BERKELEY, CA (UroToday.com) - In our publication in BJU International, we describe our analyses of the patterns of PSA testing by Dutch general practitioners (GPs) and the impact of the main publication of the European Randomized Study of Screening for Prostate Cancer (ERSPC) on this pattern. We have focused on primary PSA tests. For this, we used two distinct databases. In the first database, that originated from one of the largest Dutch insurance companies, claims of PSA tests were summed. In contrast to, for example, the USA, in the Netherlands no long history of the use of claims data is present. As far as we know, we are the first Dutch group to use claims data for this purpose.
In the Dutch medical system, GPs have a key role. All inhabitants are registered at one general practice, and GPs are regarded as the “gatekeepers” for the care system. All care provided by GPs is reimbursed. Different financial settlements are present, compared to care provided in secondary care. For primary care, diagnostic tests ordered by GPs are claimed separately by the performing laboratory. In secondary care, so called diagnostic-treatment combinations (DBC) are used. All diagnostic procedures fall within this DBC-declaration. Therefore, follow-up testing in secondary care could not be studied from this database. This was the main reason to study the second database that originated from a large district hospital. This included PSA values as well, irrespective of the doctor (GP or specialist) who ordered it. In our analyses, we predefined a short period after the publication of the ERSPC data, that we thought would be suitable. From the figure in our paper, it seems apparent that the decrease in PSA tests was much later than that short period: approximately six months after the publication, PSA test rates dropped for men aged 60 years and older. The shown decrease would have been larger when this longer time-interval was applied.
It is important to notice that in the Netherlands, the number of PSA tests is much lower than in other countries, such as the USA. Therefore, we were a bit surprised by the still considerable impact of the ERSPC publication on test rates. We assume that GPs may feel more comfortable with not performing a PSA test, based on those study results. It is however unclear if this is based on the study results itself or based on the publication of the Dutch GP organization, in which the interpretation of the ERSPC results lead to the conclusion that the already reluctant advice now has a more solid base.
We cannot explain yet why GPs seem to have worsened their follow-up policy after an abnormal test result. This seems to be in line with findings from the literature, that were summarized by our group recently (BMC Family Practice). It seems strange not to do follow-up testing in such cases, as the test was primarily performed to rule out prostate cancer. If GPs or their patients feel that it is unnecessary to do so after an increased PSA value, we believe the first test could have been skipped as well. Shared decision-making before performing a PSA test is essential in daily practice. In an accompanying editorial comment, Professor Fritz H. Schröder stressed that men who are well informed and wish to be tested for prostate cancer cannot be refused PSA testing. This is in line with the recently published revision of the Dutch GP-guideline, Male Lower Urinary Tract Symptoms.
In future studies at our departments, we will further explore the absence of follow-up testing. We hope to elucidate this remarkable finding. For now, we can only guess what the possible causes are.
Marco H. Blanker, MD, PhDa and Saskia van der Meer, MDb as part of Beyond the Abstract on UroToday.com. This initiative offers a method of publishing for the professional urology community. Authors are given an opportunity to expand on the circumstances, limitations etc... of their research by referencing the published abstract.
aGeneral Practitioner and Epidemiologist, Department of General Practice, University Medical Center Groningen, The Netherlands
bResident in Urology, Department of Urology, Isala Clinics Zwolle and University Medical Center Groningen, The Netherlands