Multilevel Small Area Estimation of Prostate-Specific Antigen Screening Test in the United States by Age Group: 2018 Behavioral Risk Factor Surveillance System

Zahava Berkowitz; Xingyou Zhang; Thomas B. Richards; Susan A. Sabatino; Lucy A. Peipins; Judith Lee Smith

doi:10.3122/jabfm.2021.03.200505

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Appendix Figure 1.
Model-Based Estimated County Prevalence Maps for Men with Prostate-Specific Antigen (PSA) Screening as Part of a Routine Examination Within the Past Year, By Age-Group, Using 2018 Data. Abbreviation: BRFSS, Behavioral Risk Factor Surveillance System.

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Table 1.

National Estimates From the 2018 Behavioral Risk Factor Surveillance System (BRFSS), and Model-Based PSA Screening Summary Estimates for the Total Population and 3142 Counties, by Age Group^*^†

Age Group, years	BRFSS 2018	Model-based national and county summary statistics						Overall Range
Age Group, years	Mean (95% CI)	Mean (95%CI)	Min	Q1	Median	Q3	Max	Overall Range
≥40
US	19.77 (19.31–20.24)	20.59 (20.18–21.00)
Counties		21.93	7.87	20.00	22.27	24.07	38.14	30.27
40 to 54
US	7.85 (7.38–8.36)	7.67 (7.43–7.92)
Counties		7.82	4.33	7.26	7.8	8.32	12.62	8.28
55 to 69
US	26.72 (25.89–27.56)	27.23 (26.50–27.96)
Counties		27.75	10.52	25.60	28.05	30.31	40.51	29.99
≥70
US	33.39 (32.16–34.65)	33.67 (32.64–34.67)
Counties		34.22	15.60	30.82	34.23	37.61	52.66	37.06

PSA, Prostate-specific antigen; Min, Minimum; Q1, 25^th percentile; Q3, 75^th percentile; Max, Maximum; CI, Confidence interval.
↵* 2018 BRFSS sample size for age ≥40 is 116,654. BRFSS percentages are weighted to the study population.
↵† Estimates are presented as percentages (%). Model-based results are based on data from the 2018 BRFSS, US Census 2018 American Community Survey 5-year county-level poverty estimates, and the US Census estimated county population counts.

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Table 2.

Spearman and Pearson Correlation Coefficients Between Model-Based PSA Screening State-Level Estimates and BRFSS 2018 Direct State Estimates, by Age Group^*^†

Age Group, years	No. of States	Correlation^‡		Min (%)	Mean (%)	Median (%)	Max (%)
Age Group, years	No. of States	Spearman^§	Pearson^{^‖}	Min (%)	Mean (%)	Median (%)	Max (%)
≥40	51	0.94	0.94
Model-based				14.36	20.71	20.94	27.00
BRFSS				12.18	19.54	19.88	27.52
40 to 54	51	0.94	0.89
Model-based				4.52	7.68	7.74	10.31
BRFSS				2.65	7.73	7.39	13.77
55 to 69	51	0.89	0.92
Model-based				17.88	27.13	27.58	32.84
BRFSS				15.26	26.07	25.77	34.56
≥70	51	0.86	0.85
Model-based				24.40	33.62	33.10	44.18
BRFSS				23.45	33.46	33.51	41.06

PSA, prostate-specific antigen; BRFSS, Behavioral Risk Factor Surveillance System; Min, Minimum; Max, Maximum.
↵* BRFSS 2018 sample size for age ≥40 is 116,654. BRFSS percentages used for comparisons with the Model-based are weighted to the study population. The total number of counties in the model-based is 3,142.
↵† Model-based results are based on data from 2018 BRFSS, US Census 2018 American Community Survey 5-year county-level poverty estimates, and the US Census estimated county population counts.
↵‡ Correlation coefficients between model-based state-level estimates and 2018 BRFSS direct state estimates.
↵§ Spearman correlation coefficient;
↵‖ Pearson correlation coefficient.

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Table 3.

