Promoting better use of the PSA test in general practice: randomized controlled trial of educational strategies based on outreach visits and mailout

Synthesis of Existent Oncology Curricula for Primary Care Providers: A Scoping Review With a Global Equity Lens

PURPOSE

Global increases in cancer, coupled with a shortage of cancer specialists, has led to an increasing role for primary care providers (PCP) in cancer care. This review aimed to examine all extant cancer curricula for PCPs and to analyze the motivations for curriculum development.

METHODS

A comprehensive literature search was conducted from inception to October 13, 2021, with no language restrictions. The initial search yielded 11,162 articles and 10,902 articles underwent title and abstract review. After full-text review, 139 articles were included. Numeric and thematic analyses were conducted and education programs were evaluated using Bloom's taxonomy.

RESULTS

Most curricula were developed in high-income countries (HICs), with 58% in the United States. Cancer-specific curricula focused on HIC priority cancers, such as skin/melanoma, and did not represent the global cancer burden. Most (80%) curricula were developed for staff physicians and 73% focused on cancer screening. More than half (57%) of programs were delivered in person, with a shift toward online delivery over time. Less than half (46%) of programs were codeveloped with PCPs and 34% did not involve PCPs in the program design and development. Curricula were primarily developed to improve cancer knowledge, and 72 studies assessed multiple outcome measures. No studies included the top two levels of Bloom's taxonomy of learning (evaluating; creating).

CONCLUSION

To our knowledge, this is the first review to assess the current state of cancer curricula for PCPs with a global focus. This review shows that extant curricula are primarily developed in HICs, do not represent the global cancer burden, and focus on cancer screening. This review lays a foundation to advance the cocreation of curricula that are aligned to the global cancer burden.

Strategies to reduce the use of low-value medical tests in primary care: a systematic review

BACKGROUND

It is recognised that medical tests are overused in primary care; however, it is unclear how best to reduce their use.

AIM

To identify which strategies are effective in reducing the use of low-value medical tests in primary care settings.

DESIGN AND SETTING

Systematic review.

METHOD

The databases MEDLINE, EMBASE, and Rx for Change were searched (January 1990 to November 2019) for randomised controlled trials (RCTs) that evaluated strategies to reduce the use of low-value medical tests in primary care settings. Two reviewers selected eligible RCTs, extracted data, and assessed their risk of bias.

RESULTS

Of the 16 RCTs included in the review, 11 reported a statistically significant reduction in the use of low-value medical tests. The median of the differences between the relative reductions in the intervention and control arms was 17% (interquartile range 12% to 24%). Strategies using reminders or audit/feedback showed larger reduction than those without these components (22% versus 14%, and 22% versus 13%, respectively) and patient-targeted strategies showed larger reductions than those not targeted at patients (51% versus 17%). Very few studies investigated the sustainability of the effect, adverse events, cost-effectiveness, or patient-reported outcomes related to reducing the use of low-value tests.

CONCLUSION

This review indicates that it is possible to reduce the use of low-value medical tests in primary care, especially by using multiple components including reminders, audit/feedback, and patient-targeted interventions. To implement these strategies widely in primary care settings, more research is needed not only to investigate their effectiveness, but also to examine adverse events, cost-effectiveness, and patient-reported outcomes.

GPs views and understanding of PSA testing, screening and early detection; survey

BACKGROUND

There is currently no national prostate cancer screening programme in the UK. However, patients 50 years and older are entitled to a prostate specific antigen (PSA) test, if informed on the advantages and disadvantages of testing and their risk of cancer. The Prostate Cancer Risk Management Programme (PCRMP) provides this guidance.

AIM

The aim of this study was to access GPs' views and understanding of PSA testing, prostate cancer screening and early detection.

METHOD

A total of 708 questionnaires were returned by GPs across two English regions in 2013 and the GP questionnaire responses were quantitatively analysed.

RESULTS

In the 699 completed questionnaires, the majority of GPs were well informed about PSA testing, screening and early detection. Only 32% used guidelines for referral, 14% knew all age-specific PSA referral levels, 71% that Black men have a higher prostate cancer risk than White men (22% correctly answered threefold increase) and 82% that family history is a risk factor. A further 78% thought electronic prompts during consultation would encourage PCRMP guideline usage and 75% had never been offered a PSA test and prostate cancer educational course, of which 73% would like to attend a course. Only 23% were aware of the latest PSA screening evidence and 94% would like an update.

