- Design
- Retrospective cohort study using linked VA-Medicare data, 2004 to 2023
- Population
- 1.41 million male veterans aged 65 or over, 8.67 million person-years
- Primary outcome
- PSA testing and prostate biopsy rates per 1,000 person-years
- Effect
- Age 80 or over: PSA 187.9 vs 267.9 per 1,000 person-years, IRR 0.70 (95% CI 0.69 to 0.71)
This retrospective cohort study used linked US Department of Veterans Affairs (VA) and fee-for-service Medicare data from 2004 to 2023 in 1.41 million male veterans aged 65 or older (8.67 million person-years). It compared PSA testing and prostate biopsy rates between VA primary care and fee-for-service Medicare primary care, stratified by age and predicted life expectancy.
From 2018 to 2023, among men aged 80 or over, adjusted PSA testing was 187.9 per 1,000 person-years in VA primary care against 267.9 in Medicare (IRR 0.70, 95% CI 0.69 to 0.71); biopsy rates were 3.38 against 5.05 (IRR 0.67, 0.60 to 0.75). Among men with a predicted life expectancy under five years, testing was also lower in VA care (IRR 0.84, 0.82 to 0.86). In men aged 65 to 69, testing was higher in VA care (IRR 1.10, 1.09 to 1.11).
The study measures testing patterns, not whether any man benefited or was harmed, and the setting differences may reflect the VA's population and policies. It is US data from two payment systems and does not describe screening practice in India.
- Ask whether a PSA is being repeated in a man whose life expectancy is short.
- Consider age and predicted life expectancy when deciding whether to offer PSA screening.
- Testing rates in men aged 80 or over differed by 30% between the two settings, whatever the reason.
- Check your own clinic's PSA ordering for men over 80.
Why it matters
It raises the question of whether the way care is organised, not only individual clinicians, shapes low-value testing.
Don't overread it
This describes testing rates in two US systems and cannot show which rate leads to better outcomes.
The statistics, in plain English
An incidence rate ratio of 0.70 means 30% fewer tests per person-year in one setting than the other, after adjustment. It says nothing about whether the lower rate was the right one for any individual.
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