Kerfoot B Price, Holmberg Erika F, Lawler Elizabeth V, Krupat Edward, Conlin Paul R
VA Boston Healthcare System, 150 S Huntington Ave, 151DIA, Jamaica Plain, MA 02130, USA.
Arch Intern Med. 2007 Jul 9;167(13):1367-72. doi: 10.1001/archinte.167.13.1367.
None of the major clinical practice guidelines recommend that prostate-specific antigen (PSA) screening be routinely performed in asymptomatic men older than 75 years or younger than 40 years. We investigated the practitioner-level determinants of inappropriate PSA screening in 7 Veterans Health Administration (VHA) hospitals.
Data on PSA test use from 1997 to 2004 were obtained from VHA databases for 181 139 male patients and the 4823 health care providers who ordered their tests. Patients were excluded from the study population if they underwent PSA testing for nonscreening reasons, as indicated by prostate cancer-specific medications, diagnoses, and procedures. Inappropriate PSA test use was defined as PSA screening in patients older than 75 years or younger than 40 years. Univariate and multivariate Poisson regressions were performed.
The mean +/- SD percentage of inappropriate tests by health care provider was 19.3% +/- 15.0%, with 18.4% +/- 14.9% in patients older than 75 years and 0.8% +/- 3.0% in patients younger than 40 years. Practitioners who were urology specialists, male, infrequent PSA test 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. Under multivariate modeling, infrequent PSA test ordering and hospital affiliation retained statistical significance. The percentage of inappropriate PSA screening increased significantly with the age of male health care providers (P<.001).
This study elucidates several important provider-level determinants of PSA screening misuse and substantiates that PSA screening is frequently performed counter to evidence-based guidelines. Further work is needed to determine the degree to which "prostatempathy" contributes to PSA misuse by older male providers.
尚无主要临床实践指南推荐对75岁以上或40岁以下无症状男性常规进行前列腺特异性抗原（PSA）筛查。我们调查了7家退伍军人健康管理局（VHA）医院中不适当PSA筛查的从业者层面的决定因素。
从VHA数据库获取1997年至2004年181139名男性患者及其4823名开具检测医嘱的医疗服务提供者的PSA检测使用数据。如果患者因前列腺癌特异性药物、诊断和手术等非筛查原因接受PSA检测，则将其排除在研究人群之外。不适当的PSA检测使用定义为对75岁以上或40岁以下患者进行PSA筛查。进行了单变量和多变量泊松回归分析。
医疗服务提供者不适当检测的平均±标准差百分比为19.3%±15.0%，其中75岁以上患者为18.4%±14.9%，40岁以下患者为0.8%±3.0%。泌尿外科专科医生、男性、较少开具PSA检测医嘱以及隶属于特定医院的从业者，其不适当PSA筛查水平显著更高。与主治医师相比，护士和医师助理的不适当筛查水平显著更低。在多变量模型中，较少开具PSA检测医嘱和医院隶属关系仍具有统计学意义。不适当PSA筛查的百分比随男性医疗服务提供者年龄的增加而显著增加（P<0.001）。
本研究阐明了PSA筛查滥用的几个重要的提供者层面的决定因素，并证实PSA筛查经常违背循证指南进行。需要进一步开展工作以确定“前列腺同理心”在老年男性提供者滥用PSA方面的影响程度。
