Preventive Medicine Reports 14 (2019) 100838

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Preventive Medicine Reports

journal homepage: www.elsevier.com/locate/pmedr

Short communication

Brief report: Impact of healthcare quality on prostate specific antigen

screening for the early detection of prostate cancer
⁎
Michael E. Rezaeea, , Charlotte E. Wardb,c, Einar F. Sverrissona, Lawrence M. Dagrosaa
a
Section of Urology, Department of Surgery, Dartmouth-Hitchcock Medical Center, One Medical Center Drive, Lebanon, NH 03766, United States of America
b
Center for Healthcare Studies, Feinberg School of Medicine, Northwestern University, Chicago, IL 60007, United States of America
c
Center for Health Statistics, University of Chicago, Chicago, IL 60007, United States of America

A R T I C LE I N FO A B S T R A C T

Keywords: With recent guidelines emphasizing patient values, patient preferences and shared decision-making in regards to
Prostate cancer prostate specific antigen (PSA) screening it is important for primary care providers and urologists to identify
Cancer screening factors that influence men's decisions to undergo PSA screening. We sought to evaluate the impact of men's
Public health perceptions of healthcare quality on obtaining a screening PSA for the early detection of prostate cancer. A
PSA screening
retrospective secondary data analysis was conducted of men ages 55–69 without a history of prostate cancer
Men's health
using 2015 Medical Expenditure Panel Survey (MEPS) data. The relationship between Consumer Assessment of
Prostate cancer
Primary care Healthcare Providers and Systems (CAHPS) questions captured in MEPS and PSA screening in the last two years
Healthcare quality were assessed using multiple logistic regression. The analysis was carried out in October 2018 at Dartmouth-
Hitchcock Medical Center. The final survey sample consisted of 1249 men that equated to 15,313,605.5 once
weighted; 69.5% underwent PSA screening. Men who were offered help with filling out forms in the office (OR:
1.86, 95% CI: 1.14–3.01) or rated the quality of healthcare from their doctors ≥7 (OR: 1.63, 95% CI: 1.10–2.44)
on a scale from 0 (worst healthcare) to 10 (best health care) had significantly greater adjusted odds of under-
going PSA screening. Men who rated the quality of healthcare delivered to them as high had significantly greater
odds of undergoing PSA screening compared to those who rated it lower. Our results may suggest that im-
provements in healthcare quality and patient experience of care have the potential to positively influence PSA
screening.

1. Introduction between patient age, education, Caucasian race, income, insurance

coverage, and attitudes towards physicians and PSA screening
The use of prostate specific antigen (PSA) screening for the early (Ogunsanya et al., 2016; Abuadas et al., 2016; Ross et al., 2009).
detection of prostate cancer remains controversial. The American However, limited evidence exists regarding how healthcare quality may
Urological Association and United States Preventive Services Task Force influence men's decisions to pursue PSA screening. The purpose of this
currently recommend shared decision-making for men ages 55 to 69 analysis was to evaluate the impact of men's perceptions of healthcare
who are considering PSA screening and proceeding based on a patient's quality on PSA screening for the early detection of prostate cancer.
values and clinical circumstances (U.S. Preventive Services Task Force,
2018; American Urological Association, 2018). In this conversation, the 2. Methods
benefits of reducing metastatic prostate cancer diagnoses and prostate
cancer-specific mortality are weighed against the potential harms of A retrospective secondary data analysis of 2015 Medical
over-diagnosis and treatment (Aus et al., 2007; Loeb et al., 2014). Expenditure Panel Survey (MEPS) data was conducted on men ages 55
With increased emphasis being placed on men's values, preferences, to 69 years without a history of prostate cancer (Agency for Healthcare
and shared-decision making, it has become increasingly more important Research and Quality, 2017). As MEPS data is publicly available, in-
to understand what factors influence patient decisions to undergo PSA stitutional review board approval was not required. However, the study
screening. Prior research has demonstrated a positive relationship was conducted in accordance with the Declaration of Helsinki (World

⁎
Corresponding author at: Section of Urology, Department of Surgery, Dartmouth Hitchcock Medical Center, Lebanon, NH, United States of America.
E-mail addresses: [email protected] (M.E. Rezaee), [email protected] (C.E. Ward),
[email protected] (E.F. Sverrisson), [email protected] (L.M. Dagrosa).

https://doi.org/10.1016/j.pmedr.2019.100838
Received 23 November 2018; Received in revised form 17 February 2019; Accepted 23 February 2019
Available online 25 February 2019
2211-3355/ © 2019 The Authors. Published by Elsevier Inc. This is an open access article under the CC BY license
(http://creativecommons.org/licenses/BY/4.0/).
M.E. Rezaee, et al. Preventive Medicine Reports 14 (2019) 100838

Table 1
Patient demographics and healthcare quality questions by PSA screening status.
Overall 100% PSA screening status in the last 2 years P-value
(15,313,605.5)
Screening PSA No screening PSA
69.5% (10,642,955.8) 30.5% (4,670,649.7)

