Changing Clinician Behavior in Geriatrics: Point-of-Care Alerts for Prostate-Specific Antigen Screening

Area of Science:

• Clinical Informatics
• Health Services Research
• Behavioral Science

Background:

• Prostate-specific antigen (PSA) screening in older men is associated with overdiagnosis and overtreatment.
• Clinical decision support (CDS) tools can mitigate overuse of PSA testing.

Purpose of the Study:

• To quantify the heterogeneity in treatment effects of a behavioral science-informed CDS designed to reduce clinician-level PSA overtesting.
• To explore clinician-level trends in alert triggering within the CDS system.

Main Methods:

• Secondary analysis of a pragmatic cluster-randomized trial involving 338 clinicians across 59 primary care practices.
• Intervention group received point-of-care CDS plus education; control group received education alone.
• Primary outcome: clinician-level annual PSA overtesting rate in men >75 years without prostate cancer; secondary outcome: monthly alert trends.

Main Results:

• Intervention clinicians reduced PSA overtesting by 12.1 per 100 patients over 18 months compared to controls.
• Reductions were significantly greater among female clinicians and those who graduated after 1999.
• Alert triggering proportion declined monthly, but PSA ordering increased slightly in encounters with triggered alerts.

Conclusions:

• Behavioral science-informed CDS effectively lowered clinician-level PSA overtesting, particularly in female and recently trained clinicians.
• Declining alert rates suggest clinician adaptation, while rising order rates in persistent alerts necessitate further engagement strategies.
• Findings highlight the importance of tailoring interventions and developing strategies for less responsive clinicians.