CONCLUSIONS

Participating GPs seem to be well informed but need more information and tools to help follow recommended guidance. In particular, increased awareness of PCRMP guidelines especially by automated methods, further educational courses and evidence updates would be beneficial.

Prostate-specific antigen testing in general practice: A survey among 325 general practitioners in Denmark

OBJECTIVES

Prostate-specific antigen (PSA) is a well-known and -utilized tumor marker for prostate cancer. Elevated PSA values are not specific for prostate cancer as they may be caused by other benign conditions. PSA testing is widely used by urologists and non-urologists. Interpretation of test results is difficult but important. Referral of patients for further work-up on suspicion of prostate diseases is mainly done by general practitioners (GPs). As the GP remains the gatekeeper between the patient and the urologist in terms of diagnosing prostate diseases, basic knowledge of PSA testing is crucial. The purpose of this study was to evaluate the basic use and knowledge of PSA testing and to give an estimate of the need for further education in PSA testing amongst GPs in our area.

MATERIAL AND METHODS

A questionnaire regarding PSA testing and associated needs for education was mailed to all GPs in the Northern County of Denmark. Non-respondents were contacted by mail.

RESULTS

Of the contacted GPs, 90% responded. Only 28% of GPs measured PSA in all males complaining of lower urinary tract symptoms (LUTS). Of patients seen as part of a general health check-up, PSA testing was done in 10%. The median PSA value for referral to urologists for further work-up was 5 ng/ml, but the decision was influenced by PSA value (79%), age (65%) and findings on digital rectal examination (DRE) (87%). Opportunistic screening for prostate cancer was done by 14% of GPs. Of the GPs who responded, 24% stated that they did not need any further education regarding PSA testing.

CONCLUSIONS

The results of this study demonstrate that PSA testing is not standardized in our area. GPs do not test patients on the basis of recommendations provided by national or international societies. PSA testing is not used as a standard test in men with LUTS, and patients are not referred to urologists at a sufficiently low PSA level to improve the early diagnosis and work-up of patients with suspected prostate cancer. However, the decision of many GPs to refer patients to urologists for further work-up is influenced by the findings of a DRE, the age of the patient and the PSA value itself. Further education regarding PSA testing amongst GPs in our area would seem to be appropriate.

Perception of abnormal serum prostate-specific antigen (PSA) test results amongst family practitioners

INTRODUCTION

With increased use of serum prostate-specific antigen (PSA) testing, prostate cancers are diagnosed at an earlier stage in younger men, when radical curative treatments are appropriate. Modifications of the PSA test such as PSA velocity and age-adjusted values are available to aid in the selection of patients for biopsy. However, it is not clear whether these data are used in general practice.

PATIENTS AND METHODS

A self-administered questionnaire was mailed to all primary care practices within one region in the UK. A series of visual analogue questions designed to identify referral thresholds for age-adjusted PSA levels and PSA velocity were used to identify patterns in referral behaviour.

RESULTS

Individual family practitioners see only small numbers of patients requesting PSA tests or with newly diagnosed prostate cancer each year. The median (range) thresholds considered for referral at ages 45, 55, 65, 75 and 85 years were 4.5 ng/ml (2.5-15.5 ng/ml), 5.5 ng/ml (3.0-15.5 ng/ml), 6.5 ng/ml (3.5-15.5 ng/ml), 6.5 ng/ml (3.5-25.5 ng/ml), and 7.5 ng/ml (3.5-25.5 ng/ml), respectively. Only 5% of practitioners correctly identified the age-specific PSA threshold for referral of a 45-year-old man.

CONCLUSIONS

It is important to remember that younger men (even those in their forties and fifties) may be at risk of prostate cancer even if asymptomatic. It is important in a climate of increasing demand for PSA testing that those who initiate the process understand the implications and limitations of testing, including appropriate triggers for referral to secondary care. The exact approach required for the successful dissemination of this information to primary care is not clear, but our data suggest that a better understanding is required.

Design and analysis of group-randomized trials in cancer: a review of current practices

BACKGROUND

Previous reviews have identified problems in the design and analysis of group-randomized trials in a number of areas. Similar problems may exist in cancer research, but there have been no comprehensive reviews.

