Prostate-Specific Antigen Practices and Outcomes in the Elderly

描述（由申请人提供）：前列腺特异性抗原（PSA）筛查用于前列腺癌的早期发现在美国的老年男性中已被广泛采用，包括那些预期寿命有限的男性。这种筛查是基于一种普遍的信念，即筛查总是最安全的行动方案，尽管PSA筛查的益处不确定。因此，该应用创新性地使用了基于VA和Medicare索赔的数据和电子健康记录，以确定与PSA筛查相关的因素，以及在年龄较大和合共疾病的老年男性中筛查后的下游后果。这包括预期寿命为10年的男性，一些指南建议对他们进行筛查，以及预期寿命有限的男性，筛查不太可能有益。这些数据对于许多考虑进行PSA筛查的老年男性做出知情的筛查决定以及制定质量措施以奖励临床医生避免过度检测是至关重要的。本申请提出了一项队列研究，研究对象为2002年至2003年间在104家退伍军人事务部（VA）就诊的826908名65岁及以上的男性，他们没有前列腺癌病史、PSA升高或前列腺癌症状。VA数据和医疗保险索赔将用于测量2003年期间PSA检测的表现，以及卫生系统、提供者和患者层面的筛查决定因素以及筛查后的下游后果。还将选择男性亚群，以便从电子健康记录中获得有关筛查的其他决定因素和后果的更丰富的临床细节。该项目的目的是：1)确定与老年男性PSA筛查相关的卫生系统、提供者和患者因素，包括高龄和合并症；2)量化在PSA筛查后的3年内，对年龄和合并症范围内的老年男性的实际下游后果（如PSA检测、前列腺活检、癌症诊断、治疗和并发症）；3)确定与这些下游后果相关的卫生系统、提供者和患者因素。将根据预期寿命确定与PSA筛查相关的因素，并启动下游后果级联中的每一步，以确定需要有针对性的干预措施，以阻止老年男性过度检测。公共卫生相关性：这项研究将具有独特的公共卫生重要性，因为它将是最大的“现实世界”研究，根据预期寿命和与这些筛查决定相关的下游后果，如何在老年男性中进行PSA筛查。本研究的结果对于改善老年男性PSA筛查决策以及改善国家筛查指南、决策辅助和该领域的质量措施至关重要。

DESCRIPTION (provided by applicant): Prostate-specific antigen (PSA) screening for the early detection of prostate cancer has been widely adopted in the U.S. among elderly men, including those with limited life expectancy. Such screening is grounded in pervasive beliefs that screening is always the safest course of action, despite the uncertain benefit of PSA screening. Therefore, this application makes innovative use of VA and Medicare claims-based data and electronic health records to determine factors associated with PSA screening and the downstream consequences following screening in elderly men across a spectrum of advancing age and comorbid illness. This includes men with favorable 10-year life expectancy for whom several guidelines recommend screening, and men with limited life expectancy for whom screening is unlikely to be beneficial. Such data are fundamental for informed PSA screening decisions among the many elderly men who are considering screening and for the development of quality measures that reward clinicians for avoiding excessive testing. This application proposes a cohort study of 826,908 men aged 65 years and older who were seen at 104 Veterans Affairs (VA) facilities during 2002 and 2003, without a history of prostate cancer, elevated PSA, or prostate cancer symptoms. VA data and Medicare claims will be used to measure the performance of PSA testing during 2003 as well as the health-system, provider, and patient-level determinants of screening and the downstream consequences following screening. Subsets of men will also be selected to obtain richer clinical detail from electronic health records about additional determinants and consequences of screening. The aims of this project are 1) to determine the health-system, provider, and patient factors associated with PSA screening in elderly men across a spectrum of advancing age and comorbid illness; 2) to quantify the real world downstream consequences (e.g., PSA testing, prostate biopsies, cancer diagnosis, treatment, and complications) during the 3 years following PSA screening in elderly men across a spectrum of advancing age and comorbid illness; and 3) to identify health-system, provider, and patient factors associated with these downstream consequences. Factors associated with PSA screening and initiating each step in the cascade of downstream consequences will be identified according to life expectancy to determine where targeted interventions are needed to discourage excessive testing in elderly men. PUBLIC HEALTH RELEVANCE: This study will have unique public health importance because it will be the largest "real world" study of how PSA screening is being targeted among elderly men according to life expectancy and the downstream consequences associated with these screening decisions. The findings of this study are critical to improving PSA screening decisions in elderly men as well as to improving national screening guidelines, decision aids, and quality measures in this area.