National Recommendations against Prostate Specific Antigen Screening versus Statewide Medicaid Expansion Initiatives: A Battle of the Titans.

PURPOSE: Medicaid expansion under the Patient Protection and Affordable Care Act occurred almost concurrently with 2012 U.S. Preventive Services Task Force recommendations against prostate specific antigen screening. Here the relative influence on prostate specific antigen screening rates by 2 concurrent and opposing system-level policy initiatives is investigated: improved access to care and change in clinical practice guidelines. MATERIALS AND METHODS: Behavioral Risk Factor Surveillance System data from years 2012 to 2018 were analyzed for trends in self-reported prostate specific antigen screening and insurance coverage. Subanalyses included state Medicaid expansion status and respondent federal poverty level. Multivariable logistic regression was performed to evaluate factors associated with prostate specific antigen screening. RESULTS: From 2012 to 2018 prostate specific antigen screening predominantly declined with a notable exception of an increase of 7.3% for men at <138% federal poverty level between 2011 and 2013 in early expansion states. Initial increases did not continue, and screening trends mirrored those of nonexpansion states by 2018. Notably, 2014 planned expansions states did not follow this trend with minimal change between 2015 and 2017 compared to declines in early expansion states and nonexpansion states (-0.4% vs -6.7% and -8.6%, respectively). CONCLUSIONS: Medicaid expansion was associated with increased rates of insured men at <138% federal poverty level from 2012 to 2018 in early expansion states. In this group, initial increases in prostate specific antigen screening were not durable and followed the trend of reduced screening seen across the United States. In planned expansions states the global drop in prostate specific antigen screening from 2016 to 2018 was offset in men at <138% federal poverty level by expanding access to care. Nonexpansion states showed a steady decline in prostate specific antigen screening rates. This suggests that policy such as U.S. Preventive Services Task Force recommendations against screening competes with and often outmatches access to care.

Prostate Cancer Screening in Early Medicaid Expansion States.

PURPOSE: The PPACA (Patient Protection and Affordable Care Act) of 2010 included a provision to expand Medicaid by 2014. Six states and jurisdictions elected to expand Medicaid early before 2012. This provided a natural experiment to test the association between expanded insurance coverage and preventive service utilization, including prostate cancer screening. MATERIALS AND METHODS: Using the 2012 and 2014 BRFSS (Behavioral Risk Factor Surveillance System) surveys we identified men 40 to 64 years old who reported prostate specific antigen testing in the preceding 12 months. Sociodemographic and access to care variables were extracted. Income was stratified by the relationship to Medicaid eligibility and the federal poverty level (less than 138%, 138% to 400% and greater than 400%). The weighted prevalence of prostate specific antigen was estimated. Multivariable logistic regression models were used to evaluate factors associated with prostate specific antigen screening. Interaction analysis for Medicaid expansion was performed. RESULTS: Among 158,103 respondents individuals in nonexpansion states had the highest incidence of prostate specific antigen screening. Nationally screening decreased between 2011 and 2013 (OR 0.87, 95% CI 0.83-0.91). In only early expansion states there was a 3% absolute increase in screening among men in the less than 138% federal poverty level, which was associated with expansion status (pinteraction = 0.04). Increased screening in early expansion states was also seen in men who were 55 to 59 years old, nonHispanic African American, Hispanic, previously married, not high school graduates and current smokers. CONCLUSIONS: Between 2011 and 2013 there were national declines in prostate cancer screening. However, there was significant narrowing of the gap in prostate specific antigen screening between higher and low income men in Medicaid early expansion states. This may reflect improved access to preventive services among populations with historic barriers to care.

Identification of common themes from after-hour telephone calls made to urology residents.

OBJECTIVES: To characterize the content and sources of after-hour telephone calls from a general urology practice so that common themes can be identified and incorporated into the education of urology residents. METHODS: After-hour telephone calls were prospectively assessed for 6 months by a single senior urology resident. Calls occurring on weekends/holidays and between 5 PM and 8 AM on weekdays were directly referred to the on-call resident. The day of week, time, source, initiating event, and required action from each call was recorded. Exclusion criteria included calls regarding established hospital urology in-patients and duplicate calls from individual patients calling more than once within 24 hours. RESULTS: Eighty-seven calls were collected. Seventy percent occurred on weekends, primarily between 8 AM and 5 PM. The most common source was from outpatients (56%) followed by emergency room physicians (30%). In general, 61% and 26% of all calls regarded new urologic symptoms and postoperative issues, respectively. Urinary calculi were the most common specific reason for a call, followed by lower urinary tract symptoms and hematuria. An acute urologic evaluation was required for 27% of all telephone calls. Nine patients (10%) required admission within 48 hours of calling. CONCLUSIONS: The education of urology residents should emphasize telephone evaluations of patients who present with urinary calculi and common postoperative issues. The number of after-hour calls may be able to be reduced if patients and nonurologist physicians are also educated in the management of nonacute urologic problems.