Wednesday, May 23, 2012

Better Care, Better Health, Better Value … and PSA Testing

Vince Fonseca, MD, MPH, FACPM, is founder of the Population Health Institute of Texas and director of medical informatics at Intellica.

Only by physicians working together with our peers, patients, employers, insurers, health care organizations, and community groups will we get better care, better health, and better value in Texas. We, and the nation, have a long way to go along this journey, but we can see what the next steps should be.

The latest U.S. Preventive Services Task Force (USPSTF) recommendation on PSA prostate cancer screening provides a good opportunity to work on these issues. The benefits of prostate cancer screening and treatment in a cohort of 3,000 55- to 69-year-old men for 10 years are very small: zero to three lives saved. The harms in this cohort are much larger: Ninety to 120 men will develop erectile dysfunction or urinary incontinence; six men will experience a serious cardiovascular event (e.g., heart attack); one man will develop a serious blood clot; and one man will die of surgical complications. This is why USPSTF recommends to not routinely screen men but to engage the patient in shared decisionmaking about whether to initiate or continue PSA screening …and why Otis Brawley, MD, chief medical officer of the American Cancer Society (ACS), agrees with the new recommendation.

So how do we put this into practice? Whether or not to be screened is a decision each man should make once he understands the facts and based on his own values and preferences. It will take a persistent, committed, multitargeted effort to do better in decreasing the impact of cancer in Texas, especially related to prostate cancer. Even after the 2008 USPSTF recommendation to not do PSA screening routinely in men over 75 years old, 60 percent of men over 75 had PSA testing in 2010, according to the Center for Disease Control and Prevention’s Behavioral Risk Factor Surveillance System … the same proportion as before the recommendation in 2006. The 2012 USPSTF recommendation, without supporting activities, is likely to return similar results.

Better Care 
Physicians and other providers will need to put evidenced-based recommendations into practice and have patients participate in shared decisionmaking in areas such as PSA screening. Patient satisfaction increases when patients participate in shared decisionmaking. Since this approach is different from what most of us learned in medical school, residency, and continuing education, there will be challenges and barriers. But we can begin to decrease the barriers by having materials available to patients and providing opportunity for patients to ask questions with appropriate clinical staff before they see their doctor.

Physicians and other providers need to understand the science behind the recommendations. Physicians can redouble efforts to develop evidence-based education, training, and tools around cancer prevention and screening. USPSTF has a good set of materials available on PSA screening.

Groups like ACS can promote patient-centered educational materials about risks and benefits and why patients may not want to participate in the health fair or shopping mall “free” PSA screening.

Better Health
Population health is improved by delivering the appropriate amount/frequency of services that will maximize the benefits and minimize harms. This means performing fewer PSA screenings, and the way to do this is to provide better care.

Better Value 
Improving the value received for health-related expenditures means maximizing the net benefit (benefits minus harms) divided by expenditures. We want the best value for health expenditures. This means providing more high-value services and fewer low-value services. Employers who purchase commercial insurance, Medicaid, and Medicare all have struggled with the increases in health care expenditures that are larger than then the accompanying increases in health (i.e., lower value) over recent years. Decreased use of PSA screening (a low-value service) will result in better value (through lower costs) and better health (through fewer harms).

USPSTF summarizes the PSA screening issue well:
“Prostate cancer is a serious health problem that affects thousands of men and their families. But before getting a PSA test, all men deserve to know what the science tells us about PSA screening: There is a very small potential benefit and significant potential harms. We encourage clinicians to consider this evidence and not screen their patients with a PSA test unless the individual being screened understands what is known about PSA screening and makes the personal decision that even a small possibility of benefit outweighs the known risk of harms.”
                 — USPSTF Co-Chair Michael LeFevre, MD, MSPH, May 22, 2012

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