METHODS

We searched Medline and PubMed for group-randomized trials focused on cancer prevention and control that were published between 2002 and 2006. We located and reviewed 75 articles to determine whether articles included evidence of taking group randomization into account in establishing the size of the trial, such as reporting the expected intraclass correlation, the group component of variance, or the variance inflation factor. We also examined the analytical approaches to determine their appropriateness.

RESULTS

Only 18 (24%) of the 75 articles documented appropriate methods for sample size calculations. Only 34 (45%) limited their reports to analyses judged to be appropriate. Fully 26 (34%) failed to report any analyses that were judged to be appropriate. The most commonly used inappropriate analysis was an analysis at the individual level that ignored the groups altogether. Nine articles (12%) did not provide sufficient information.

CONCLUSIONS

Many investigators who use group-randomized trials in cancer research do not adequately attend to the special design and analytic challenges associated with these trials. Failure to do so can lead to reporting type I errors as real effects, mislead investigators and policy-makers, and slow progress toward control and prevention of cancer. A collaborative effort by investigators, statisticians, and others will be required to ensure that group-randomized trials are planned and analyzed using appropriate methods so that the scientific community can have confidence in the published results.

Educational outreach visits: effects on professional practice and health care outcomes

BACKGROUND

Educational outreach visits (EOVs) have been identified as an intervention that may improve the practice of healthcare professionals. This type of face-to-face visit has been referred to as university-based educational detailing, academic detailing, and educational visiting.

OBJECTIVES

To assess the effects of EOVs on health professional practice or patient outcomes.

SEARCH STRATEGY

For this update, we searched the Cochrane EPOC register to March 2007. In the original review, we searched multiple bibliographic databases including MEDLINE and CINAHL.

SELECTION CRITERIA

Randomised trials of EOVs that reported an objective measure of professional performance or healthcare outcomes. An EOV was defined as a personal visit by a trained person to healthcare professionals in their own settings.

DATA COLLECTION AND ANALYSIS

Two reviewers independently extracted data and assessed study quality. We used bubble plots and box plots to visually inspect the data. We conducted both quantitative and qualitative analyses. We used meta-regression to examine potential sources of heterogeneity determined a priori. We hypothesised eight factors to explain variation across effect estimates. In our primary visual and statistical analyses, we included only studies with dichotomous outcomes, with baseline data and with low or moderate risk of bias, in which the intervention included an EOV and was compared to no intervention.

MAIN RESULTS

We included 69 studies involving more than 15,000 health professionals. Twenty-eight studies (34 comparisons) contributed to the calculation of the median and interquartile range for the main comparison. The median adjusted risk difference (RD) in compliance with desired practice was 5.6% (interquartile range 3.0% to 9.0%). The adjusted RDs were highly consistent for prescribing (median 4.8%, interquartile range 3.0% to 6.5% for 17 comparisons), but varied for other types of professional performance (median 6.0%, interquartile range 3.6% to 16.0% for 17 comparisons). Meta-regression was limited by the large number of potential explanatory factors (eight) with only 31 comparisons, and did not provide any compelling explanations for the observed variation in adjusted RDs. There were 18 comparisons with continuous outcomes, with a median adjusted relative improvement of 21% (interquartile range 11% to 41%). There were eight trials (12 comparisons) in which the intervention included an EOV and was compared to another type of intervention, usually audit and feedback. Interventions that included EOVs appeared to be slightly superior to audit and feedback. Only six studies evaluated different types of visits in head-to-head comparisons. When individual visits were compared to group visits (three trials), the results were mixed.

AUTHORS' CONCLUSIONS

EOVs alone or when combined with other interventions have effects on prescribing that are relatively consistent and small, but potentially important. Their effects on other types of professional performance vary from small to modest improvements, and it is not possible from this review to explain that variation.

Prostate cancer, the PSA test and academic detailing in Australian general practice: an economic evaluation

OBJECTIVES

To evaluate whether introduction of a national education program for GPs to improve decision making relating to the use of prostate specific antigen (PSA) testing for screening represents 'value-for-money' from the perspective of the Australian Government.

METHODS

The annual equivalent costs and consequences of a proposed national program in steady state operation are estimated for Australia using 1996 as the reference year. Because of the controversy about the efficacy of screening using PSA testing, two scenarios are modelled. Uncertainty in the model is examined using Monte Carlo simulation methods.

