Department of Veterans Affairs 

Office of Inspector General 

Healthcare Inspection 

Evaluation of Patient Prostate Care 

Tennessee Valley Healthcare System 

Nashville, Tennessee 

Report No. 11-00181-153 April 28, 2011 VA Office of Inspector General 

Washington, DC 20420 
To Report Suspected Wrongdoing in VA Programs and Operations: 

Telephone: 1-800-488-8244 

E-Mail: vaoighotline@va.gov 

(Hotline Information: http://www.va.gov/oig/contacts/hotline.asp) 
Evaluation of Patient Prostate Care, Tennessee Valley Healthcare System, Nashville, Tennessee 

Executive Summary 

The VA Office of Inspector General Office of Healthcare Inspections evaluated the 

validity of an allegation that the Chattanooga, TN, Community Based Outpatient Clinic 

(CBOC) did not provide appropriate medical follow-up for elevated prostate-specific 

antigen (PSA) levels.1 

We did not substantiate the allegation. The patient’s CBOC providers routinely 

measured PSA levels and communicated results to the patient. The patient told his VA 

provider that he received routine urology care from community providers that included 

prescribing medications and performing examinations, biopsies, and surgery. 

The VISN and facility Directors agreed with our findings. We made no 

recommendations. 

1 PSA is a protein produced by the prostate gland. PSA is present in small quantities in the serum of individuals 

with healthy prostates but may be elevated in the presence of prostate cancer and in other prostate disorders. 

VA Office of Inspector General i 
DEPARTMENT OF VETERANS AFFAIRS 

Office of Inspector General 

Washington, DC 20420 

TO: Director, VA Mid South Healthcare Network (10N9) 

SUBJECT: Healthcare Inspection – Evaluation of Patient Prostate Care, Tennessee 

Valley Healthcare System, Nashville, Tennessee 

Purpose 

The VA Office of Inspector General (OIG) Office of Healthcare Inspections evaluated 

the validity of the allegation that primary care providers (PCPs) at the Chattanooga, TN, 

Community Based Outpatient Clinic (CBOC) did not follow-up on elevated prostatespecific antigen (PSA) levels.2 The purpose of the inspection was to determine if the 

allegation had merit. 

Background 

The CBOC provides outpatient primary care services to approximately 14,000 unique 

veterans. The CBOC is part of the Tennessee Valley Healthcare System (facility). The 

facility provides inpatient and outpatient services at the Alvin C. York VA Medical 

Center, Murfreesboro, TN; the Nashville VA Medical Center, Nashville, TN; and 

13 community based outpatient clinics located in Tennessee and Kentucky. The facility 

is part of Veterans Integrated Service Network (VISN) 9. 

In October 2010, a complainant contacted the OIG Hotline Division regarding medical 

follow-up of a patient. Specifically, the complainant alleged that a patient had elevated 

PSA levels that were not appropriately addressed. 

Scope and Methodology 

We conducted telephone interviews with the patient, available PCPs, and CBOC 

leadership. We reviewed the patient’s medical record, the records from the community 

urology provider, relevant facility policies, and Veterans Health Administration 

directives. 

2 PSA is a protein produced by the prostate gland. PSA is present in small quantities in the serum of individuals 

with healthy prostates but may be elevated in the presence of prostate cancer and in other prostate disorders. 

VA Office of Inspector General 1 
Evaluation of Patient Prostate Care, Tennessee Valley Healthcare System, Nashville, Tennessee 

We conducted the inspection in accordance with Quality Standards for Inspection and 

Evaluation published by the Council of the Inspectors General on Integrity and 

Efficiency. 

Case Summary 

The patient has a history of hypertension, diabetes, anxiety disorder, post-traumatic stress 

disorder, and benign prostatic hyperplasia.3 The patient first visited the CBOC in 

May 1999 and returned after relocating to the area in October 2004. There is 

documentation by his VA PCPs that community primary care and urology providers were 

seeing the patient. 

In October 2005, the patient had an elevated PSA level of 5.1 ng/ml.4 The PCP treated 

the patient with antibiotics and 3 months later the PSA level was 3.0 ng/ml. In 

May 2006, the patient’s PSA level was 4.0 ng/ml, and the PCP requested urology 

consultation. The urologist cancelled the consult and recommended that the patient be 

treated with antibiotics for 45 days, with repeat PSA. The PCP was to refer the patient 

back to urology if the PSA level did not decrease or if the patient developed an abnormal 

prostate exam. At the patient’s next CBOC appointment in June 2006, the patient 

reported that a prostate exam performed 2 months earlier by a community provider was 

normal, and that a prostate biopsy done 2 years earlier was normal. The patient had a 

PSA drawn three times over the next 2 years, with levels of 4.3, 4.8, and 

4.3 ng/ml, all only slightly above the upper limits of normal and with no rising trend. 

In April 2010, the patient’s PSA level was 6.5 ng/ml with a free PSA5 of 13.7 percent. At 

the next appointment in June 2010, the PCP noted the elevated PSA. The patient refused 

a prostate exam and was to return to the CBOC in 6 months with a PSA drawn prior to 

the appointment. The patient did not return to the CBOC. 

We reviewed the medical records from the community urologist dating back to 2004. 

The community urologist saw the patient on a regular basis and monitored PSA levels. 

In 2004, the patient had a PSA level of 10.5 ng/ml and a negative prostate biopsy. 

