Low-Value Prostate-Specific Antigen Test for Prostate Cancer Screening and Subsequent Health Care Utilization and Spending

Abstract

Importance: Delivering low-value care can lead to unnecessary follow-up services and associated costs, and such care cascades have not been well examined in common clinical scenarios.

Objective: To evaluate the utilization and costs of care cascades of prostate-specific antigen (PSA) tests for prostate cancer screening, as the routine use of which among asymptomatic men aged 70 years and older is discouraged by multiple guidelines.

Design, setting, and participants: This cross-sectional study included men aged 70 years and older without preexisting prostate conditions enrolled in a Medicare Advantage plan during January 2016 to December 2018 with at least 1 outpatient visit. Medical billing claims data from the deidentified OptumLabs Data Warehouse were used. Data analysis was conducted from September 2020 to August 2021.

Exposures: At least 1 claim for low-value PSA tests for prostate cancer screening during the observation period.

Main outcomes and measures: Utilization of and spending on low-value PSA cancer screening and associated care cascades and the difference in overall health care utilization and spending among individuals receiving low-value PSA cancer screening vs those who did not, adjusting for observed characteristics using inverse probability of treatment weighting.

Results: Of 995 442 men (mean [SD] age, 78.0 [5.6] years) aged 70 years or older in a Medicare Advantage plan included in this study, 384 058 (38.6%) received a low-value PSA cancer screening. Utilization increased for each subsequent cohort from 2016 to 2018 (49 802 of 168 951 [29.4%] to 134 404 of 349 228 [38.5%] to 199 852 of 477 203 [41.9%]). Among those receiving initial low-value PSA cancer screening, 241 188 of 384 058 (62.8%) received at least 1 follow-up service. Repeated PSA testing was the most common, and 27 268 (7.1%) incurred high-cost follow-up services, such as imaging, radiation therapy, and prostatectomy. Utilization and spending associated with care cascades also increased from 2016 to 2018. For every $1 spent on a low-value PSA cancer screening, an additional $6 was spent on care cascades. Despite avoidable care cascades, individuals who received low-value PSA cancer screening were not associated with increased overall health care utilization and spending during the 1-year follow-up period compared with an unscreened population.

Conclusions and relevance: In this cross-sectional study, low-value PSA tests for prostate cancer screening remained prevalent among Medicare Advantage plan enrollees and were associated with unnecessary expenditures due to avoidable care cascades. Innovative efforts from clinicians and policy makers, such as payment reforms, to reduce initial low-value care and avoidable care cascades are warranted to decrease harm, enhance equity, and improve health care efficiency.

Figure 1.. Cascading Care of Low-Value Prostate-Specific Antigen (PSA) Cancer Screening in a Medicare Advantage Population, 2016 to 2018

Figure 2.. Associated Spending of Cascading Care of Low-Value Prostate-Specific Antigen (PSA) Cancer Screening in a Medicare Advantage Population, 2016 to 2018

Figure 3.. Difference-in-Differences (DID) Analysis of Total Health Care Spending Between the Prostate-Specific Antigen (PSA) Screening Group and Non-PSA Screening Group After Inverse Probability Weighting

Those who received the initial low-value PSA cancer screening were associated with increased health care spending by $5980 (95% CI, $5840-$6120) during the 1 year after the PSA screening (mean, $18 330) relative to baseline health care spending during 1-year prior to the PSA screening (mean, $12 350). Those who did not receive PSA screening were associated with increased health care spending by $6290 (95% CI, $6180-$6400). The final DID estimates found that, after accounting for changes from the baseline, the PSA group, on average, spent $310 ($130-$480) less than the non-PSA group.