RESULTS

In scenario one, our model predicts that the national program would cost dollars 12.5 million (gross) or dollars 6.6 million (net), would reduce the burden of disease by 4.7% of total DALYs due to prostate cancer in those aged 70 and over, with no loss of life and an incremental cost effectiveness ratio (ICER) of dollars 16,000/DALY (gross) and dollars 8,500/DALY (net). In scenario two, the proposed program would cost dollars 12.5 million (gross) or dollars 7.1 million (net), would reduce the burden of disease by 3.1% of total, increase by 44 the prostate cancer deaths at an ICER of dollars 24,000/DALY (gross) and dollars 14,000/DALY (net).

CONCLUSIONS

These findings, with an overall health benefit at moderate cost and acceptable ICER, support the case for consideration of a national education program on the assumption that prostate cancer screening over age 70 does not reduce mortality. A larger Australian study currently being conducted should provide stronger evidence on the value of implementing a full national program.

Is untargeted educational outreach visiting delivered by pharmaceutical advisers effective in primary care? A pragmatic randomized controlled trial

BACKGROUND

There is increasing evidence that clinical guidelines can lead to improvements in clinical care. However, they are not self-implementing. While educational outreach visits may improve prescribing behaviour, the effectiveness of routine delivery of these visits by existing pharmaceutical advisers is unknown.

METHODS

Within a pragmatic randomized controlled trial, involving all general practices in two primary care trusts (PCTs), routine methods were used to distribute guidelines for the choice of antidepressants for the management of depression. Intervention practices were offered two visits (most accepted only one) by their PCT pharmaceutical adviser who had been trained in the techniques of outreach visiting. Intervention practices were visited regardless of whether they had prior problems with prescribing ('untargeted' visits). The intervention was evaluated using level three prescribing analysis and cost (PACT) data for antidepressant drugs for the six months during which the intervention was delivered and the subsequent twelve months.

RESULTS

Across the 72 study practices there was no significant impact of the intervention on usage of any group of antidepressant drugs.

CONCLUSION

The routine use of untargeted educational outreach visiting delivered by existing pharmaceutical advisers may not be a worthwhile strategy.

A meta-analysis of continuing medical education effectiveness

INTRODUCTION

We undertook a meta-analysis of the Continuing Medical Education (CME) outcome literature to examine the effect of moderator variables on physician knowledge, performance, and patient outcomes.

METHODS

A literature search of MEDLINE and ERIC was conducted for randomized controlled trials and experimental design studies of CME outcomes in which physicians were a major group. CME moderator variables included the types of intervention, the types and number of participants, time, and the number of intervention sessions held over time.

RESULTS

Thirty-one studies met the eligibility criteria, generating 61 interventions. The overall sample-size weighted effect size for all 61 interventions was r = 0.28 (0.18). The analysis of CME moderator variables showed that active and mixed methods had medium effect sizes (r = 0.33 [0.33], r = 0.33 [0.26], respectively), and passive methods had a small effect size (r = 0.20 [0.16], confidence interval 0.15, 0.26). There was a positive correlation between the effect size and the length of the interventions (r = 0.33) and between multiple interventions over time (r = 0.36). There was a negative correlation between the effect size and programs that involved multiple disciplines (r = -0.18) and the number of participants (r = -0.13). The correlation between the effect size and the length of time for outcome assessment was negative (r = -0.31).

DISCUSSION

The meta-analysis suggests that the effect size of CME on physician knowledge is a medium one; however, the effect size is small for physician performance and patient outcome. The examination of moderator variables shows there is a larger effect size when the interventions are interactive, use multiple methods, and are designed for a small group of physicians from a single discipline.

Prostate-specific antigen testing: uncovering primary care influences

OBJECTIVES

To examine influences on the behaviour of General Practitioner (GP) in relation to prostate-specific antigen (PSA) testing.

SUBJECTS AND METHODS

In Northern Ireland in 2003-2004, all GPs (1067) were invited to complete a self-administered postal questionnaire survey that was then matched with a regional PSA-testing database. The main outcome measures were individual GP responses for demographic, practice and training characteristics, PSA testing behaviour and perceived influences, matched against GP-initiated first PSA tests performed in 2003 and 2004 (22 207 tests).

