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Original Investigation |

Clinician Factors Associated With Prostate-Specific Antigen Screening in Older Veterans With Limited Life Expectancy

Victoria L. Tang, MD, MAS1,2; Ying Shi, PhD1,2; Kathy Fung, MS2; Jessica Tan, BA1,2; Roxanne Espaldon, BA1,2; Rebecca Sudore, MD1,2; Melisa L. Wong, MD1,2,3; Louise C. Walter, MD1,2
[+] Author Affiliations
1Division of Geriatrics, Department of Medicine, University of California, San Francisco
2Division of Geriatrics, Veterans Affairs Medical Center, San Francisco, California
3Division of Hematology/Oncology, Department of Medicine, University of California, San Francisco
JAMA Intern Med. 2016;176(5):654-661. doi:10.1001/jamainternmed.2016.0695.
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Published online

Importance  Despite guidelines recommending against prostate-specific antigen (PSA) screening in elderly men with limited life expectancy, PSA screening remains common.

Objective  To identify clinician characteristics associated with PSA screening rates in older veterans stratified by life expectancy.

Design, Setting, and Participants  Cross-sectional study of 826 286 veterans 65 years or older eligible for PSA screening who had VA laboratory tests performed in 2011 in the VA health care system.

Main Outcomes and Measures  The primary outcome was the percentage of men with a screening PSA test in 2011. Limited life expectancy was defined as age of at least 85 years with Charlson comorbidity score of 1 or greater or age of at least 65 years with Charlson comorbidity score of 4 or greater. Primary predictors were clinician characteristics including degree-training level, specialty, age, and sex. We performed log-linear Poisson regression models for the association between each clinician characteristic and PSA screening stratified by patient life expectancy and adjusted for patient demographics and clinician clustering.

Results  In 2011, 466 017 (56%) of older veterans received PSA screening, including 39% of the 203 717 men with limited life expectancy. After adjusting for patient demographics, higher PSA screening rates in patients with limited life expectancy was associated with having a clinician who was an older man and was no longer in training. The PSA screening rates ranged from 27% for men with a physician trainee to 42% for men with an attending physician (P < .001); 22% for men with a geriatrician to 82% for men with a urologist as their clinician (P < .001); 29% for men with a clinician 35 years or younger to 41% for those with a clinician 56 years or older (P < .001); and 38% for men with a female clinician older than 55 years vs 43% for men with a male clinician older than 55 years (P < .001).

Conclusions and Relevance  More than one-third of men with limited life expectancy received PSA screening. Men whose clinician was a physician trainee had substantially lower PSA screening rates than those with an attending physician, nurse practitioner, or physician assistant. Interventions to reduce PSA screening rates in older men with limited life expectancy should be designed and targeted to high-screening clinicians— older male, nontrainee clinicians—for greatest impact.

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Figure 1.
Exclusions Used to Define the Final Cohort of Elderly Men Eligible for Prostate-Specific Antigen Screening
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Figure 2.
Percentage of Men With Screening PSA Categorized by Clinician Degree and Training Level

The percentage of prostate-specific antigen (PSA) screening among men with limited life expectancy and favorable life expectancy were significantly different in all clinician groups (P < .001). Physician trainees and nurse practitioners were slightly more likely to use differential PSA screening based on life expectancy than attending physicians or physician assistants (P < .001 for interaction). However, our large sample size is detecting rather modest differences in the magnitude of the effect across groups. The association between clinician groups and differential PSA screening based on life expectancy is robust across all groups.

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