Reducing PSA-Based Prostate Cancer Screening in Men Aged 75 Years and Older with the Use of Highly Specific Computerized Clinical Decision Support

Abstract

INTRODUCTION:In 2012, the Veterans Health Administration (VHA) implemented guidelines seeking to reduce PSA-based screening for prostate cancer in men aged 75 years and older. OBJECTIVES: To reduce the use of inappropriate PSAbased prostate cancer screening among men aged 75 and over. SETTING: The Veterans Affairs Greater Los Angeles Healthcare System (VA GLA) PROGRAM DESCRIPTION: We developed a highly specific computerized clinical decision support (CCDS) alert to remind providers, at the moment of PSA screening order entry, of the current guidelines and institutional policy. We implemented the tool in a prospective interrupted time series study design over 15 months, and compared the trends in monthly PSA screening rate at baseline to the CCDS on and off periods of the intervention. RESULTS: A total of 30,150 men were at risk, or eligible, for screening, and 2,001 men were screened. The mean monthly screening rate during the 15-month baseline period was 8.3 %, and during the 15-month intervention period, was 4.6 %. The screening rate declined by 38 % during the baseline period and by 40 % and 30 %, respectively, during the two periods when the CCDS tool was turned on. The screening rate ratios for the baseline and two periods when the CCDS tool was on were 0.97, 0.78, and 0.90, respectively, with a significant difference between baseline and the first CCDS-on period (p<0.0001), and a trend toward a difference between baseline and the second CCDS-on period (p=0.056). CONCLUSION: Implementation of a highly specific CCDS tool alone significantly reduced inappropriate PSA screening in men aged 75 years and older in a reproducible fashion. With this simple intervention, evidence-based guidelines were brought to bear at the point of care, precisely for the patients and providers for whom they were most helpful, resulting in more appropriate use of medical resources.

The Roles of Providers and Patients in the Overuse of Prostate-Specific Antigen Screening in the United States

“…We are impressed with studies that suggest the power of discussions about the benefits and harms of screening between physicians and patients (3) and that the physician’s approach to over- and underdiagnoses affects how those discussions unfold (4). We also recommend a highly specific computerized clinical decision-support tool that reminds physicians about current guidelines when they order PSA screening because it seems to reduce overuse in men older than 75 years (5). …”

Protocol: A Multi-Modal, Physician-Centered Intervention to Improve Guideline-Concordant Prostate Cancer Imaging

“…A Clinical Order Check is an evidence-based, systems-level method to affect behavior change. 16,[25][26][27] It addresses the intervention functions of education, enablement and incentivization which are effective methods to change behaviors driven by beliefs about capabilities, knowledge, social influences, beliefs about consequences, and environmental context and resources; all domains previously established to be associated with prostate cancer imaging. 4,28,29 All VA facilities currently use locally adapted clinical reminders.…”

Caring for the Complex Patient: The Next Hurdle for Information Technology Is Care Coordination

“…1 He had suffered at least six documented infections in the past 21 months. He looked well, but complained of frequency, dysuria, and mild right-sided flank pain.…”

“…In this issue of JGIM, four articles address technological solutions to high-value care, two from the clinician's perspective and two from the patient's. The first piece, authored by Shelton et al, addresses a relatively simple problem in an elegant way 1 . The problem is too many prostate-specific antigen (PSA) tests in men over age 75, a group in which such testing should occur selectively, if at all.…”