Model-Based SAE State Prevalence Estimate, and County Statistics Summarized by State for PSA Screening Among Men Aged ≥40 Years, for 50 States, the District of Columbia, and 3142 Counties, 2018

State	State Mean^*	County Summary Statistic^*
State	State Mean^*	Min	Q1	Mean	Median	Q3	Max	Range^†
Alabama	24.98	20.03	23.13	24.45	24.53	25.50	30.24	10.21
Alaska	19.14	7.87	13.56	16.57	17.82	19.40	22.39	14.52
Arizona	21.76	10.97	15.92	19.15	19.17	21.81	26.71	15.74
Arkansas	23.12	18.38	21.47	27.67	22.40	23.96	27.33	8.95
California	15.85	11.65	15.01	16.94	16.38	18.84	23.22	11.57
Colorado	17.36	11.56	16.93	18.73	18.86	20.33	24.36	12.80
Connecticut	21.69	18.25	20.68	21.62	22.25	22.81	23.23	4.97
Delaware	24.43	22.00	22.00	25.10	23.75	29.54	29.54	7.54
District of Columbia	17.76			17.76
Florida	25.61	19.21	22.58	25.38	24.87	27.68	38.14	18.94
Georgia	24.14	17.78	23.22	24.47	24.23	25.63	32.01	14.23
Hawaii	15.64	14.98	15.46	15.83	15.73	16.10	16.88	1.90
Idaho	20.17	15.42	18.74	20.55	20.65	22.16	24.66	9.24
Illinois	19.44	16.30	21.14	22.11	22.09	23.15	25.88	9.57
Indiana	19.43	16.71	18.94	19.78	19.76	20.53	22.79	6.08
Iowa	21.22	16.63	21.23	22.22	22.32	23.14	27.31	10.68
Kansas	22.55	14.46	23.13	23.99	24.43	25.47	29.06	14.60
Kentucky	21.86	16.74	20.84	21.98	22.00	23.11	27.60	10.86
Louisiana	23.81	17.01	21.94	23.02	22.92	24.14	27.21	10.20
Maine	15.84	13.71	14.49	15.93	15.74	16.81	19.21	5.49
Maryland	19.55	16.43	18.21	20.57	19.84	22.96	25.74	9.30
Massachusetts	18.39	16.11	17.78	19.10	18.37	19.68	25.69	9.58
Michigan	20.27	17.20	19.94	21.31	21.16	22.44	26.51	9.31
Minnesota	17.69	14.67	18.09	19.14	19.26	19.99	23.54	8.87
Mississippi	23.53	17.31	22.01	23.02	23.16	24.53	27.75	10.43
Missouri	23.93	19.26	23.00	24.00	24.07	25.12	29.74	10.47
Montana	23.87	15.48	23.02	24.56	25.52	26.73	29.16	13.67
Nebraska	20.12	16.09	21.26	22.64	23.08	24.00	28.83	12.74
Nevada	17.21	15.81	17.20	19.02	18.58	19.52	25.94	10.13
New Hampshire	19.29	15.38	17.04	19.02	19.59	20.02	23.31	7.92
New Jersey	24.20	18.95	23.24	24.63	25.49	26.80	29.03	10.08
New Mexico	14.36	8.37	13.75	14.98	14.69	16.33	20.44	12.07
New York	20.68	14.45	19.03	20.43	20.68	22.03	28.58	14.13
North Carolina	23.66	17.19	22.67	24.17	23.94	25.29	32.34	15.14
North Dakota	21.37	10.70	21.57	22.97	23.79	24.86	27.87	17.17
Ohio	21.97	17.09	21.11	22.28	21.92	23.50	27.88	10.79
Oklahoma	23.32	17.24	22.56	23.33	23.22	24.36	27.18	9.94
Oregon	15.97	13.27	16.23	17.09	17.22	18.46	20.15	6.88
Pennsylvania	21.90	18.76	21.30	22.32	22.38	23.10	25.86	7.10
Rhode Island	20.60	18.53	20.56	22.91	23.25	25.37	26.82	8.29
South Carolina	26.14	20.44	23.16	25.14	24.95	26.17	34.97	14.53
South Dakota	21.73	8.57	19.94	21.37	22.70	24.16	26.06	17.49
Tennessee	23.25	18.99	22.99	23.88	23.90	24.97	30.26	11.23
Texas	18.59	11.22	18.22	20.30	20.60	22.64	29.21	17.99
Utah	16.52	12.43	16.95	18.19	18.61	20.30	23.07	10.64
Vermont	15.02	12.62	13.65	15.15	15.34	16.08	19.14	6.52
Virginia	20.94	15.11	20.41	22.06	22.13	23.67	27.82	12.70
Washington	15.44	13.01	15.52	17.45	17.13	19.92	22.68	9.67
West Virginia	27.00	22.52	25.56	26.79	26.77	27.96	31.79	9.38
Wisconsin	19.56	12.96	19.65	20.49	20.42	21.46	25.03	12.07
Wyoming	24.57	20.86	22.96	24.74	24.56	26.83	29.82	8.96

