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

Abstract

Prostate-specific antigen screening in older men may lead to overdiagnosis and overtreatment. This study quantified treatment effect heterogeneity of a behavioral science-informed clinical decision support to reduce clinician-level prostate-specific antigen overtesting and explored clinician-level trends in alert triggering. A secondary analysis of a pragmatic cluster-randomized trial was performed, including 338 clinicians in 59 primary care practices. Clinics received point-of-care clinical decision support plus brief education (intervention) or education alone (control). The primary outcome was clinician-level annual prostate-specific antigen overtesting rate-the proportion of male patients aged >75 years without prostate cancer receiving prostate-specific antigen testing in the prior 12 months, evaluated overall and across clinician subgroups. Monthly trends in alerts were also examined. Data were collected in 2019-2022 and analyzed in 2024-2025. Over 18 months, intervention clinicians reduced prostate-specific antigen overtesting by 12.1 per 100 patients versus controls (95% CI=7.5, 16.7). Reductions were greater among female (15.6; 95% CI=9.4, 21.9) than among male (6.9; 95% CI=2.2, 11.6; p-interaction=0.01) clinicians and for graduates after 1999 (17.4; 95% CI=9.5, 25.3) versus earlier graduates (7.8; 95% CI=3.4, 12.3; p-interaction=0.03). The proportion of intervention clinicians triggering alerts declined by -0.6% per month (95% CI=0.3%, 0.8%). In encounters with triggered alerts, prostate-specific antigen ordering increased slightly (0.56 per 100 patients per month; 95% CI=0.04, 1.1). A behavioral science-informed clinical decision support reduced clinician-level prostate-specific antigen overtesting, with greater effectiveness among female and more recently trained clinicians. Falling alert rates suggested clinician learning, whereas increasing order rates among persistent alerts called for additional strategies to engage less responsive clinicians. This study is registered at ClinicalTrials.gov: NCT04289753.