PD32-01 IMPACT OF ACCOUNTABLE CARE ORGANIZATIONS ON PROSTATE SPECIFIC ANTIGEN (PSA) TESTING AND PROSTATE BIOPSY
Amy N. LuckenbaughTudor BorzaSamuel R. KaufmanPhyllis YanLindsey A. HerrelTed A. SkolarusEdward C. NortonFlorian R. SchroeckBruce L. JacobsDavid C. MillerVahakn B. ShahinianBrent K. Hollenbeck
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You have accessJournal of UrologyGeneral & Epidemiological Trends & Socioeconomics: Value of Care: Cost and Outcomes Measures III1 Apr 2017PD32-01 IMPACT OF ACCOUNTABLE CARE ORGANIZATIONS ON PROSTATE SPECIFIC ANTIGEN (PSA) TESTING AND PROSTATE BIOPSY Amy N. Luckenbaugh, Tudor Borza, Samuel R. Kaufman, Phyllis Yan, Lindsey A. Herrel, Ted A. Skolarus, Edward Norton, Florian R. Schroeck, Bruce L. Jacobs, David C. Miller, Vahakn B. Shahinian, and Brent K. Hollenbeck Amy N. LuckenbaughAmy N. Luckenbaugh More articles by this author , Tudor BorzaTudor Borza More articles by this author , Samuel R. KaufmanSamuel R. Kaufman More articles by this author , Phyllis YanPhyllis Yan More articles by this author , Lindsey A. HerrelLindsey A. Herrel More articles by this author , Ted A. SkolarusTed A. Skolarus More articles by this author , Edward NortonEdward Norton More articles by this author , Florian R. SchroeckFlorian R. Schroeck More articles by this author , Bruce L. JacobsBruce L. Jacobs More articles by this author , David C. MillerDavid C. Miller More articles by this author , Vahakn B. ShahinianVahakn B. Shahinian More articles by this author , and Brent K. HollenbeckBrent K. Hollenbeck More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2017.02.1392AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES The USPSTF recommendations against PSA screening for prostate cancer have reduced screening and result in fewer diagnoses. Accountable Care Organizations (ACOs), which aim to improve population health and enhance financial stewardship, have the potential to accelerate the impact of such national recommendations. The extent to which ACOs translate such evidence into practice inevitably will determine their ability to improve value. In this context, we examined the effect of Medicare Shared Savings Program (MSSP) ACO participation on screening PSA tests and prostate biopsy. METHODS We performed a retrospective cohort study using a 20% national Medicare sample to evaluate rates of PSA testing and prostate biopsy among men without prostate cancer between 2010 and 2014. Patients were aligned to ACOs based on MSSP alignment criteria. We measured secular trends over time and performed a difference-in-differences analysis to determine the causal effects of ACOs on rates of PSA testing and prostate biopsy by comparing outcomes in the post-implementation period to the pre-implementation period. RESULTS Among 1.1 million eligible men without prostate cancer, 144,109 (13.7%) were aligned to an ACO. In the non-ACO group we noted a 14% decrease in the annual rate of PSA testing and a 10% decrease in the annual rate of prostate biopsy (both p < 0.001). As shown in the Figure, ACOs had no effect beyond the secular trend on the rate of PSA testing (difference-in-differences estimator p=0.11). However, ACOs accounted a slower decline in the rate of biopsies performed (difference-in-differences estimator p=0.043). CONCLUSIONS Screening PSA testing and prostate biopsy rates decreased significantly over our study period. The rate of PSA testing, the decision for which is largely under the control of primary care physicians, was not affected by ACO participation. Conversely, the rate of prostate biopsy, the decision for which is under the control of urologists, resulted in a slower decrease in biopsy performance among ACO aligned men. Better engagement of ACOs with specialists is necessary for these organizations to achieve their objective. © 2017FiguresReferencesRelatedDetails Volume 197Issue 4SApril 2017Page: e588 Advertisement Copyright & Permissions© 2017MetricsAuthor Information Amy N. Luckenbaugh More articles by this author Tudor Borza More articles by this author Samuel R. Kaufman More articles by this author Phyllis Yan More articles by this author Lindsey A. Herrel More articles by this author Ted A. Skolarus More articles by this author Edward Norton More articles by this author Florian R. Schroeck More articles by this author Bruce L. Jacobs More articles by this author David C. Miller More articles by this author Vahakn B. Shahinian More articles by this author Brent K. Hollenbeck More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...Keywords:
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Prostate cancer screening
Using the 1993-2011 data from the Wisconsin Longitudinal Study ( N = 5,218), we examine prostate cancer screening, mortality after the diagnosis, and health behaviors as potential mechanisms explaining the paradoxical association between men’s higher education and higher prostate cancer risk. Our study combines within-cohort longitudinal hazard models predicting a prostate cancer diagnosis with Monte Carlo simulations estimating the joint effects of socioeconomic differences in prostate cancer screening and mortality after the diagnosis. Our findings strongly suggest that higher utilization of prostate cancer screening and lower mortality after the diagnosis are important explanations for higher prostate rates among more educated men. In addition to applying an innovative method to the issues of prostate cancer incidence and survival, our results have potentially important implications for the current debate about the utility of prostate cancer screening as well as for accurate predictions of future mortality and morbidity trends in the expanding older population.
