Inappropriate PSA Testing in Primary Care – Can it be stopped?
BAUS ePoster online library. Hatem E. 11/10/20; 304272; PCU-4
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Inappropriate PSA Testing in Primary Care - Can it be stopped?
Hatem, E 1, Hughes-Hallett 1, Green J 1
1 Guy's Hospital, London, United Kingdom

Introduction
Prostate specific antigen (PSA) testing is routinely used in primary care to aid in the early diagnosis of prostate cancer. Although a valuable tool in the diagnosis of clinically relevant cancer, the test has low specificity, and diagnosis of prostate cancer in men with a life expectancy of <10 years has no effect on overall mortality.
There is frequently a lack of indication for, or even contraindication to a PSA test, and often, inappropriate referrals are made to secondary care services based solely on a single 'raised' PSA result. This result may skewed by a multitude of factors, or may even be within age-specific normal limits. Such referrals saturate secondary care, add to target burdens, and cause possibly avoidable patient anxiety.
GPs have a pivotal role in influencing PSA testing, so in 2016, the Department of Health articulated the above points regarding PSA testing, in a guidance for primary care physicians to rationalise the use of PSA.

Aims
Herein are presented the results of an audit of PSA testing in the community, before and after the introduction of a 'pop-up' window highlighting the salient points of this guidance. We aimed to explore whether number of 'inappropriate' PSA tests ordered in primary care could be reduced.

Changes
Our intervention consisted of a 'pop-up' window that general practitioners would see prior to ordering a PSA test. Via the primary care IT portal, we created the following pop-up window that appeared on-screen when ordering a PSA test:
“PSA testing is not usually indicated in men< 50 or with life expectancy < 10yrs. It is advisable PSA is not tested in active UTI, or within 24h of ejaculation or vigorous exercise”

Methods
Following a GP focus group to determine whether education was needed, all PSAs submitted to Barts Health from primary care over a three month period were collected and evaluated. Following out intervention we compared a three-month time period post intervention with the identical period a year previously.
Points examined were (1) Age of those tested, and (2) Proportion of abnormal results (as per BAUS age-specific guidelines).
Patients were categorised into three age groups - <50, 50-70, and >70.

Results
As seen in the contingency table, following our intervention, the proportion of abnormal tests increased in all age groups, whilst total number of tests did not. This implies the correct patients (those who produce an abnormal result) are those who are being tested. The difference was statistically significant (p<0.05) in the two older age groups.
It is notable also, that the proportion of total tests being done in the 50-70 age group increased - this is the target group who are at highest risk of clinically relevant cancer that requires treatment, and therefore the group we want to see tested.

Summary
Results imply that the number of inappropriate PSA tests ordered in primary care was safely reduced; whilst total number of tests was similar, the proportion of abnormal tests has significantly (p<0.05) increased in all age groups.
This reduction in 'normal' PSA results could in turn decrease the number of clinically unnecessary or inappropriate referrals to secondary care, reducing burden on these services, reducing cost to the NHS, and decreasing patient anxiety.


References:
Inappropriate PSA Testing in Primary Care - Can it be stopped?
Hatem, E 1, Hughes-Hallett 1, Green J 1
1 Guy's Hospital, London, United Kingdom

Introduction
Prostate specific antigen (PSA) testing is routinely used in primary care to aid in the early diagnosis of prostate cancer. Although a valuable tool in the diagnosis of clinically relevant cancer, the test has low specificity, and diagnosis of prostate cancer in men with a life expectancy of <10 years has no effect on overall mortality.
There is frequently a lack of indication for, or even contraindication to a PSA test, and often, inappropriate referrals are made to secondary care services based solely on a single 'raised' PSA result. This result may skewed by a multitude of factors, or may even be within age-specific normal limits. Such referrals saturate secondary care, add to target burdens, and cause possibly avoidable patient anxiety.
GPs have a pivotal role in influencing PSA testing, so in 2016, the Department of Health articulated the above points regarding PSA testing, in a guidance for primary care physicians to rationalise the use of PSA.

Aims
Herein are presented the results of an audit of PSA testing in the community, before and after the introduction of a 'pop-up' window highlighting the salient points of this guidance. We aimed to explore whether number of 'inappropriate' PSA tests ordered in primary care could be reduced.

Changes
Our intervention consisted of a 'pop-up' window that general practitioners would see prior to ordering a PSA test. Via the primary care IT portal, we created the following pop-up window that appeared on-screen when ordering a PSA test:
“PSA testing is not usually indicated in men< 50 or with life expectancy < 10yrs. It is advisable PSA is not tested in active UTI, or within 24h of ejaculation or vigorous exercise”

Methods
Following a GP focus group to determine whether education was needed, all PSAs submitted to Barts Health from primary care over a three month period were collected and evaluated. Following out intervention we compared a three-month time period post intervention with the identical period a year previously.
Points examined were (1) Age of those tested, and (2) Proportion of abnormal results (as per BAUS age-specific guidelines).
Patients were categorised into three age groups - <50, 50-70, and >70.

Results
As seen in the contingency table, following our intervention, the proportion of abnormal tests increased in all age groups, whilst total number of tests did not. This implies the correct patients (those who produce an abnormal result) are those who are being tested. The difference was statistically significant (p<0.05) in the two older age groups.
It is notable also, that the proportion of total tests being done in the 50-70 age group increased - this is the target group who are at highest risk of clinically relevant cancer that requires treatment, and therefore the group we want to see tested.

Summary
Results imply that the number of inappropriate PSA tests ordered in primary care was safely reduced; whilst total number of tests was similar, the proportion of abnormal tests has significantly (p<0.05) increased in all age groups.
This reduction in 'normal' PSA results could in turn decrease the number of clinically unnecessary or inappropriate referrals to secondary care, reducing burden on these services, reducing cost to the NHS, and decreasing patient anxiety.


References:
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