Low-Value Prostate Cancer Screening Among Older Men Within the Veterans Health Administration

J Am Geriatr Soc. 2019 Sep;67(9):1922-1927. doi: 10.1111/jgs.16057. Epub 2019 Jul 5.


Background/objectives: Prostate-specific antigen (PSA) screening can be of low value in older adults. Our objective was to quantify the prevalence and variation of low-value PSA screening across the Veterans Health Administration (VA), which has instituted programs to reduce low-value care.

Design: Retrospective cohort.

Setting: VA administrative data, 2014 to 2015.

Participants: National random sample (N = 214 480) of male veterans, aged 75 years or older.

Measurements: We defined PSA screening in men aged 75 years or older without a history of prostate cancer as low value, per established definitions in Medicare. We calculated screening rates overall and by VA Medical Center (VAMC), adjusting for patient and VAMC-level factors. We characterized variation across VAMCs using the adjusted median odds ratio (OR) and compared the adjusted OR of screening between VAMCs in different deciles of low-value screening rates. In separate sensitivity analyses, we assessed screening in veterans at greatest risk of 1-year mortality and among veterans after excluding those who underwent prostatectomy, had a prior PSA elevation, or had a clinical indication for testing.

Results: Overall, 37 867 (17.7%) of veterans underwent low-value PSA screening (VAMC range = 3.3%-38.2%). The adjusted median OR was 1.88, meaning the median odds of screening would increase by 88% were a veteran to transfer his care to a VAMC with higher screening rates. Veterans at VAMCs in the top decile had an adjusted OR of 12.9 (95% confidence interval = 11.0-15.2) compared to those veterans in the lowest decile. Among veterans with the greatest mortality risk (n = 23 377), 3496 (15.0%) underwent screening (VAMC range = 1.7%-46.3%). After excluding veterans with a prior prostatectomy, PSA elevation, or a potential clinical indication, 31 556 (14.7%) underwent screening (VAMC range = 2.0%-49.9%).

Conclusions: In a national cohort of older veterans, more than one in six received low-value PSA screening, with greater than 10-fold variation across VAMCs and high rates of screening among those with the greatest mortality risk. J Am Geriatr Soc 67:1922-1927, 2019.

Keywords: low-value care; prostate cancer screening; veterans.

Publication types

  • Research Support, N.I.H., Extramural
  • Research Support, U.S. Gov't, Non-P.H.S.

MeSH terms

  • Aged
  • Early Detection of Cancer / statistics & numerical data*
  • Humans
  • Male
  • Medicare
  • Prevalence
  • Prostate-Specific Antigen / blood*
  • Prostatic Neoplasms / diagnosis*
  • Prostatic Neoplasms / epidemiology
  • Retrospective Studies
  • United States / epidemiology
  • United States Department of Veterans Affairs / statistics & numerical data
  • Unnecessary Procedures / statistics & numerical data
  • Veterans / statistics & numerical data*
  • Veterans Health Services / statistics & numerical data*


  • Prostate-Specific Antigen