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Research Highlights
Which providers are most likely to order
inappropriate prostate screenings?
September 7, 2007
Past research in both VA and non-VA settings has shown that the
prostate-specific antigen (PSA) test to screen for prostate cancer is
often performed for patients for whom the test has shown no benefit.
Now, researchers who analyzed VA data on more than 230,00 PSA
tests have profiled—by gender, age and other characteristics—
which providers are more likely to order inappropriate tests. Their
report appeared in the July 9 Archives of Internal Medicine.
A team led by B. Price Kerfoot, MD, EdM, of the VA Boston
Healthcare System and Harvard Medical School, analyzed data
from 105,765 male patients who were treated at VA facilities in New
England from 1997 to 2004. Information about the patients and the
1,552 health care clinicians who ordered PSA tests was gathered
from VA databases. Inappropriate screening was defined as PSA
testing in patients older than 75 or younger than 40 who had not
been diagnosed with prostate cancer, were not taking prostate cancer–specific medications or had not undergone related procedures.
Most guidelines for clinical practice do not recommend routine
PSA screening for men who are younger than 40 or older than 75,
or who are expected to live less than 10 years. "To our knowledge,
there is currently no solid evidence that PSA screening provides any
health benefits for these patient populations," wrote Kerfoot and his
coauthors. "Rather, it imposes substantial psychological and financial
costs and may lead to diagnostic and therapeutic procedures of
questionable benefit."
According to the study, of the 232,302 PSA tests ordered during
the study period, 16.1 percent were inappropriate, with 15.3
percent performed in patients older than 75 years and the remainder
in patients younger than 40 years. Of the clinicians who ordered
inappropriate tests, 51.3 percent were male, 79.4 percent were
physicians, 53.4 percent were trainee physicians and 8.2 percent
were urologists. "Practitioners who were urology specialists, male,
infrequent PSA tests-orderers and affiliated with specific hospitals
had significantly higher levels of inappropriate PSA screening.
Compared with attending physicians, nurses and physician assistants
had significantly lower levels of inappropriate screening,"
the authors wrote.
The article also notes that the percentage of inappropriate
PSA screening increased significantly with the age of male providers,
and suggests a possible explanation: "The cause of these
sex and age differences is not clear. It is possible that, as they
age, male health care providers increasingly empathize with their
older male patients over prostate cancer concerns. Their 'prostatempathy'
may then lead to more aggressive screening in these
older male patients."
Kerfoot emphasizes that "whether their healthcare provider
is suffering from 'prostatempathy' or not, patients older than 75
should be informed that the clinical practice guidelines do not
recommend further prostate screening with PSA. The patient and
his care provider can then decide together whether to continue
screening."
The researchers suggest that both patient and provider education
may be part of the solution, although Kerfoot notes that
computerized clinical reminders for providers have produced
mixed results in terms of their effectiveness. With funding from
a VA Career Development Award, he is currently working to
develop Web-based education for doctors that he believes may
help promote the translation of evidence-based guidelines into
clinical practice.
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