.3%) underwent cervical cancer screening. Of patients screened, low-value testing was rare for 3 cancers, with receipt of a low-value test in 633 of 21 930 of women screened for breast cancer (2.9%), 630 of 65 511 of women screened for cervical cancer (1.0%), and 6790 of 299 765 of patients screened for colorectal cancer (2.3%). However, 350 705 of 4 647 479 of screened men (7.5%) received a low-value prostate cancer test. Patient race and ethnicity, sociodemographic factors, and illness burden were significantly associated with likelihood of receipt of low-value tests among screened patients. No single patient-, clinician-, or clinic-level factor explained the receipt of a low-value test across cancer screening cohorts.

CONCLUSIONS AND RELEVANCE

This large cohort study found that low-value breast, cervical, and colorectal cancer screenings were rare in the Veterans Health Administration, but more than one-third of patients screened for prostate cancer were tested outside of clinical practice guidelines. Guideline-discordant care has quality implications and is not consistently explained by associated multilevel factors.

Cancer Prevention and Screening for Older Adults: Part 2. Interventions to Prevent and Screen for Breast, Prostate, Cervical, Ovarian, and Endometrial Cancer

The incidence of most cancers increase with age. Cancer is the second most common cause of death in older adults after cardiovascular disease. Many common cancers in older adults can be prevented from occurring or can be identified at an early stage and treated effectively. Although cancer is feared primarily because of premature mortality, for many older adults, preventing and identifying cancer in its early stages, in an attempt to reduce discomfort and disability associated with advanced cancer and cancer treatment, is also a priority. Overscreening for cancer in older adults can lead to unnecessary diagnostic testing and unnecessary treatment. Both older adults and their healthcare providers need guidance on the appropriate use of cancer prevention and screening interventions. This is the second part of a two-part clinical review on cancer prevention and screening for adults aged 65 and older. Guidance is provided regarding the prevention and early identification of breast, prostate, cervical, ovarian, and endometrial cancer. The prevention of lung, colorectal, bladder, and kidney cancer is addressed in Part 1.

Evaluation of Low-Value Diagnostic Testing for 4 Common Conditions in the Veterans Health Administration

IMPORTANCE

Low-value care is associated with harm among patients and with wasteful health care spending but has not been well characterized in the Veterans Health Administration.

OBJECTIVES

To characterize the frequency of and variation in low-value diagnostic testing for 4 common conditions at Veterans Affairs medical centers (VAMCs) and to examine the correlation between receipt of low-value testing for each condition.

DESIGN, SETTING, AND PARTICIPANTS

This retrospective cohort study used Veterans Health Administration data from 127 VAMCs from fiscal years 2014 to 2015. Data were analyzed from April 2018 to March 2020.

EXPOSURES

Continuous enrollment in Veterans Health Administration during fiscal year 2015.

MAIN OUTCOMES AND MEASURES

Receipt of low-value testing for low back pain, headache, syncope, and sinusitis. For each condition, sensitive and specific criteria were used to evaluate the overall frequency and range of low-value testing, adjusting for sociodemographic and VAMC characteristics. VAMC-level variation was calculated using median adjusted odds ratios. The Pearson correlation coefficient was used to evaluate the degree of correlation between low-value testing for each condition at the VAMC level.

RESULTS

Among 1 022 987 veterans, the mean (SD) age was 60 (16) years, 1 008 336 (92.4%) were male, and 761 485 (69.8%) were non-Hispanic White. A total of 343 024 veterans (31.4%) were diagnosed with low back pain, 79 176 (7.3%) with headache, 23 776 (2.2%) with syncope, and 52 889 (4.8%) with sinusitis. With the sensitive criteria, overall and VAMC-level low-value testing frequency varied substantially across conditions: 4.6% (range, 2.7%-10.1%) for sinusitis, 12.8% (range, 8.6%-22.6%) for headache, 18.2% (range, 10.9%-24.6%) for low back pain, and 20.1% (range, 16.3%-27.7%) for syncope. With the specific criteria, the overall frequency of low-value testing across VAMCs was 2.4% (range, 1.3%-5.1%) for sinusitis, 8.6% (range, 6.2%-14.6%) for headache, 5.6% (range, 3.6%-7.7%) for low back pain, and 13.3% (range, 11.3%-16.8%) for syncope. The median adjusted odds ratio ranged from 1.21 for low back pain to 1.40 for sinusitis. At the VAMC level, low-value testing was most strongly correlated for syncope and headache (ρ = 0.56; P < .001) and low back pain and headache (ρ = 0.48; P < .001).

CONCLUSIONS AND RELEVANCE

In this cohort study, low-value diagnostic testing was common, varied substantially across VAMCs, and was correlated between veterans' receipt of different low-value tests at the VAMC level. The findings suggest a need to address low-value diagnostic testing, even in integrated health systems, with robust utilization management practices.

