Low-Value Prostate-Specific Antigen Test for Prostate Cancer Screening and Subsequent Health Care Utilization and Spending

Abstract

ImportanceDelivering low-value care can lead to unnecessary follow-up services and associated costs, and such care cascades have not been well examined in common clinical scenarios.ObjectiveTo evaluate the utilization and costs of care cascades of prostate-specific antigen (PSA) tests for prostate cancer screening, as the routine use of which among asymptomatic men aged 70 years and older is discouraged by multiple guidelines.Design, Setting, and ParticipantsThis cross-sectional study included men aged 70 years and older without preexisting prostate conditions enrolled in a Medicare Advantage plan during January 2016 to December 2018 with at least 1 outpatient visit. Medical billing claims data from the deidentified OptumLabs Data Warehouse were used. Data analysis was conducted from September 2020 to August 2021.ExposuresAt least 1 claim for low-value PSA tests for prostate cancer screening during the observation period.Main Outcomes and MeasuresUtilization of and spending on low-value PSA cancer screening and associated care cascades and the difference in overall health care utilization and spending among individuals receiving low-value PSA cancer screening vs those who did not, adjusting for observed characteristics using inverse probability of treatment weighting.ResultsOf 995 442 men (mean [SD] age, 78.0 [5.6] years) aged 70 years or older in a Medicare Advantage plan included in this study, 384 058 (38.6%) received a low-value PSA cancer screening. Utilization increased for each subsequent cohort from 2016 to 2018 (49 802 of 168 951 [29.4%] to 134 404 of 349 228 [38.5%] to 199 852 of 477 203 [41.9%]). Among those receiving initial low-value PSA cancer screening, 241 188 of 384 058 (62.8%) received at least 1 follow-up service. Repeated PSA testing was the most common, and 27 268 (7.1%) incurred high-cost follow-up services, such as imaging, radiation therapy, and prostatectomy. Utilization and spending associated with care cascades also increased from 2016 to 2018. For every $1 spent on a low-value PSA cancer screening, an additional $6 was spent on care cascades. Despite avoidable care cascades, individuals who received low-value PSA cancer screening were not associated with increased overall health care utilization and spending during the 1-year follow-up period compared with an unscreened population.Conclusions and RelevanceIn this cross-sectional study, low-value PSA tests for prostate cancer screening remained prevalent among Medicare Advantage plan enrollees and were associated with unnecessary expenditures due to avoidable care cascades. Innovative efforts from clinicians and policy makers, such as payment reforms, to reduce initial low-value care and avoidable care cascades are warranted to decrease harm, enhance equity, and improve health care efficiency.

Opportunistic prostate‐specific antigen testing in Norwegian men: a public health challenge

“…States the USPSTF recommends against PSA screening for prostate cancer in men aged ≥70 years, but a recent report documented that >40% of men in the USA aged >70 years underwent PSA testing in 2018 [23].…”

“…NICE in the UK recently suggested the following guidelines for referral to a specialist: >2.5, >3.5, >4.5 and >6.5 ng/mL for men aged 40–49, 50–59, 60–69, and 70–79 years, respectively [22]. In the United States the USPSTF recommends against PSA screening for prostate cancer in men aged ≥70 years, but a recent report documented that >40% of men in the USA aged >70 years underwent PSA testing in 2018 [23].…”

“…Unfortunately, screening using a clinical cascade raises new concerns. A recent cross‐section study of almost 1 million United States men aged ≥70 years, without pre‐existing conditions enrolled in a Medicare Advantage Plan from 2016 to 2018, revealed that 38% had received a PSA test and 63% received follow‐up tests [23]. In all, 7% of the men tested subsequently underwent imaging, prostate biopsy and radiation therapy or prostatectomy.…”

Association of Frailty and Complications Following Prostate Biopsy: Results From a Population-Based, Privately Insured Cohort

“…7 Despite guideline recommendations against prostate cancer (PCa) screening for men with limited life expectancy, its rates remain exceedingly elevated at around 38.6% among older patients. 8,9 While age is an important factor in decisionmaking, providers are often faced with a clinical dilemma when deciding whether to proceed with prostate needle biopsy (PNBx) in the setting of frailty. Despite the known morbidity associated with this procedure, clinicians lack validated tools to estimate the risk of complications, particularly among elderly patients with functional decline.…”

PSA testing in older men adds unnecessary expenditures to Medicare Advantage plans

“…The use of low‐value prostate‐specific antigen (PSA) tests for prostate cancer screening in men aged 70 years or older remains prevalent among Medicare Advantage plans and is associated with unnecessary expenditures according to a study published in JAMA Network Open 1 …”