Low-Value PSA Testing Has Cascade Effect for US Veterans

Care cascade after receipt of a low-value prostate-specific antigen (PSA) testing occurred commonly among veterans dually enrolled in the Veterans Health Administration (VHA) and Medicare, according to a study published in JAMA Network Open.

Low-value PSA testing refers to a health service the cost or harms of which exceeds it benefits. A low-value care cascade refers to unnecessary downstream tests, treatments, and visits.

“A substantial proportion of the initial low-value tests and downstream care occurred in non-VHA health care settings through Medicare, demonstrating that we must examine care across multiple health care systems to fully understand and ultimately develop policies to reduce low-value health service use among VHA-enrolled veterans,” study researchers wrote.

The retrospective cohort study used VHA and Medicare administrative data from fiscal years 2017 and 2018 to look at differences in the use and cost of cascade services occurring 6 months after receipt of low-value PSA testing. The study included data from male US veterans aged 75 or older without a history of prostate cancer, elevated PSA, prostatectomy, radiation therapy, androgen deprivation therapy, or a urology visit.

Researchers identified 300,393 veterans at risk for receipt of low-value PSA testing. Of these, 12.1% received a low-value PSA test through the VHA. After adjustment for veteran- and facility-level covariables, receipt of this low-value PSA test was associated with 31.2 additional cascade services per 100 veterans, costing an additional $24.5 per veteran compared with a control group.

These cascade services included 12.3 additional PSA tests per 100 veterans, 9.4 additional related outpatient visits per 100 veterans, and 7.6 additional urology visits. The total cost of these potential cascade services was more than $1.2 million.

A low-value PSA test was given to 5.9% of these veterans through Medicare. This was associated with 39.3 additional cascade services per 100 veterans at a cost of $35.9 per veteran. In this group, the common cascade services included 16.6 additional urology visits per 100 veterans and 13.3 additional PSA tests per 100 veterans. The total cost of these potential cascade services was more than $800,000.

A multivariable analysis showed that veterans who underwent low-value PSA testing through Medicare experienced 5.6 additional cascade services compared with those who had low-value PSA testing within the VHA.

“The total cost of approximately $2 million associated with low-value care cascades was low compared with the $72.3 billion in total VHA expenditures in FY 2018,” the researchers wrote. “However, this does not account for indirect costs such as patient anxiety surrounding false-positive results, inconvenience associated with downstream visits, and risks of invasive procedures.”

Based on the results of this study, the researchers concluded, “we must examine care across multiple health care systems to fully understand and ultimately develop policies to reduce low-value health service use among VHA-enrolled veterans.”

Reference

Assessment of Care Cascades Following Low-Value Prostate-Specific Antigen Testing Among Veterans Dually Enrolled in the US Veterans Health Administration and Medicare Systems