Prostate-Specific Antigen screening of elderly men varies significantly in primary care

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1. Primary care physicians accounted for 27% of the variance in whether an elderly man (>75 years old) received a PSA screen. 

2. Variance in PSA screening among elderly men attributable to PCPs (0.27) is higher than mammography (0.10) and colorectal cancer (0.09) screening. 

Evidence Rating Level: 3 (Average) 

Study Rundown: Prostate-specific antigen (PSA) screening has ignited significant controversy in recent years. For men 75 years or older, however, the medical community is generally in agreement: no PSA screening is recommended. Despite this, elderly men are still commonly screened in the community. This study identified the role of primary care physicians (PCP) in determining whether an older man received a PSA screen. The authors found a 10-fold difference in screening rates between the highest and lowest deciles of PCPs. In a model that evaluated PCP’s ordering of PSA testing, the intra-class correlation coefficient (ICC), which represents the percentage of variance attributable to the patient’s PCP, was 0.27. The ICC among PCPs for PSA screening stands in contrast to other studies that have demonstrated a ICC of 0.10 for mammography and 0.09 for colorectal cancer screening. This study is notable for a large sample size, but is limited due to analysis of data from a single year in only one state. Nonetheless, these findings suggest confusion among PCPs about the value of PSA screening in elderly men. Future research is needed to better characterize this high variability.

Click to read the study, published today as a Research Letter in JAMA

Relevant Reading: Screening for Prostate Cancer: A Guidance Statement From the Clinical Guidelines Committee of the American College of Physicians

In-Depth [cross-sectional study]: This cross-sectional study identified 1,963 PCPs with patient panels that included 61,351 men aged 75 or older. The authors used Medicare Part A and B data for Texas in 2010 to conduct a multi-level, multi-variable logistic regression analysis and controlled for patient characteristics such as race/ethnicity, comorbidities, and Medicaid eligibility among others. Overall, 41% of men received PSA screening, of which 28.8% was ordered by their PCP. Screenings with PSA significantly decreased with age. The intra-class correlation coefficient (ICC) was 0.27, which means that 27% of the variance in PSA screening was attributed to the patient’s PCP. Patient characteristics such as age, comorbidities, or race/ethnicity accounted for only 3.7% of the observed variance.

By Jonathan Lichkus and Rif Rahman

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