Patient Characteristics (%)

Age (95% CI) 61.8 (61.5–62.0) 61.9 (61.6–62.3) 61.3 (60.8–61.9) 0.04
Race
White 84.6% 87.2% 78.8%
Black 9.0% 8.5% 10.2%
American Indian/Alaskan 0.7% 0.3% 1.7%
Asian/Hawaiian/Pacific 3.4% 2.3% 6.3%
Multiracial 2.1% 1.7% 3.2% < 0.01
Non-White Race 15.4% 12.8% 21.2% < 0.01
Ethnicity - Hispanic 7.9% 7.6% 8.6% 0.47
Insurance status
Private 77.2% 80.8% 69.1%
Public 18.5% 16.6% 22.9%
Uninsured 4.3% 2.6% 7.9% < 0.01
Educational obtainment
≤ 8th Grade 3.6% 3.5% 3.9%
9–12th Grade, no HS diploma 4.8% 4.0% 6.5%
GED or HS Diploma 27.9% 26.3% 31.7%
Beyond HS, Some College 25.6% 24.9% 27.2%
4-year Bachelor Degree 20.0% 22.8% 13.9%
Master or Doctoral Degree 17.5% 18.2% 15.7% 0.01
Poverty category
Poor 6.6% 5.9% 8.2%
Near poor 3.1% 2.9% 3.4%
Low income 10.2% 10.3% 9.9%
Middle income 21.4% 20.1% 24.3%
High income 58.8% 60.8% 54.2% 0.19
Self-reported health status
Poor 4.3% 4.1% 4.7%
Fair 12.8% 11.2% 16.5%
Good 30.5% 31.7% 27.9%
Very Good 33.8% 33.9% 33.5%
Excellent 18.6% 19.1% 17.4% 0.24
Marital status - not married 26.6% 25.5% 29.2% 0.21
Healthcare quality measures (Response = Usually or Always)
Got care right away 85.3% 88.2% 79.8% 0.08
Got an appointment for health care as soon as he or she thought it was needed 87.4% 88.4% 85.2% 0.19
It was easy to get care, tests or treatment you or a doctor believed necessary 93.9% 94.5% 92.5% 0.32
Health providers listened carefully to you 93.4% 93.6% 92.8% 0.61
Health providers explained things in a way that was easy to understand 94.8% 95.3% 93.6% 0.30
Health providers showed respect for what you had to say 94.2% 95.2% 92.2% 0.09
Health providers spent enough time with you 89.4% 90.4% 86.9% 0.11
Advice given by health providers was easy to understand 96.6% 96.5% 96.8% 0.85
Health providers asked you to describe how you are going to follow their instructions 60.4% 60.7% 59.8% 0.84
Offered help with filling out forms at the office 32.1% 34.9% 25.0% 0.03
Rating of healthcare from all doctors and other health providers ≥7 from 0 (worst 80.2% 83.5% 72.5% < 0.01
health care possible) to 10 (best health care possible)

Medical Association, 2018) status. Interaction terms were created for each primary survey variable
PSA screening in the last two years was our primary outcome. PSA and race to determine the presence of effect modification. The p value
screening was determined based on a man's response to “how long since used for statistical significance was < 0.05. The statistical software
your last PSA?”, one of the preventive health questions. Our main in- STATA 11.2 (StataCorp, College Station, TX) was used for all analyses.
dependent variables were responses to eleven Consumer Assessment of The analysis was carried out in October 2018 at Dartmouth-Hitchcock
Healthcare Providers and Systems (CAHPS) questions captured in Medical Center.
MEPS. CAHPS questions assessed men's perceptions of healthcare
quality. Men who answered, “never” or “sometimes” were considered to 3. Results
have disagreed with the CAHPS question; those who answered
“usually” or “always” were considered to have agreed. The survey sample consisted of 1249 men that equated to
MEPS sampling weights, primary sampling units, and strata were 15,313,605.5 weighted individuals (see Table 1); 69.5% of these men
used to account for the complex survey design (Agency for Healthcare underwent PSA screening in the last two years. Men who underwent
Research and Quality, 2017). Corrected, weighted Pearson Chi-square PSA screening were more likely to be White (87.2% vs. 78.8%,
and simple linear regression were used in bivariable analyses to ex- p < 0.01), have private insurance (80.8% vs. 69.1%, p < 0.01), and a
amine the relationship between each survey item and PSA screening. college degree or higher (41.0% vs. 29.6%, p = 0.01). In contrast, non-
Separate multivariable logistic regression models were used to evaluate White men were much less likely to have undergone PSA screening in
the relationship between each survey item and PSA screening. We ad- the last 2 years (12.8% vs. 21.2%, p < 0.01). A greater proportion of
justed for: patient age, race, ethnicity, insurance status, educational men underwent PSA screening if they were offered help filling out
obtainment, poverty status, self-reported health status, and marital forms in a doctor's office (34.9% vs. 25.0%, p = 0.03). Similarly, a

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M.E. Rezaee, et al. Preventive Medicine Reports 14 (2019) 100838

Fig. 1. Percent of patients by quality of healthcare rating by PSA screening status.

