Context
Prostate cancer screening with prostate-specific antigen (PSA) is frequently performed,
counter to clinical practice guidelines.
Background
It was hypothesized that an e-mail–based intervention termed “spaced education” could
reduce clinicians' inappropriate screening for prostate cancer.
Design
The study was conducted as an RCT.
Setting/participants
The study involved 95 primary care clinicians in eight Veterans Affairs medical centers
from January 2007 to February 2009.
Intervention
Participants were randomized into two cohorts: spaced education clinicians received
four isomorphic cycles of nine e-mails over 36 weeks (zero to two e-mails per week),
whereas control clinicians received no intervention. Each e-mail presented a clinical
scenario and asked whether it was appropriate to obtain a PSA test. Participants received
immediate feedback after submitting their answers.
Main outcome measures
The primary outcome was the number and percentage of inappropriate PSA screening tests
ordered. Inappropriate testing was defined as use of PSA for prostate cancer screening
in patients aged >76 or <40 years. Appropriateness of screening was dichotomized based
on patient age at time of screening. Patients with PSA testing for non-screening reasons
were excluded using a validated protocol. Logistic regression with adjustment for
patient clustering by clinician was performed. Analyses were conducted in 2009.
Results
During the intervention period (Weeks 1–36), clinicians receiving spaced education
e-mails ordered significantly fewer inappropriate PSA screening tests than control
clinicians (10.5% vs 14.2%, p=0.041). Over the 72-week period following the intervention (Weeks 37–108), spaced
education clinicians continued to order fewer inappropriate tests compared to controls
(7.8% vs 13.1%, respectively, p=0.011), representing a 40% relative reduction in inappropriate screening.
Conclusions
Spaced education durably improves the prostate cancer screening behaviors of clinicians
and represents a promising new methodology to improve patient care across healthcare
systems.
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