Medical center characteristics associated with PSA screening in elderly veterans with limited life expectancy

Abstract

Background: Although guidelines recommend against prostate-specific antigen (PSA) screening in elderly men with limited life expectancy, screening is common.

Objective: We sought to identify medical center characteristics associated with screening in this population.

Design/participants: We conducted a prospective study of 622,262 screen-eligible men aged 70+ seen at 104 VA medical centers in 2003.

Main measures: Primary outcome was the percentage of men at each center who received PSA screening in 2003, based on VA data and Medicare claims. Men were stratified into life expectancy groups ranging from favorable (age 70-79 with Charlson score = 0) to limited (age 85+ with Charlson score ≥1 or age 70+ with Charlson score ≥4). Medical center characteristics were obtained from the 1999-2000 VA Survey of Primary Care Practices and publicly available VA data sources.

Key results: Among 123,223 (20%) men with limited life expectancy, 45% received PSA screening in 2003. Across 104 VAs, the PSA screening rate among men with limited life expectancy ranged from 25-79% (median 43%). Higher screening was associated with the following center characteristics: no academic affiliation (50% vs. 43%, adjusted RR = 1.14, 95% CI 1.04-1.25), a ratio of midlevel providers to physicians ≥3:4 (55% vs. 45%, adjusted RR = 1.20, 95% CI 1.09-1.32) and location in the South (49% vs. 39% in the West, adjusted RR = 1.25, 95% CI 1.12-1.40). Use of incentives and high scores on performance measures were not independently associated with screening. Within centers, the percentages of men screened with limited and favorable life expectancies were highly correlated (r = 0.90).

Conclusions: Substantial practice variation exists for PSA screening in older men with limited life expectancy across VAs. The high center-specific correlation of screening among men with limited and favorable life expectancies indicates that PSA screening is poorly targeted according to life expectancy.

Figure 1.

Exclusions used to define the final cohort of elderly men eligible for PSA screening.

Figure 2.

Percentage of men aged 70 and older who received PSA screening at each of 104 VAs. VAs with the highest screening rates are identified A-E and those with the lowest screening rates are identified F-J.

Figure 3.

Correlation of PSA screening among older men with favorable and limited life expectancies at each of 104 VAs. Favorable life expectancy defined as men aged 70–79 with Charlson score = 0 (life expectancy >10 years). Limited life expectancy defined as men aged 85+ with Charlson score ≥1 or men aged 70+ with Charlson score ≥4 (life expectancy ≤5 years). Letters correspond to the highest and lowest screening VAs from Figure 2. The lower right quadrant is where screening is best targeted according to life expectancy (i.e., low screening in men with limited life expectancy and high screening in men with favorable life expectancy).