• Cynthia So, Katharine A Kirby, Kala Mehta, Richard M Hoffman, Adam A Powell, Stephen J Freedland, Brenda Sirovich, Elizabeth M Yano, and Louise C Walter.
• School of Medicine, University of California, San Francisco, CA, USA.
• J Gen Intern Med. 2012 Jun 1; 27 (6): 653660653-60.

BackgroundAlthough guidelines recommend against prostate-specific antigen (PSA) screening in elderly men with limited life expectancy, screening is common.ObjectiveWe sought to identify medical center characteristics associated with screening in this population.Design/ParticipantsWe conducted a prospective study of 622,262 screen-eligible men aged 70+ seen at 104 VA medical centers in 2003.Main MeasuresPrimary outcome was the percentage of men at each center who received PSA screening in 2003, based on VA data and Medicare claims. Men were stratified into life expectancy groups ranging from favorable (age 70-79 with Charlson score = 0) to limited (age 85+ with Charlson score ≥1 or age 70+ with Charlson score ≥4). Medical center characteristics were obtained from the 1999-2000 VA Survey of Primary Care Practices and publicly available VA data sources.Key ResultsAmong 123,223 (20%) men with limited life expectancy, 45% received PSA screening in 2003. Across 104 VAs, the PSA screening rate among men with limited life expectancy ranged from 25-79% (median 43%). Higher screening was associated with the following center characteristics: no academic affiliation (50% vs. 43%, adjusted RR = 1.14, 95% CI 1.04-1.25), a ratio of midlevel providers to physicians ≥3:4 (55% vs. 45%, adjusted RR = 1.20, 95% CI 1.09-1.32) and location in the South (49% vs. 39% in the West, adjusted RR = 1.25, 95% CI 1.12-1.40). Use of incentives and high scores on performance measures were not independently associated with screening. Within centers, the percentages of men screened with limited and favorable life expectancies were highly correlated (r = 0.90).ConclusionsSubstantial practice variation exists for PSA screening in older men with limited life expectancy across VAs. The high center-specific correlation of screening among men with limited and favorable life expectancies indicates that PSA screening is poorly targeted according to life expectancy.

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