We've become a nation of defensive medicine. Health care is expensive not because of drug companies or overpaid doctors or malpractice premiums, but rather the largest cost for health care is administering tests to check off boxes and prevent legal problems in a future lawsuit that may never come.

No medical organization recommends the prostate-specific antigen test for older men, but many primary care doctors continue to administer it even to those over age 75.

In a research letter published in the Journal of the American Medical Association, University of Texas Medical Branch at Galveston researchers found that some doctors ordered the test for their older male patients regularly, despite more than a decade of recommendations against doing so. The doctors' tendency to order the test had little to do with measurable patient characteristics.

Why? It's unknown. It could be cultural. In the past the criticism was that hospitals and doctors did not do enough and that was considered corporate greed. In a future of government-controlled health care, it may be required that overtesting rates be included as quality measures of Primary Care Physicians.

"Our results suggest that a major reason for the continued high PSA rate is decision-making by the physicians," said senior author Dr. James Goodwin, director of UTMB's Sealy Center on Aging. "That's why there was so much variation among physicians, after accounting for differences among patients. It is clear that some of the overuse is because of preferences of individual patients, but the conclusion of our results is that much more is coming from their primary care physicians."

The purpose of the study was to determine the role primary care physicians play in whether a man receives PSA screening. They looked at the complete Medicare Part A and Part B data for 1,963 Texas physicians who had at least 20 men age 75 or older in their panels and who saw a man three or more times in 2009. Of the 61,351 patient records examined, 41 percent of men received a PSA screening that year, and 29 percent received a screening ordered by their primary care physician.

Which primary care physician a man sees explained approximately seven times more of the variance in PSA screening than did the measurable patient characteristics, such as age, ethnicity, and location, according to the study.

"Overtesting can create harms, including overdiagnosis," said Dr. Elizabeth Jaramillo, lead author and an instructor of internal medicine-geriatrics at UTMB. "The vast majority of prostate cancers are so slow growing that an elderly man is much more likely to die of another condition in his lifetime than from the cancer."

Additional research is needed to understand why some primary care physicians order PSA screenings more often than others. The study suggests that overtesting rates be included as quality measures of PCPs. Medicare data can be used to generate such measures.

Citation:Upcoming in JAMA, no DOI yet.