Reducing unnecessary and potentially harmful tests and treatment of geriatric patients may require ongoing interventions, according to new research published in Annals of Internal Medicine.
At the end of a year-long follow-up to an 18-month randomized controlled trial, reductions in overuse rebounded in two out of three areas. The first: Prostate-specific antigen (PSA) testing of men aged ≥ 76 years who did not have a history of prostate cancer. Clinicians also continued to prescribe insulin or meglitinide to patients with diabetes older than 75 years with A1c levels < 7%.
However, reductions in unnecessary urine screens for women were sustained.
“I’m not surprised that the effect of these interventions waned over time,” said Christine Liu, MD, an assistant professor of population health and primary care medicine at Stanford Medicine in California, who was not involved in the research. “They added a couple of extra steps, but I don’t think that’s sufficient. Behavior change takes multiple interventions and also more of a systemic, wider change as well.”
The cluster trial took place at 60 primary care practices in Chicago. The targeted services were derived from the Choosing Wisely initiative, which ran for 11 years until 2023 under the American Board of Internal Medicine.
The control group of 187 clinicians received education about the harms of overtreatment and recommendations on the areas of focus. The intervention group of 184 clinicians received electronic health record prompts when they attempted to order a screen or prescription, with both the urine and PSA screens requiring documentation of a reason for bypassing the warning. If clinicians prescribed a flagged medication to a patient with diabetes, they had to input if they were planning to reduce treatment.
“Doctors might think, ‘the recommendations right now are that we probably shouldn’t do this, but the patient still wants it. What’s the harm?’” said Stephen Persell, MD, a professor of medicine in the Division of General Internal Medicine at the Feinberg School of Medicine in Chicago and lead author of the study. “With these alerts, we’re saying ‘There is potential harm, and you should think about it before you do this.’”
PSA screens in the men older than 76 years are unnecessary given the life expectancy and the often slow-growing and asymptomatic nature of prostate cancer, Persell said. Treatments come with risks that outweigh potential benefits among older adults, he said. For instance, radiation can cause rectal bleeding, and androgen deprivation therapy increases the risk for heart attack and dementia.
Despite these harms, reductions in screens were not sustained once the prompts disappeared. At the end of the 18-month trial, clinicians in the intervention group showed lower rates of PSA screens per 100 eligible patients than those in the control group (21.8% vs 31.6%). After the year of no alerts, screen rates rebounded in the intervention group (26.2% vs 31.8%).
Physicians who bypassed the warning most frequently cited patient demand, a previously elevated test, or a patient-reported request from another clinician as the reason, Persell said.
PSA screens in particular may be hard to reduce because “cancer is a scary word,” said Liu. “When patients hear the word cancer, they assume death,” she said.
Meanwhile, attempts to curb diabetes overtreatment were only marginally successful in the initial trial — annual rates per 100 eligible patients were 14.2% in the intervention group vs 15.6% in the control group. The slight reduction evaporated by the end of the year-long trial. For adults older than 75 years with A1c levels < 7%, the researchers tracked whether or not providers prescribed insulin, meglitinide, or a sulfonylurea. These drugs can cause hypoglycemia, possibly leading to effects like falls, cardiac events, and frailty. Persell said the risk for dangerous blood sugar drops increases for older adults.
Patients may have a hard time accepting that they do not need these medications, Persell said.
Liu said that time-pressed doctors, who are expected to be efficient, may find it easier to cave into a patient request — even if they have to ignore a flag — than take the time needed to dissuade patients against medication.
The bright spot was with screenings for urine bacteria for women older than 65 years without symptoms of a urinary tract infection (UTI), which can lead to inappropriate antibiotic use and resulting complications. At the end of the intervention period, UTI screen rates were lower in the intervention group than in the control group (18.3% vs 23.1% per 100 patients). Screen rates were nearly unchanged after the 1-year period.
Keeping pop-ups in place would be helpful because “physicians have so many things to keep track of and watch out for, trying to rely upon memory to adhere to it all is way too difficult to achieve,” said Ian Neel, MD, a geriatrician and medical director of the Geriatric Medicine Consult Service at Senior Behavioral Health at UC San Diego Health.
Clinicians may lack training to understand and best treat the geriatric population and need the reminders, Neel said.
This study was funded by the National Institute on Aging. Pursell, Liu, and Neel reported no disclosures.
Brittany Vargas is a medicine, mental health, and wellness journalist.