SAE, small area estimation; PSA, prostate-specific antigen; Min, Minimum; Max, Maximum; Q1, 25^th percentile; Q3, 75^th percentile; BRFSS, Behavioral Risk Factor Surveillance System.
↵* State prevalence is presented as means and estimates are presented as percentages (%). Model-based results are based on data from the 2018 BRFSS, US Census 2018 American Community Survey 5-year county-level poverty estimates, and the US Census estimated county population counts.
↵† Range means the difference between the minimum and maximum estimated percentages.

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Table 4.

Model-Based SAE State Prevalence Estimate and County Statistics Summarized by State for PSA Screening among Men Aged 55 to 69 Years and ≥70 Years for 50 States, the District of Columbia, and 3142 Counties, 2018

State	State Mean^‡	55 to 69 Years *								≥70 Years^†*
		County Summary Statistic^‡							State Mean	County Summary Statistic^‡
		Min	Q1	Mean	Median	Q3	Max	Range^§		Min	Q1	Mean	Median	Q3^‖	Max	Range^§
Alabama	31.05	22.31	27.83	29.90	29.77	31.72	40.47	18.15		40.73	31.97	36.09	39.20	39.20	41.86	52.37	20.40
Alaska	25.32	10.52	19.16	22.03	22.49	26.45	28.79	18.27	33.32	18.14	24.37	28.45	28.75	31.96	40.36	22.22
Arizona	27.42	14.07	21.58	24.08	23.81	27.90	32.07	18.01	35.76	17.94	25.58	29.03	29.96	32.33	40.45	22.51
Arkansas	31.13	24.10	27.36	29.03	28.90	30.31	40.51	16.41	35.05	27.86	31.93	33.82	33.38	35.56	45.15	17.29
California	21.98	15.39	20.45	22.16	22.04	24.01	29.10	13.71	28.47	20.60	26.81	27.94	28.33	29.53	34.57	13.97
Colorado	25.63	17.51	23.93	25.41	25.62	27.21	32.52	15.01	28.65	22.23	27.30	29.70	29.64	31.97	36.03	13.80
Connecticut	27.19	20.38	25.25	26.60	27.74	28.37	29.72	9.34	34.02	30.50	32.46	33.89	33.25	34.96	39.33	8.83
Delaware	32.84	27.89	27.89	32.15	32.64	35.92	35.92	8.03	37.19	34.15	34.15	38.11	39.29	40.91	40.91	6.77
District of Columbia	23.24			23.24					30.20			30.20
Florida	31.10	23.43	27.51	30.30	30.15	32.58	40.45	17.02	39.76	30.65	36.07	39.39	39.34	42.46	48.43	17.78
Georgia	31.56	24.35	28.00	30.02	29.78	31.41	39.21	14.86	39.80	31.20	37.02	39.00	38.98	40.61	48.06	16.86
Hawaii	18.94	18.29	18.86	20.64	20.38	22.69	23.01	4.72	31.68	18.89	24.59	26.99	28.28	29.09	34.10	15.21
Idaho	28.48	22.60	25.53	27.40	27.35	28.79	31.43	8.82	30.96	25.31	29.17	31.09	31.42	33.25	36.74	11.44
Illinois	25.94	22.05	27.48	28.59	28.58	29.38	33.03	10.99	29.61	23.96	32.13	33.01	33.08	34.25	36.44	12.48
Indiana	26.83	22.19	25.83	27.09	26.87	28.09	32.93	10.74	30.53	24.78	28.64	30.11	29.81	31.50	38.81	14.03
Iowa	29.43	24.44	28.30	29.41	29.40	30.77	36.83	12.38	31.38	24.88	29.81	31.53	31.35	32.91	40.97	16.09
Kansas	29.70	21.65	28.83	30.31	30.51	31.67	38.46	16.82	36.25	23.66	33.34	35.06	34.72	36.75	45.32	21.66
Kentucky	29.03	23.56	26.91	28.70	28.39	30.23	36.19	12.62	37.14	27.51	35.61	37.59	37.56	39.00	46.00	18.49
Louisiana	30.75	22.72	27.73	29.68	29.24	31.46	37.92	15.19	35.82	29.12	32.84	34.62	34.51	36.08	43.81	14.69
Maine	21.64	15.84	19.03	22.09	22.13	25.01	29.07	13.23	24.68	18.79	21.37	23.55	23.44	25.67	28.88	10.09
Maryland	26.16	20.65	25.34	27.01	26.52	29.56	33.52	12.84	32.87	25.41	30.51	32.66	32.64	34.48	41.20	15.79
