Maine Medical Center Research Institute, Portland, Maine.
Tufts University School of Medicine, Boston, Massachusetts.
J Urol. 2021 Jun;205(6):1641-1647. doi: 10.1097/JU.0000000000001594. Epub 2021 Feb 3.
Medicaid expansion under the Patient Protection and Affordable Care Act occurred almost concurrently with 2012 U.S. Preventive Services Task Force recommendations against prostate specific antigen screening. Here the relative influence on prostate specific antigen screening rates by 2 concurrent and opposing system-level policy initiatives is investigated: improved access to care and change in clinical practice guidelines.
Behavioral Risk Factor Surveillance System data from years 2012 to 2018 were analyzed for trends in self-reported prostate specific antigen screening and insurance coverage. Subanalyses included state Medicaid expansion status and respondent federal poverty level. Multivariable logistic regression was performed to evaluate factors associated with prostate specific antigen screening.
From 2012 to 2018 prostate specific antigen screening predominantly declined with a notable exception of an increase of 7.3% for men at <138% federal poverty level between 2011 and 2013 in early expansion states. Initial increases did not continue, and screening trends mirrored those of nonexpansion states by 2018. Notably, 2014 planned expansions states did not follow this trend with minimal change between 2015 and 2017 compared to declines in early expansion states and nonexpansion states (-0.4% vs -6.7% and -8.6%, respectively).
Medicaid expansion was associated with increased rates of insured men at <138% federal poverty level from 2012 to 2018 in early expansion states. In this group, initial increases in prostate specific antigen screening were not durable and followed the trend of reduced screening seen across the United States. In planned expansions states the global drop in prostate specific antigen screening from 2016 to 2018 was offset in men at <138% federal poverty level by expanding access to care. Nonexpansion states showed a steady decline in prostate specific antigen screening rates. This suggests that policy such as U.S. Preventive Services Task Force recommendations against screening competes with and often outmatches access to care.
《患者保护与平价医疗法案》（Patient Protection and Affordable Care Act）下的医疗补助计划扩大几乎与 2012 年美国预防服务工作组（U.S. Preventive Services Task Force）反对前列腺特异性抗原筛查的建议同时发生。本研究旨在探讨同时存在的两种系统层面政策举措对前列腺特异性抗原筛查率的相对影响：改善获得医疗服务的机会和临床实践指南的变化。
分析 2012 年至 2018 年期间行为风险因素监测系统（Behavioral Risk Factor Surveillance System）数据，以了解自我报告的前列腺特异性抗原筛查和保险覆盖情况的趋势。亚分析包括州医疗补助计划的扩大情况和受访者的联邦贫困水平。采用多变量逻辑回归评估与前列腺特异性抗原筛查相关的因素。
2012 年至 2018 年，前列腺特异性抗原筛查率主要呈下降趋势，但在 2011 年至 2013 年期间，联邦贫困水平低于 138%的男性筛查率增加了 7.3%，这是一个显著的例外。最初的增长并未持续，到 2018 年，筛查趋势与非扩张州的趋势一致。值得注意的是，2014 年计划扩张的州并没有遵循这一趋势，与早期扩张州和非扩张州相比，2015 年至 2017 年期间的变化微乎其微（分别为-0.4%、-6.7%和-8.6%）。
在早期扩张的州，医疗补助计划的扩大与 2012 年至 2018 年间联邦贫困水平低于 138%的男性中保险覆盖人数的增加有关。在这一人群中，前列腺特异性抗原筛查的最初增加是不可持续的，并且遵循了全美范围内筛查减少的趋势。在计划扩张的州，由于扩大了获得医疗服务的机会，2016 年至 2018 年期间前列腺特异性抗原筛查的全球下降趋势在联邦贫困水平低于 138%的男性中得到了弥补。非扩张州的前列腺特异性抗原筛查率持续下降。这表明，诸如美国预防服务工作组反对筛查的建议等政策与获得医疗服务的机会竞争，并且通常超过后者。
