News: Reducing overtreatment in geriatric patients may take sustained effort, research shows

Reducing unnecessary, potentially harmful tests and treatment of geriatric patients may require ongoing interventions, according to a new study research published in Annals of Internal Medicine. At the end of a year-long follow-up to an 18-month trial aimed to reduce overuse, previous reductions had rebounded in two of three areas targeted (prostate-specific antigen testing [PSA], insulin or meglitinide prescriptions, and unnecessary urine screenings), Medscape Medical News reported.

According to the follow-up results, two areas saw rebounds: PSA testing of men aged greater than 76 years who did not have a history of prostate cancer, as well as insulin or meglitinide prescriptions to patients with diabetes older than 75 years with A1c levels less than 7%. Reductions in unnecessary urine screens for women were sustained, however.

The trial took place at 60 primary care practices in Chicago, in which a control group of 187 clinicians received education about the harms of overtreatment and recommendations for each area, while an intervention group of 184 clinicians received electronic health record (EHR) prompts when they attempted to order a screen or prescription. Both the urine and PSA screens required documentation of a reason for bypassing the warning in the EHR system, and clinicians had to input if they were planning to reduce treatment if they prescribed a flagged medication to a patient with diabetes.

At the end of the trial, clinicians in the intervention group had a 21% rate of PSA screens per 100 eligible patients, compared to a 31.6% rate by those in the control group. After a year of no alerts, however, screen rates had risen again in the intervention group to 26.2%.

“Doctors might think, ‘The recommendations right now are that we probably shouldn’t do this, but the patient still wants it. What’s the harm?’ ” Stephen Persell, MD, a professor of medicine in the Division of General Internal Medicine at the Feinberg School of Medicine in Chicago and lead author of the study, told Medscape Medical News. “With these alerts, we’re saying, ‘There is potential harm, and you should think about it before you do this.’ ”

According to Persell, PSA screens in the men older than 76 years “are unnecessary given the life expectancy and the often slow-growing and asymptomatic nature of prostate cancer,” Medscape Medical News reported. The treatments for it have risks that often outweigh potential benefits for older patients, he said, such as radiation causing rectal bleeding and androgen deprivation therapy increasing the risk for heart attack and dementia.

When physicians who bypassed the warning most frequently were asked for a reason, they cited either patient demand, a previously elevated test, or a patient-reported request from another clinician.

Diabetes overtreatment saw only slight success in the initial trial (a 14.2% annual rate per 100 eligible patients for the intervention group vs. 15.6% in the control group), which disappeared at the year follow-up.  For adults older than 75 years with A1c levels < 7%, prescriptions like insulin, meglitinide, or sulfonylurea can cause hypoglycemia, which can possibly lead to effects like falls, cardiac events, and frailty. But time-pressed doctors may find it easier to cave into a patient request, even if it means ignoring an EHR flag, than to take the time needed to dissuade the patient against medication.

More positively, screenings for urine bacteria for women older than 65 years without symptoms of a urinary tract infection did not see an upward tick in the intervention group rates after the year follow-up.

Editor’s note: To read Medscape Medical News’ coverage of this story, click here. To access the study, click here.