Massachusetts	25.82	21.91	23.86	26.26	26.11	28.66	31.32	9.41	27.02	21.51	25.84	27.75	27.87	29.75	34.57	13.06
Michigan	26.91	19.75	26.04	27.56	27.59	28.95	34.13	14.39	32.22	24.85	30.09	31.89	31.35	33.54	40.49	15.64
Minnesota	24.05	19.46	23.62	25.19	25.20	26.54	31.81	12.35	29.49	22.9	28.12	30.25	30.41	31.87	38.10	15.20
Mississippi	27.74	19.24	24.53	26.39	26.46	28.59	35.32	16.09	41.23	32.61	37.96	40.36	40.02	42.58	47.07	14.46
Missouri	30.10	23.63	27.53	28.86	28.77	30.28	34.82	11.19	37.79	30.56	36.09	38.00	37.74	39.47	45.93	15.37
Montana	31.08	21.07	28.74	30.33	30.95	32.25	37.13	16.06	35.85	25.96	33.55	35.78	36.37	37.52	45.39	19.44
Nebraska	26.03	18.79	26.59	28.12	28.01	30.32	35.78	16.99	33.09	24.96	30.73	32.92	32.58	35.22	39.37	14.41
Nevada	23.60	20.79	23.69	24.79	24.28	25.47	31.55	10.77	30.79	23.00	27.40	28.71	28.60	29.96	35.97	12.97
New Hampshire	24.09	18.63	20.24	23.39	12.73	25.81	27.66	9.03	33.97	24.15	30.11	32.33	33.03	35.32	37.65	13.50
New Jersey	30.56	23.27	27.17	30.96	31.52	35.34	38.28	15.00	38.49	33.09	37.53	38.84	38.98	40.89	45.03	11.94
New Mexico	17.88	11.36	17.08	18.85	18.37	20.59	26.26	14.90	24.74	15.5	20.55	22.76	22.55	24.88	29.70	14.09
New York	27.58	16.24	24.08	26.73	25.91	29.85	35.79	19.55	31.92	21.9	27.75	31.03	30.52	34.23	43.95	22.05
North Carolina	30.48	20.74	27.86	29.82	29.70	31.75	38.02	17.28	38.83	31.51	36.08	38.00	37.72	48.58	50.47	18.96
North Dakota	29.47	15.83	28.19	29.63	29.74	31.69	35.01	19.18	30.80	21.66	29.24	31.70	31.57	33.64	39.12	17.47
Ohio	28.74	22.07	27.09	29.06	29.25	30.53	39.00	16.93	34.95	27.23	32.60	35.20	34.83	37.34	50.59	23.36
Oklahoma	27.67	19.36	24.50	26.33	26.01	28.14	31.84	12.49	40.13	33.17	37.35	39.66	39.57	41.37	50.38	17.21
Oregon	21.42	17.42	20.46	21.23	21.36	22.19	26.62	9.20	29.78	25.68	28.13	29.78	29.43	31.18	36.94	11.26
Pennsylvania	31.93	26.56	30.52	31.92	31.46	33.42	37.72	11.16	30.37	25.89	28.84	30.43	30.20	31.90	37.49	11.60
Rhode Island	27.04	24.62	26.27	29.64	31.21	32.33	33.78	9.16	31.68	28.81	29.67	34.51	34.81	35.00	44.26	15.45
South Carolina	32.41	24.12	28.35	30.40	29.37	33.04	38.63	12.77	39.85	30.94	34.16	37.51	37.22	40.46	49.43	18.50
South Dakota	27.88	12.20	24.60	26.75	28.32	29.87	37.29	25.08	34.63	19.18	31.37	32.63	33.38	35.02	44.57	25.39
Tennessee	29.74	23.02	28.61	30.14	30.06	31.32	37.65	14.63	37.81	31.10	36.21	37.74	37.67	39.14	45.02	13.93
Texas	25.67	14.96	23.55	25.07	25.46	27.12	32.78	17.83	33.10	21.32	31.48	32.93	33.59	35.15	45.19	23.87
Utah	25.22	17.75	23.56	25.15	25.39	26.75	32.72	14.97	29.85	23.93	28.46	30.29	29.94	32.11	39.82	15.89
Vermont	18.79	15.45	16.68	18.98	19.50	20.37	24.83	9.38	24.40	17.99	21.35	23.99	23.10	27.95	29.08	11.09
Virginia	28.62	22.58	26.96	28.90	28.90	30.71	35.76	13.18	35.54	27.67	33.59	35.56	35.25	37.50	45.75	18.08
Washington	19.87	15.98	18.51	20.33	20.11	21.76	26.87	10.89	28.73	23.42	27.58	30.41	29.60	34.60	40.05	16.62
West Virginia	31.91	25.84	29.62	31.51	31.70	33.73	39.52	13.68	44.18	36.56	40.59	42.94	42.51	44.89	52.66	16.10
Wisconsin	26.45	15.73	26.14	27.08	27.16	28.5	33.47	17.74	30.06	23.46	28.56	29.93	29.54	31.73	34.85	11.38
Wyoming	29.44	22.28	27.30	29.37	29.50	32.21	35.69	13.41	39.53	33.73	35.10	38.25	37.77	40.47	46.94	13.21