Comparison by Race of Conservative Management for Low-Risk and Intermediate-Risk Prostate Cancers in Veterans From 2004 to 2018

Importance

Conservative management (ie, active surveillance or watchful waiting) is a guideline-based strategy for men with low-risk and intermediate-risk prostate cancer. However, use of conservative management is controversial for African American patients, who have worse prostate cancer outcomes compared with White patients.

Objective

To examine the association of African American race with the receipt and duration of conservative management in the Veterans Health Administration (VA), a large equal-access health system.

Design, Setting, and Participants

This cohort study used data from the VA Corporate Data Warehouse for 51 543 African American and non-Hispanic White veterans diagnosed with low-risk and intermediate-risk localized node-negative prostate cancer between January 1, 2004, and December 31, 2013. Men who did not receive continuous VA care were excluded. Data were analyzed from February 1 to June 30, 2020.

Exposures

All patients received either definitive therapy (ie, prostatectomy, radiation, androgen deprivation therapy) or conservative management (ie, active surveillance or watchful waiting).

Main Outcomes and Measures

Receipt of conservative management and (for patients receiving conservative management) time from diagnosis to definitive therapy.

Results

The median (interquartile range) age of the 51 543 veterans in our cohort was 65 (61-70) years, and 14 830 veterans (28.8%) were African American individuals. Compared with White veterans, African American veterans were more likely to have intermediate-risk disease (18 988 [51.7%] vs 8526 [57.5%]), 3 or more comorbidities (15 438 [42.1%] vs 7614 [51.3%]), and high disability-related or income-related needs (9078 [24.7%] vs 4614 [31.1%]). Overall, 20 606 veterans (40.0%) received conservative management. African American veterans with low-risk disease (adjusted relative risk, 0.95; 95% CI, 0.92-0.98; P < .001) and intermediate-risk disease (adjusted relative risk, 0.92; 95% CI, 0.87-0.97; P = .002) were less likely to receive conservative management than White veterans. Compared with White veterans, African American veterans with low-risk disease (adjusted hazard ratio, 1.71; 95% CI, 1.50-1.95; P < .001) and intermediate-risk disease (adjusted hazard ratio, 1.46; 95% CI, 1.27-1.69; P < .001) who received conservative management were more likely to receive definitive therapy within 5 years of diagnosis (restricted mean survival time [SE] at 5 years, 1679 [5.3] days vs 1740 [2.4] days; P < .001).

Conclusions and Relevance

In this study, conservative management was less commonly used and less durable for African American veterans than for White veterans. Prospective trials should assess the comparative effectiveness of conservative management in African American men with prostate cancer.

Low-Value Prostate Cancer Screening Among Older Men Within the Veterans Health Administration

BACKGROUND/OBJECTIVES

Prostate-specific antigen (PSA) screening can be of low value in older adults. Our objective was to quantify the prevalence and variation of low-value PSA screening across the Veterans Health Administration (VA), which has instituted programs to reduce low-value care.

DESIGN

Retrospective cohort.

SETTING

VA administrative data, 2014 to 2015.

PARTICIPANTS

National random sample (N = 214 480) of male veterans, aged 75 years or older.

MEASUREMENTS

We defined PSA screening in men aged 75 years or older without a history of prostate cancer as low value, per established definitions in Medicare. We calculated screening rates overall and by VA Medical Center (VAMC), adjusting for patient and VAMC-level factors. We characterized variation across VAMCs using the adjusted median odds ratio (OR) and compared the adjusted OR of screening between VAMCs in different deciles of low-value screening rates. In separate sensitivity analyses, we assessed screening in veterans at greatest risk of 1-year mortality and among veterans after excluding those who underwent prostatectomy, had a prior PSA elevation, or had a clinical indication for testing.

RESULTS

Overall, 37 867 (17.7%) of veterans underwent low-value PSA screening (VAMC range = 3.3%-38.2%). The adjusted median OR was 1.88, meaning the median odds of screening would increase by 88% were a veteran to transfer his care to a VAMC with higher screening rates. Veterans at VAMCs in the top decile had an adjusted OR of 12.9 (95% confidence interval = 11.0-15.2) compared to those veterans in the lowest decile. Among veterans with the greatest mortality risk (n = 23 377), 3496 (15.0%) underwent screening (VAMC range = 1.7%-46.3%). After excluding veterans with a prior prostatectomy, PSA elevation, or a potential clinical indication, 31 556 (14.7%) underwent screening (VAMC range = 2.0%-49.9%).

CONCLUSIONS

In a national cohort of older veterans, more than one in six received low-value PSA screening, with greater than 10-fold variation across VAMCs and high rates of screening among those with the greatest mortality risk. J Am Geriatr Soc 67:1922-1927, 2019.