Clinician characteristics affect likelihood of PSA testing in older men


A new article in JAMA Internal Medicine has quantified (to some extent) how characteristics of clinicians affect the probability of older men being given PSA tests within the Veterans Administration health system here in the US.

Tang et al. set out to explore the degree to which clinician characteristics were associated with PSA screening rates among older US veterans stratified by life expectancy. To do this, they studied available data from 826,286 veterans, all aged 65 years or older, who were eligible for PSA screening and who had VA laboratory tests performed in 2011 within the VA health care system.

The primary outcome for this study was the percentage of men who were given a screening PSA test in 2011. However, it is important to understand how they defined certain patient and clinician characteristics in conducting this study. For example:

  • Limited patient life expectancy was defined as
    • Either age of at least 85 years with a Charlson comorbidity score of 1 or greater
    • Or age of at least 65 years with a Charlson comorbidity score of 4 or greater
  • Clinician characteristics including degree-training level, specialty, age, and sex.

Here are the core findings from the study, based on the 2011 data:

  • 466,017/826,286 (56.4 percent) of veterans of ≥ 65 years received PSA screening tests
  • PSA screening tests were given to 39 percent of 203,717 men with limited life expectancies (as defined above).
  • Ranges for PSA screening rates were
    • From 27 percent for men whose clinician was a physician in training to 42 percent for men whos clinician was an attending physician (P < 0.001)
    • From 22 percent for men whose clinician was a geriatrician to 82 percent for men whose clinician was a urologist (P < 0.001)
    • From 29 percent for men whose clinician was ≤ 35 years old to 41 percent for men whose clinician was ≥ 56 years old (P  < 0.001)
    • From 38 percent for men whose clinician was female and > 55 years to 43 percent for men whose clinician was male and > 55 years (P < 0.001).

In other words, men with limited life expectancies were more likely to get a screening PSA test if their clinician was an older male who was no longer in training.

Tang et al. draw four basic conclusions:

  • That more than a third of the men with limited life expectancies were being screened with PSA tests.
  • That veterans whose clinician was a physician still in training had substantially lower PSA screening rates than those with an attending physician, nurse practitioner, or physician assistant.
  • That educational interventions are needed (at least in the VA health system) to reduce PSA screening rates in older men with limited life expectancies.
  • That for greatest impact such educational interventions should be designed and targeted to high-screening clinicians, i.e., older, male, non-trainee clinicians.

How one reacts to these data and the authors’ conclusions may be influenced by one’s personal beliefs about the value of PSA testing among asymptomatic men with limited life expectancies (and how the authors defined limited life expectancy). Your sitemaster would tend to agree with the authors that a testing rate of nearly 40 percent among such men was high, although he is by no mean suggesting that none of these men should have been tested at all. That would depend on a variety of other factors. For example, some of these men may have been being tested because their PSA had been rising for years and they were being monitored to see if and when a bone scan might be appropriate because they were, to all intents and purposes, on watchful waiting, even though they had never been formally diagnosed with prostate cancer.

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