Wide Variation in Testosterone Prescribing Across the VA System

Liam Davenport

July 25, 2017

There is wide variation in testosterone prescribing across the Veterans Health Administration (VA) system, related to the experience and specialty of the provider and the region where an individual is being treated, say US researchers in findings that point to potential ways to harmonize prescribing practices.

The study, involving data on more than 700,000 veteran patients, showed that younger providers with less experience in the VA, alongside endocrinologists and urologists, were more likely to prescribe testosterone than other providers.

Moreover, patients being treated in community-based clinics were more likely to receive the hormone, while those in the Northeast were less likely to be given testosterone, although prescribers in that region were more likely to carry out appropriate testing of testosterone levels.

The research was published online July 18 in the Journal of Clinical Endocrinology & Metabolism.

"Our study clearly shows that there is variation in both receipt of testosterone as well as guideline-concordant prescribing of testosterone in the VA," Guneet K Jasuja, PhD, Center for Healthcare Organization and Implementation Research, Bedford VA Medical Center, Bedford, Massachusetts, commented in a press release.

She added that the findings "highlight the opportunity to intervene at the provider and local level to improve testosterone prescribing practices."

"The VA and other healthcare systems can use these insights to promote targeted efforts that can help decrease inappropriate prescribing of testosterone, while ensuring that those patients who can benefit the most can still receive it."

Endocrinologists and Urologists Most Likely to Prescribe Testosterone

There has been a large rise in the number of prescriptions for testosterone over the past decade in the United States, with new prescriptions increasing substantially in the VA between 2009 and 2012. However, the clinical context within which testosterone prescriptions occur is unclear — it is thought to be influenced by a range of patient, provider, and system-level factors, and it is believed that a better understanding of this could help improve appropriate prescribing.

To investigate further, the researchers gathered data on 132,764 male patients from the national VA system who received at least one testosterone prescription between October 2007 and September 2012 and a random sample of 550,151 men who received at least one prescription for another medication, from a total of 38,648 providers and 130 stations.

Mixed-models analysis fully adjusted for clustering revealed that providers aged 31 to 60 years were more likely than those aged ≥61 years of age to prescribe testosterone at odds ratios [ORs] ranging from 1.17 to 1.22 (< .01).

Furthermore, providers with ≤1 year of VA service were more likely to prescribe testosterone than those with ≥16 years of service (adjusted OR, 1.29; < .01), while endocrinologists and urologists were more likely to prescribe the hormone than primary-care physicians (ORs, 3.86 and 1.40, respectively; < .01 for both). Other providers were less likely to prescribe testosterone than primary-care physicians.

The researchers also found that, compared with sites in the Northeast of the country, those in the West (OR, 1.75), South (OR, 1.63), and Midwest (OR, 1.37) were more likely to prescribe testosterone (< .01 for all).

Patients treated in community-based outreach clinics were also more likely to receive testosterone than those undergoing care at a main facility (OR, 1.22; < .01).

Physician Education Could Help Improve Best Practice for Testosterone Prescribing

In terms of the appropriateness of testosterone testing, providers aged 31 to 40 years, those with ≥16 years in the VA, female providers, and endocrinologists were significantly more likely to perform appropriate diagnostic evaluation before prescribing testosterone (< 0.01 for all).

Geographically, sites in the Northeast were more likely to document appropriate testosterone testing before prescribing than those in other regions, while being the least likely to prescribe testosterone, leading the authors to say that the two variables may be linked — while those treated in community-based outreach clinics were less likely than those at main facilities to undergo such testing (< .01 for all).

Overall, category 1a sites, which are the largest and most complex, and category 1c sites were more likely than category 3 sites to adhere to appropriate testing (ORs, 1.33 and 1.23, respectively; < .01 for both).

Discussing the between-provider differences in testosterone prescribing, the team writes: "Assuming that the physician specialists in endocrinology and urology have received a higher level of training in managing male reproductive disorders than nonspecialists, these findings raise the possibility that testosterone prescribing practices could be improved by targeted provider training or computer-based decision support."

They suggest that their results therefore "highlight the opportunity to intervene both at the provider and the site level."

They note: "A variety of interventions in the literature have been used to improve and standardize provider prescribing practice, such as mailed educational materials, educational programs, audit and feedback, and academic detailing.

"Through such efforts, providers' knowledge of how to manage male hypogonadism could be increased, which could help promote adherence to existing clinical practice guidelines for testosterone prescribing."

The research was supported by the Department of Veterans Affairs, Veterans Health Administration, Health Services Research and Development Service. Dr Jasuja is a VA HSR&D Career Development awardee at the Bedford VA. Disclosures for the coauthors are listed in the paper.  

J Clin Endocrinol Metab. Published online July 18, 2017. Abstract

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