Table 2
Crude and adjusted odds of PSA screening by quality of healthcare question.
Covariate Crude OR (95% CI) Adjusted OR (95% CI)

All patients
Offered help with filling out forms at the office 1.60 (1.04–2.46) 1.86 (1.14–3.01)
Rating of healthcare from all doctors and other health providers ≥7 from 0 (worst health care possible) to 10 (best health care 1.93 (1.32–2.81) 1.63 (1.10–2.44)
possible)

White patients
Offered help with filling out forms at the office 1.79 (1.09–2.97) 1.94 (1.13–3.32)
Rating of healthcare from all doctors and other health providers ≥7 from 0 (worst health care possible) to 10 (best health care 2.02 (1.33–3.07) 1.78 (1.12–2.83)
possible)

Non-White patients
Offered help with filling out forms at the office 1.05 (0.49–2.22) 1.15 (0.42–3.17)
Rating of healthcare from all doctors and other health providers ≥7 from 0 (worst health care possible) to 10 (best health care 1.32 (0.74–2.34) 1.53 (0.83–2.83)
possible)

greater proportion of men who rated healthcare quality from their mammography for breast cancer was women's perceptions of the
doctors ≥7 on a scale from 0 (worst healthcare possible) to 10 (best quality of care delivered by local health centers (Cruz-Castillo et al.,
health care possible) underwent PSA screening (83.5% vs. 72.5%, 2015). Chawla et al. found that patients who reported higher quality
p < 0.01) (see Fig. 1). healthcare services were more likely to undergo screening colonoscopy
In our multivariable model, men who were offered help filling out for colon cancer (Chawla et al., 2018). In terms of PSA screening,
forms in the office (OR: 1.86, 95% CI: 1.14–3.01) or rated healthcare Finney Rutten et al. observed that men who reported that providers
quality from their doctors ≥7 (OR: 1.63, 95% CI: 1.10–2.44) had sig- involved them in medical decision-making had significantly greater
nificantly greater adjusted odds of undergoing PSA screening (see odds of undergoing PSA screening (Finney Rutten et al., 2005). Similar
Table 2). Effect modification was observed between race and quality. to these studies, we observed a positive relationship between perceived
Unlike non-White men, White men who were offered help filling out healthcare quality and PSA screening.
forms (OR: 1.94, 95% CI: 1.14–2.44) or rated healthcare quality ≥7 Negative perceptions of healthcare quality may not only serve as
(OR: 1.78, 95% CI: 1.12–2.83) had significantly greater adjusted odds barriers to accessing and engaging with healthcare, but may also hinder
of undergoing screening. thoughtful and collaborative discussions between men and physicians
regarding the risks/benefits of PSA screening. The most severe im-
plication of this is the possibility of delaying or forgoing PSA screening,
4. Discussion
which may subsequently increase a patient's risk of metastatic prostate
cancer and prostate cancer-specific mortality. Thus, it's important for
We found that men 55 to 69 years without a history of prostate
physicians and healthcare facilities to optimize healthcare delivery and
cancer who rated the quality of care delivered to them by their doctors
continually work to improve healthcare quality in an effort to foster and
≥7 (on a scale 0–10) and who received help filling out forms in the
promote screening discussions, which may prevent delayed screening.
office had 63% and 86% increased odds of undergoing PSA screening,
Interestingly, we observed a significant relationship between
respectively. This relationship was primarily noted among White men
healthcare quality and PSA screening in White men, primarily. It's un-
who were found to have 78% and 94% increased odds of PSA screening,
clear why quality would positively impact PSA screening in White men
respectively. To our knowledge, we are one of the first to thoroughly
and not in non-Whites. Unlike White men, non-White men are known to
investigate the relationship between perceptions of healthcare quality
experience lower healthcare quality and health outcomes (Finney
and PSA screening using a large, nationally representative survey.
Rutten et al., 2005). It's possible that unmeasured factors in our study,
Perceptions of healthcare quality can influence patients' willingness
such as provider-patient race concordance, communication barriers,
to undergo routine preventive health exams and screenings. Crus-
and healthcare access were more important drivers of PSA screening in
Castillo et al. found that one of the most important drivers of screening

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M.E. Rezaee, et al. Preventive Medicine Reports 14 (2019) 100838

non-Whites (Finney Rutten et al., 2005; Collins et al., 2002; Saha et al., of this manuscript. The authors of this manuscript have no conflicts of
1999). However, further research is needed to understand this dis- interest or financial disclosures to report.
parity.
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Acknowledgments

All authors contributed equally to the design, conduct, and drafting