Several Screenings for Older Adults May Bring Unnecessary Harm

Stephen Persell, MD, MPH

Credit: Northwestern University Feinberg School of Medicine

Giving unnecessary prostate, urinary tract infection, and blood sugar screenings to older adults can do more harm than good, and in a new study, investigators found successful measures to prevent over-screenings.¹

Practitioners may think that is what you are supposed to do—an older adult comes in and you automatically give them a prostate, urinary tract infection, and blood sugar screening—but research suggests otherwise. According to an AGS Choosing Wisely statement, it is not recommended to screen for breast, colorectal, prostate, or lung cancer for older adults without considering life expectancy and the risks of testing, overdiagnosis, and overtreatment^.2

Unnecessary screening can lead to overtreatment and can result in serious health problems. For instance, prostate cancer may lead to surgery or radiation treatment which can cause urinary incontinence or urinary symptoms, harm sexual function, or cause rectal bleeding.

“If a man is not going to live another 10 or 15 years due to his age, you won’t save his life from prostate cancer by screening him, but you will subject him to the potential harms of treatment,” said lead investigator Stephen Persell, MD, MPH, from the Northwestern University Feinberg School of Medicine, in a press release.³ “What’s right for a 68-year-old man might not be right for one who is 75 of 85.”

Likewise, women ≥ 65 years old will be tested for a urinary tract infection without experiencing symptoms. However, there is no evidence antibiotics can improve a woman’s health if they have an asymptomatic urinary tract infection—and the antibiotics can cause allergic reactions, diarrhea, and antibiotic resistance. The resistance can make bacterial infections harder to treat in the future.

Diabetes is also overtreated with hypoglycemic agents in patients ≥ 75 years old. Treating blood sugar to very low levels with insulin or sulfonylureas puts patients at risk for dangerous low blood sugar events.

“We have taught patients to strive to control their blood sugar, even when it gets to a point when it’s safer to have slightly less controlled blood sugar,” Persell said. “It’s hard to convince patients and doctors to change their goals.”

To reduce over-screenings, Persell and colleagues conducted an 18-month single-blind, pragmatic, cluster randomized trial to assess a clinician’s response to seeing an alert about a screening causes harm in older primary care patients and whether the alert would deter them from screening a patient for prostate cancer, urinary tract infection, and diabetes.¹ Intervention began September 1, 2020, and was followed up by March 1, 2022.

The study included 371 primary care clinicians and their older adult patients. The team gave primary care clinicians support tools and case-based education to increase awareness of potential harms in particular screenings.

The team assessed prostate-specific antigen (PSA) screening in men ≥ 76 years old without previous prostate cancer, urine testing for women ≥ 65 years old, and overtreatment of diabetes with hypoglycemic agents in patients ≥ 75 years old and a hemoglobin A1c (HbA1c) less than 7%.

In the study, when a doctor ordered a routine prostate screening for an 80-year-old man, a “dramatic yellow alert” appeared on the electronic health record with the warning: “You are ordering a test that no guideline recommends. Screening with PSA can lead to harm from diagnosis and treatment procedures. If you proceed without a justification, the unnecessary test will be noted on the health record.”³

At baseline, investigators found mean clinic annual PSA testing, unspecified urine testing, and diabetes overtreatment rates were 24.9, 23.9, and 16.8 per 100 patients, respectively.1 After 18 months of intervention, PSA screening among men aged ≥ 76 years fell from 32 per 100 patients to 28.5 (control: rose 28.2 to 32.4) (adjusted difference-in-differences [aDID] in annual rates, 8.7; 95% CI, 10.2 – 7.1), unspecified urine screening fell from 33.7 to 24.2 (control: 27.3 to 24.9) (aDID, - 5.5; 95% CI, 7.0 – 3.6), and diabetes overtreatment fell from 20.0 to 16.7 (control: remained 15.9) (aDID, - 1.4; 95% CI, 2.9 – 0.03]) compared with clinicians who only received education.

Additionally, they found after the intervention, an HbA1c was > 9% was more common among patients who were previously over-treated for diabetes (adjusted difference-in-differences, 0.4, 0.47 per 100 patients; 95% CI, 0.04 – 1.20).

Limitations investigators pointed out included using a single health system which limits generalizability, not knowing if men screened for PSA experienced symptoms indicating a need for testing, not having a sufficient follow-up duration, and using an electronic health make makes it difficult to differentiate between over-testing and under-documentation.

“These findings suggest that point-of-care behaviorally informed interventions can reduce overtesting and overuse among older patients of primary care clinicians while preserving clinician discretion,” investigators wrote.

^References

1. ^{Persell SD, Petito LC, Lee JY, et al. Reducing Care Overuse in Older Patients Using Professional Norms and Accountability : A Cluster Randomized Controlled Trial. Ann Intern Med. Published online February 6, 2024. doi:10.7326/M23-2183}
2. ^{American Geriatrics Society. Ten Things Clinicians and Patients Should Question. Released 21 February 2014 (6-10); revised 23 April 2015 (2, 3, 6, 7, 8 and 10); last reviewed 2021. www.choosingwisely.org/societies/american-geriatrics-society. Accessed February 9, 2024.}
3. ^{Reducing Harmful Health Screenings and Overtreatment in Older Adults. EurekAlert! February 7, 2024. https://www.eurekalert.org/news-releases/1033844. Accessed February 9, 2024.}