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Although both PSA nadir (PSAn) and testosterone levels at PSA failure are known prognostic factors in men undergoing radiation therapy (RT) and androgen deprivation therapy (ADT) for unfavorable-risk prostate cancer (PC), it is unclear whether their prognostic significance is independent or overlapping.Seventy-five men treated with RT with or without 6 months of ADT for unfavorable-risk nonmetastatic PC enrolled in 2 prospective clinical trials between 1986 and 2001 formed the study cohort. Competing risks and Cox multivariable regression were used to assess whether low versus normal serum testosterone at the time of PSA failure and higher PSAn after initial therapy were independently associated with the risk of PC-specific (PCSM) and all-cause mortality (ACM) adjusting for PC prognostic factors.After a median follow-up of 15.34 years (interquartile range, 6.66-16.88 years), there were 53 deaths (73.3%): 30 (56.6%) were from PC. Low testosterone at PSA failure was significantly associated with an increased risk of PCSM (adjusted HR [AHR], 7.77; 95% CI, 1.14-52.99; P = .04) and ACM (AHR, 3.01; 95% CI, 1.01-8.96; P = .05), as was higher PSAn (PCSM AHR, 1.03; 95% CI, 1.01-1.05; P < .01; ACM AHR, 1.04; 95% CI, 1.02-1.07; P < .01), although the prognostic significance of PSAn was only noted in men with a normal testosterone at PSA failure.Low testosterone level at PSA failure in high-risk patients with PC treated with RT is associated with increased PCSM and ACM risk. In men with normal testosterone levels at the time of PSA failure, an elevated PSAn was associated with worse PCSM and ACM risk.This study investigates whether the prostate-specific antigen (PSA) nadir and normal versus low testosterone at the time of PSA failure provide mutually exclusive or overlapping prognostic information following treatment with radiation and androgen deprivation therapy for unfavorable-risk patients with prostate cancer using data from 2 prospective clinical trials. It was found that both provided prognostic information; however, higher PSA nadir was only found to be of prognostic significance in men with normal testosterone levels at PSA failure.
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Dissemination of prostate-specific antigen (PSA) testing in the United States coincided with an increasing incidence of prostate cancer, a shift to earlier stage disease at diagnosis, and decreasing prostate cancer mortality. We compared PSA screening performance with respect to prostate cancer detection in the US population vs in the Rotterdam section of the European Randomized Study of Screening for Prostate Cancer (ERSPC-Rotterdam). We developed a simulation model for prostate cancer and PSA screening for ERSPC-Rotterdam. This model was then adapted to the US population by replacing demography parameters with US-specific ones and the screening protocol with the frequency of PSA tests in the US population. We assumed that the natural progression of prostate cancer and the sensitivity of a PSA test followed by a biopsy were the same in the United States as in ERSPC-Rotterdam. The predicted prostate cancer incidence peak in the United States was then substantially higher than the observed prostate cancer incidence peak (13.3 vs 8.1 cases per 1000 man-years). However, the actual observed incidence was reproduced by assuming a substantially lower PSA test sensitivity in the United States than in ERSPC-Rotterdam. For example, for nonpalpable local- or regional-stage cancers (ie, stage T1M0), the estimates of PSA test sensitivity were 0.26 in the United States vs 0.94 in ERSPC-Rotterdam. We conclude that the efficacy of PSA screening in detecting prostate cancer was lower in the United States than in ERSPC-Rotterdam.
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To clarify the recent trends in prostate-specific antigen (PSA) distribution in men in Japan, we analyzed the PSA distributions of men undergoing PSA-based population screening. We summarized the annual individual data of PSA-based population screening in Kanazawa, Japan, from 2000 to 2011, and analyzed baseline serum PSA values of the participants at the first population screening. Serum PSA distributions were estimated in all participants and those excluding prostate cancer patients according to age. From 2000 to 2011, 19 620 men participated aged 54-69 years old in this screening program. Mean baseline serum PSA level of all participants at the first screening was 2.64 ng ml−1 in 2000, and gradually decreased to approximately 1.30 ng ml−1 in 2006. That of participants excluding prostate cancer patients was 1.46 ng ml−1 in 2000, and there was no remarkable change during the study period. The 95 th percentiles in the participants excluding prostate cancer patients detected at the first population screening of men aged 54-59, 60-64, and 65-69 years old were 2.90, 3.60, and 4.50 ng ml−1 , respectively. After the commencement of population screening, the proportion of prostate cancer patients with high serum PSA levels decreased. However, there were no changes in serum PSA levels in men without prostate cancer. Age-specific PSA reference level of men without prostate cancer in Japan was similar to that in China and Korea.
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Even when a screening study has demonstrated a mortality reduction, the degree of pre-testing and contamination is of importance as it can dilute the "true" effect of screening. Our object was to describe the level of pre-testing and contamination in the Göteborg-1 prostate cancer screening trial.A total of 20,000 men, 50-64 years old, were invited in 1994 and randomized to either a screening group (offered prostate specific antigen testing every 2 years) or to a control group. Follow-up was through December 31, 2014. Outcome measurement was overall testing in the screening group and control group. A positive prostate specific antigen test was defined as a prostate specific antigen ≥3 ng/ml.In the study, 4.2% in the screening group and 4.6% men in the control group were tested before study start. During follow-up, 72% in the control group took at least 1 prostate specific antigen test (contamination) compared to 87% of men in the screening group. Of all prostate specific antigens, 24% in the screening group and 39% in the control group were above threshold. In total, 66% of the men underwent prostate biopsy within 12 months from a raised prostate specific antigen in the screening group and 28% in the control group.Similar proportions of men were prostate specific antigen-tested in both the screening group and control group, yet only a minority of contamination prostate specific antigens led to biopsy. Also, men in the screening group started screening at a younger age. These could both be explanations for our result that organized screening is more effective in reducing prostate cancer mortality than non-organized testing. When carried out properly and compared to an unscreened population, the effects of organized screening are likely even greater than previously shown in the Göteborg screening trial.
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