Variability and Hospital-Level Predictors of MRI for Elevated PSA: Results of a Medicare and American Hospital Association Linkage

INTRODUCTION: Despite level 1 evidence supporting prostate MRI for suspected prostate cancer, its use remains limited in the United States. The impact of patient- and hospital-level factors on MRI use after a new elevated prostate-specific antigen (PSA) among Medicare beneficiaries is unclear. We evaluated these factors to explain variation in MRI utilization. METHODS: statistics. RESULTS: Of 304,161 patients across 2,657 hospitals, the top quartile of hospitals achieved a mean pre-biopsy MRI utilization rate of 8.5% (SD:2.9); the bottom quartile reported rates below 1.75%. Black patients were more likely to undergo MRI than White patients (OR: 1.15, 95% CI: 1.06-1.26; p < 0.001), as were those residing in metropolitan areas. Major teaching hospitals were associated with increased MRI use (OR: 1.19; 95% CI: 1.07-1.32; p = 0.001). Patient-level variables explained 37.2% of the variance in MRI utilization, while hospital-level factors accounted for less than 1%. CONCLUSIONS: Patient-level factors represent the primary drivers of variation in pre-biopsy MRI use, with minimal contribution from hospital characteristics. Efforts to improve equity in prostate cancer care should prioritize reducing patient-level barriers and standardizing referral practices across institutions.