RESULTS

In all, 704 GPs (66%) responded and 49% of these reported awareness of the national guidelines, which was highest among those attending postgraduate meetings. PSA tests were more likely to be ordered by full-time male GPs who had attended a local postgraduate urology meeting; ran a 'well-man' clinic; tested men with unrelated complaints; and were not in a training practice. Testing levels were highest among GPs who had been practising for 21-30 years and those in rural practices. Awareness of national guidelines or having had a postgraduate post in urology did not affect testing behaviour. After adjusting for gender, working hours, duration in practice and urban/rural setting, independent influences increasing testing behaviour were: testing men with a positive family history or unrelated complaints; testing any man who requests it; and previous experience of prostate cancer being detected in an asymptomatic patient by PSA testing. Working in an accredited training practice was associated with lower testing levels.

CONCLUSION

There are complex influences on the PSA testing behaviour of GPs; addressing these influences could contribute to the rationalization of testing. A low awareness of national guidelines indicates a need for new strategies to disseminate and implement guidelines. The influence of local educational meetings on PSA testing is an unharnessed force.

Effects of a shared protocol between urologists and general practitioners on referral patterns and initial diagnostic management of men with lower urinary tract symptoms in Italy: the Prostate Destination study

OBJECTIVE

To assess whether adopting a shared protocol between urologists and general practitioners (GPs) might change diagnostic procedures and referral patterns in the management of men with lower urinary tract symptoms (LUTS).

SUBJECTS AND METHODS

Forty-five urological centres and 263 GPs in Italy participated in this prospective study. Procedures adopted by GPs for evaluating five consecutive patients (aged > or = 50 years) were compared before (phase 1) and after (phase 2) implementation of the shared protocol. An evidence-based diagnostic algorithm was developed and approved by participating urologists and presented to local GPs at a training session. Protocol modifications were allowed after discussion with GPs. Direct costs of diagnostic procedures carried out before and after implementing the protocol were calculated from the perspective of the national health service.

RESULTS

In all, 903 patients were evaluable in phase 1 and 856 in phase 2. Implementation of the protocol did not change referral patterns, with about half the patients being managed entirely by GPs. The use of a digital rectal examination by GPs increased from 32% to 41%, use of transrectal and suprapubic ultrasonography decreased from 33% to 23% and 53% to 44%, respectively, (all P < 0.001) and use of the International Prostate Symptom Score increased from 4.5% to 23.1% (P < 0.001). Overall, protocol-recommended tests were used more frequently, while those not recommended decreased after implementing the protocol. However, overuse of the tests not recommended (i.e. urine culture and free/total prostate specific antigen ratio) remained high. The mean cost per patient of diagnostic procedures ordered by GPs decreased from Euros 71.82 to Euros 61.93, with Euros 9.9 saved for each patient.

CONCLUSION

Our intervention failed to decrease the percentage of cases of LUTS being referred to specialists, but was moderately effective in inducing changes in the diagnostic management by GPs that were indicative of increased compliance with best-practice principles, and produced cost savings of 13.8%.

Screening for carotid artery disease in the general public

BACKGROUND: Screening for various diseases is now being offered to the public in settings other than their physicians' office, often using expensive and sophisticated technology. Little is known about how patients decide to participate in such programs, whether they understand the implications of a positive or negative test, or if their primary care physician is involved in the decision to screen. METHODS: We surveyed a cohort of patients who participated in a free carotid artery screening using Doppler ultrasound at a tertiary care academic medical center. RESULTS: One hundred twenty-four patients participated and underwent the ultrasound exam. Their mean age was 68.8 (+/-9.8) years and 54% were female. Some 117 patients (94%) completed the survey. Five patients (4%) tested positive for significant carotid artery stenosis. Sixty-two percent (95% CI: 53-71%) of the patients learned about the program through a newspaper advertisement. Eighty-eight percent (95% CI: 82-94%) of the subjects stated that their primary physician had not suggested that they have the test, and 59% (95% CI: 50-68%) did not know that carotid artery surgery is often recommended for patients who test positive. CONCLUSIONS: This study of one group of patients who voluntarily took a screening test for carotid artery stenosis raises some important questions since most subjects did not understand the implications of a positive result, nor did they involve their physicians in their decision to take the test. Further studies are needed to evaluate whether providing patients with more information about the implications of a screening test would change their desire to have the test and about the nature of the informed consent required before such screening is carried out.