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

Abstract

Objectives: To determine the rate of prostate-specific antigen (PSA) screening in men aged 80 and older in Medicare and to examine geographic variation in screening rates across the U.S.

Design: Retrospective cohort study of variation across hospital referral regions using administrative data.

Setting: National random sample in fee-for-service Medicare.

Participants: Medicare beneficiaries aged 80 and older in 2003.

Measurements: Percentage of men aged 80 and older screened using the PSA test.

Results: The national rate of PSA screening in men aged 80 and older was 17.2%, but there was wide variation across regions (<2-38%). Higher PSA screening in a region was positively associated with greater total costs (correlation coefficient (r)=0.49, P<.001), greater intensive care unit use at the end of life (r=0.46, P<.001), and greater number of unique physicians seen (r=0.36, P<.001). PSA screening was negatively associated with proportion of beneficiaries using a primary care physician as opposed to a medical subspecialist for the predominance of ambulatory care (r=-0.38, P<.001).

Conclusion: PSA screening in men aged 80 and older is common practice, although its frequency is highly variable across the United States. Its association with fragmented physician care and aggressive end-of-life care may reflect less reliance on primary care and consequent difficulty informing patients of the potential harms and low likelihood of benefit of this procedure.

Figure 1

Variation across hospital referral regions (HRRs) in the percentage of men aged 80 and older who had a screening prostate-specific antigen (PSA) test in 2003. Each circle represents the PSA screening rate for each hospital referral region—age, sex, and race adjusted. The panel shows the actual screening rates in the five highest and five lowest screening regions.

Figure 2

U.S. hospital referral region map of screening prostate-specific antigen (PSA) rates in men aged 80 and older categorized in quintiles.

Figure 3

Association between percentage of men aged 80 and older who had a screening prostate-specific antigen (PSA) test and (A) total Medicare spending for beneficiaries aged 80 and older, (B) average number of intensive care unit days in the last 6 months of life for all decedents aged 80 and older, (C) average number of unique physicians visited by all beneficiaries aged 80 and older, and (D) percentage of all beneficiaries aged 80 and older whose predominant ambulatory physician was in a primary care specialty.