Between 2004 and 2010, the urologist monitored the patient’s PSA levels. In July 2010, 

the PSA level was 10.4 ng/ml and a prostate biopsy in August 2010 revealed cancer. The 

patient underwent a prostatectomy in September 2010 by a community provider. 

3 Benign prostatic hyperplasia refers to the increase in size of the prostate gland. 4 The optimal range for PSA is less than 4 ng/ml. 5 A free PSA level below 15 percent suggests an increased probability of prostate cancer. 

VA Office of Inspector General 2 
Evaluation of Patient Prostate Care, Tennessee Valley Healthcare System, Nashville, Tennessee 

Inspection Results 

Issue: Medical Follow-Up of Elevated PSA Levels 

We did not substantiate the allegation that the CBOC PCPs communicated elevated PSA 

levels to a patient without further medical follow-up. The CBOC PCPs routinely ordered 

PSA levels. The PCP treated the patient’s first elevated PSA level with antibiotics and a 

follow-up PSA level was normal. The CBOC PCPs documented that the patient either 

reported a recent normal prostate examination by a community provider or refused 

prostate examination. They also documented that the patient reported that a prostate 

biopsy in 2006 was normal. The CBOC nursing staff documented the provision of 

prostate screening education on three occasions. 

During our interviews, PCPs stated that the patient reported receiving care from 

community providers. PCPs requested that the patient provide documentation of visits 

with community providers, but none were provided. The patient preferred to see the 

community provider for urology care. The PCPs continued to order PSA levels as part of 

the CBOC routine prevention screening. 

Conclusion 

We did not substantiate that the CBOC PCPs did not follow-up on elevated PSA levels. 

The patient chose to receive primary care and urology care from community providers. 

Recommendation 

We made no recommendations. 

Comments 

The VISN and System Directors concurred with our findings. See Appendixes A and B, 

pages 4–5 for the full text of their comments. 

JOHN D. DAIGH, JR., M.D. 

Assistant Inspector General for 

Healthcare Inspections 

VA Office of Inspector General 3 
Evaluation of Patient Prostate Care, Tennessee Valley Healthcare System, Nashville, Tennessee 

Appendix A 

VISN Director Comments 

Department of 

Veterans Affairs Memorandum 

Date: March 7, 2011 

From: Director, VA Mid South Healthcare Network (10N9), 

Subject: Healthcare Inspection – Evaluation of Patient Prostate Care, 

Tennessee Valley Healthcare System, Nashville, Tennessee 

To: Director, Dallas Office of Healthcare Inspections (54DA) 

Thru: Director, Management Review Service (10B5) 

1. I concur with the report and have no comments. 

2. Should you need additional information, please contact 

Tammy Williams, VISN 9 Continuous Readiness 

Coordinator at (615) 695-2200. 

(original signed by:) 

John Dandridge, Jr. 

Director, VA Mid South Healthcare Network (10N9) 

VA Office of Inspector General 4 
Evaluation of Patient Prostate Care, Tennessee Valley Healthcare System, Nashville, Tennessee 

Appendix B 

Facility Director Comments 

Department of 

Veterans Affairs Memorandum 

Date: March 7, 2011 

From: Director, Tennessee Valley Healthcare System (626/00) 

Subject: Healthcare Inspection – Evaluation of Patient Prostate Care, 

Tennessee Valley Healthcare System, Nashville, Tennessee 

To: Director, VA Mid South Healthcare Network (10N9) 

I concur with the subject Office of Inspector General’s inspection 

report and have no comments. 

(original signed by:) 

Juan A. Morales, RN, MSN 

Director, Tennessee Valley Healthcare System (626/00) 

VA Office of Inspector General 5 
Evaluation of Patient Prostate Care, Tennessee Valley Healthcare System, Nashville, Tennessee 

Appendix C 

OIG Contact and Staff Acknowledgments 

OIG Contact	 For more information about this report, please contact the 

Office of Inspector General at (202) 461-4720. 

Acknowledgments	 Cathleen King, Project Leader 

Gayle Karamanos 

Maureen Washburn 

Monika Gottlieb 

Misti Kincaid 

VA Office of Inspector General 6 
Evaluation of Patient Prostate Care, Tennessee Valley Healthcare System, Nashville, Tennessee 

Appendix D 

Report Distribution 

VA Distribution 

Office of the Secretary 

Veterans Health Administration 

Assistant Secretaries 

General Counsel 

Director, VA Mid South Healthcare Network (10N9) 

Director, Tennessee Valley Healthcare System (626/00) 

Non-VA Distribution 

House Committee on Veterans’ Affairs 

House Appropriations Subcommittee on Military Construction, Veterans Affairs, and 

Related Agencies 

House Committee on Oversight and Government Reform 

Senate Committee on Veterans’ Affairs 

Senate Appropriations Subcommittee on Military Construction, Veterans Affairs, and 

Related Agencies 

Senate Committee on Homeland Security and Governmental Affairs 

National Veterans Service Organizations 

Government Accountability Office 

Office of Management and Budget 

US Senate: Lamar Alexander, Bob Corker 

US House of Representatives: Marsha Blackburn, Jim Cooper, Scott DesJarlais, Charles 

Fleischmann 

This report is available at http://www.va.gov/oig/publications/reports-list.asp. 

VA Office of Inspector General 7