Assessment of Care Cascades Following Low-Value Prostate-Specific Antigen Testing Among Veterans Dually Enrolled in the US Veterans Health Administration and Medicare Systems

Abstract

ImportanceOlder US veterans commonly receive health care outside of the US Veterans Health Administration (VHA) through Medicare, which may increase receipt of low-value care and subsequent care cascades.ObjectiveTo characterize the frequency, cost, and source of low-value prostate-specific antigen (PSA) testing and subsequent care cascades among veterans dually enrolled in the VHA and Medicare and to determine whether receiving a PSA test through the VHA vs Medicare is associated with more downstream services.Design, Setting, and ParticipantsThis retrospective cohort study used VHA and Medicare administrative data from fiscal years (FYs) 2017 to 2018. The study cohort consisted of male US veterans dually enrolled in the VHA and Medicare who were aged 75 years or older without a history of prostate cancer, elevated PSA, prostatectomy, radiation therapy, androgen deprivation therapy, or a urology visit. Data were analyzed from December 15, 2020, to October 20, 2022.ExposuresReceipt of low-value PSA testing.Main Outcomes and MeasuresDifferences in the use and cost of cascade services occurring 6 months after receipt of a low-value PSA test were assessed for veterans who underwent low-value PSA testing in the VHA and Medicare compared with those who did not, adjusted for patient- and facility-level covariates.ResultsThis study included 300 393 male US veterans at risk of undergoing low-value PSA testing. They had a mean (SD) age of 82.6 (5.6) years, and the majority (264 411 [88.0%]) were non-Hispanic White. Of these veterans, 36 459 (12.1%) received a low-value PSA test through the VHA, which was associated with 31.2 (95% CI, 29.2 to 33.2) additional cascade services per 100 veterans and an additional $24.5 (95% CI, $20.8 to $28.1) per veteran compared with the control group. In the same cohort, 17 981 veterans (5.9%) received a PSA test through Medicare, which was associated with 39.3 (95% CI, 37.2 to 41.3) additional cascade services per 100 veterans and an additional $35.9 (95% CI, $31.7 to $40.1) per veteran compared with the control group. When compared directly, veterans who received a PSA test through Medicare experienced 9.9 (95% CI, 9.7 to 10.1) additional cascade services per 100 veterans compared with those who underwent testing within the VHA.Conclusions and RelevanceThe findings of this cohort study suggest that US veterans dually enrolled in the VHA and Medicare commonly experienced low-value PSA testing and subsequent care cascades through both systems in FYs 2017 and 2018. Care cascades occurred more frequently through Medicare compared with the VHA. These findings suggest that low-value PSA testing has substantial downstream implications for patients and may be especially challenging to measure when care occurs in multiple health care systems.

Veterans Health Administration (VA) vs. Non-VA Healthcare Quality: A Systematic Review

“…43 In the fifth study (VA: n = 36,469; non-VA: n = 17,981), low-value PSA testing was associated with 9.9 fewer downstream services per 100 Veterans (95% CI 9.7 to 10.1) and $11.9 less spending per Veteran, (95% CI $7.6 to $16.2) in VA compared to non-VA care. 35 In the last study (VA: n = 303; non-VA; n = 242), the numbers of encounters did not significantly differ (p = 0.276) between patients receiving VA tele-mental healthcare or VA-paid, in-person mental healthcare in the community. 18 …”

“…Twenty-five included studies 8 , 11 , 12 , 14 – 16 , 19 – 22 , 24 , 25 , 27 , 28 , 30 , 32 , 33 , 35 , 37 , 39 – 44 met all our risk of bias criteria. These good quality studies were given more weight in our narrative synthesis than studies that did not meet one or more criterion.…”

“…We identified 6 studies reporting on efficiency or cost outcomes: one study analyzed patients with cardiac disease, 11 one study examined imaging in patients with prostate cancer, 30 one study investigated end-of-life care, 19 one study looked at patients undergoing dialysis, 43 another study analyzed low-value prostate-specific antigen testing (PSA), 35 and the last study examined in-person and tele-mental healthcare. 18 Five studies were of good quality, 11 , 19 , 30 , 35 , 43 and one was of fair quality. 18 Cost/efficiency in VA care was equal or mixed to non-VA care in four studies, 11 , 18 , 19 , 43 and better in two studies.…”

“… 18 Cost/efficiency in VA care was equal or mixed to non-VA care in four studies, 11 , 18 , 19 , 43 and better in two studies. 30 , 35 …”

Care cascades following low‐value cervical cancer screening in dually enrolled Veterans

“…[10][11][12] Such dual enrollment has been shown to increase their risk of experiencing healthcare overuse including low-value care cascades. 9,13,14 Whereas rates of low-value cervical cancer screening have been estimated within VA alone, 3,4 low-value cervical cancer screening and subsequent care cascades that Veterans experience both within and outside VA through Medicare have not been characterized. This information is essential when prioritizing and developing interventions and policies aimed at reducing lowvalue care and value-based performance measures among VA-enrolled Veterans.…”