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Study identifies characteristics of clinicians likely to order inappropriate prostate screenings

July 10, 2007

Prostate-specific antigen (PSA) tests to screen for prostate cancer are frequently performed among patients for whom the PSA test is not shown to be beneficial, and clinicians with certain characteristics are more likely to order such inappropriate screening tests, according to a report in the July 9 issue of Archives of Internal Medicine, one of the JAMA/Archives journals.

Most guidelines for clinical practice do not recommend routine PSA screening for men younger than 40, older than 75 or who are expected to live less than 10 years, according to background information in the article. "To our knowledge, there is currently no solid evidence that PSA screening provides any health benefits for these patient populations," the authors write. "Rather, it imposes substantial psychological and financial costs and may lead to diagnostic and therapeutic procedures of questionable benefit." Because the ultimate decision to perform PSA testing rests with the clinician, it is likely that demographic and other characteristics of physicians, nurses and physician assistants may influence inappropriate screening behaviors.

B. Price Kerfoot, M.D., Ed.M., of the Veterans Affairs Boston Healthcare System and Harvard Medical School, Boston, and colleagues analyzed data from 105,765 male patients who were treated at Veterans Health Affairs (VHA) facilities in New England from 1997 to 2004. Information about the patients and the 1,552 health care clinicians who ordered PSA tests was gathered from VHA databases. Inappropriate screening was defined as PSA testing in patients older than 75 or younger than 40 who had not been diagnosed with prostate cancer, were not taking prostate cancer-specific medications or had not undergone related procedures.

Of the 232,302 PSA tests ordered during the study period, 37,483 (16.1 percent) were considered inappropriate, with 35,612 (15.3 percent) performed in patients older than 75 years and 1,871 (0.8 percent) in patients younger than 40 years. Of the health care clinicians who ordered inappropriate tests, 51.3 percent were male, 79.4 percent were physicians, 53.4 percent were trainee physicians and 8.2 percent were urologists. "Practitioners who were urology specialists, male, infrequent PSA tests orderers and affiliated with specific hospitals had significantly higher levels of inappropriate PSA screening. Compared with attending physicians, nurses and physician assistants had significantly lower levels of inappropriate screening," the authors write.

"The percentage of inappropriate PSA screening increased significantly with the age of male health care providers," they continue. "The cause of these sex and age differences is not clear. It is possible that, as they age, male health care providers increasingly empathize with their older male patients over prostate cancer concerns. Their 'prostatemphathy' may then lead to more aggressive screening in these older male patients."

Patient education and systems-level changes, such as a computerized system that could alert clinicians when they attempt to order an inappropriate PSA test, could help reduce the level of PSA screening misuse, the authors conclude.

JAMA and Archives Journals