SAE, small area estimation; PSA, Prostate-specific antigen; Min, Minimum; Max, Maximum; Q1, 25^th percentile; Q3, 75^th percentile; BRFSS, Behavioral Risk Factor Surveillance System.
* The age group for which the USPSTF recommendations suggest that benefits might exist after discussion with a health care provider.
↵† This age group is not recommended by the USPSTF for routine PSA screening after discussion with a health care provider.
↵‡ State prevalence is presented as means and estimates are presented as percentages (%).
Model-based results are based on data from the 2018 BRFSS, US Census 2018 American Community Survey 5-year county-level poverty estimates, and the US Census estimated county population counts.
↵§ Range means the difference between the minimum and maximum estimated percentages.
↵‖ Bold percentages in the 75^th percentiles are ≥40.0%.

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Appendix Table 1.

Unweighted and Weighted Percentages of PSA Screening Within One Year by Age and Race and Ethnicity Groups, BRFSS 2018, (n = 116,654)^*^†

Age Group, years	Sample Size	Unweighted %^‡	Weighted % (95% CI)
40 to 49	22,561	4.32	4.51 (4.04-5.03)
50 to 59	29,595	16.90	16.81 (15.98-17.68)
60 to 69	33,718	30.79	30.30 (29.25-31.36)
70 to 79	21,449	37.28	37.50 (35.96-39.05)
≥80	9,331	23.50	23.38 (21.48-25.39)
Race and ethnicity
NH white	92,133	24.43	22.26 (21.75-22.78)
NH black	8,044	21.12	18.40 (17.01-19.87)
NH AIAN	2,009	12.10	12.46 (9.42-16.31)
NH Asian	2,076	14.45	12.26 (9.72-15.33)
NH PI	369	10.57	11.48 (7.11-18.00)
NH ≥2 races	2,024	15.12	15.02 (12.79-19.40)
Hispanic	6,572	11.41	11.65 (10.04-13.48)

BRFSS, Behavioral Risk Factor Surveillance System; PSA, Prostate-Specific Antigen; CI, Confidence interval; NH, Non-Hispanic; AIAN, American Indian Alaska Native; PI, Pacific Islander.
↵* We excluded the NH other race group in our analysis to match the US Census race and ethnicity categorization, which we used in our simulation models.
↵† Sample size is the number of men who answered the question whether they had had a PSA test in the past year (Yes/No or never).
↵‡ An unweighted percentage is the percentage of men reporting having had a PSA screening test within 1 year of the interview in a specific age or race and ethnicity group category. Weighted percentage is an estimate of the prevalence of having had a PSA screening test in the past year in a specific age or race and ethnicity group in the study population.