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Ascertainment of Testosterone Prescribing Practices in the VA
Guneet K Jasuja1, Shalender Bhasin, Joel I Reisman
1*Center for Healthcare Organization and Implementation Research, Bedford VA Medical Center, Bedford †Department of Health Policy and Management, Boston University School of Public Health ‡Research Program in Men's Health, Aging and Metabolism, Boston Claude D. Pepper Older Americans Independence Center, Brigham and Women's Hospital, Harvard Medical School §Department of Medicine, Section of General Internal Medicine, Boston University School of Medicine, Boston, MA.
Background:
Prescribing of exogenous testosterone is increasing. Because of the risks associated with testosterone, it is important to follow evidence-based procedures when initiating therapy.
Objective:
We evaluated whether dispensing of testosterone was preceded by appropriate ascertainment of androgen deficiency, and consideration of potential contraindications, in accordance with practice guidelines.
Research Design:
A cross-sectional study.
Setting:
All outpatient clinics within Veterans Affairs (VA) during fiscal years 2009-2012 (FY09-FY12).
Subjects:
A total of 111,631 men who had not previously received testosterone from VA, and received at least 1 testosterone dispensing during the study period. A 1-year "look-back" period was used to check for diagnostic tests that occurred before the first fill.
Measures:
Proportion who underwent appropriate diagnostic evaluation of androgen deficiency and ascertainment of contraindications for testosterone therapy during the year before receiving their first testosterone dispensing.
Results:
New testosterone dispensing in VA increased from 20,437 in FY09 to 36,394 in FY12. Only 3.1% of men who received testosterone had 2 or more low (total or free) testosterone levels in the morning, LH and/or FSH level measured, and no contraindications to testosterone therapy. A total of 16.5% did not have their testosterone level checked at all. Among those prescribed therapy, 1.4% had prostate cancer, 7.6% had obstructive sleep apnea, and 3.5% had elevated hematocrit at baseline.
Conclusions:
Only a small proportion of men receiving testosterone in VA underwent appropriate testing, and some received this therapy despite important contraindications. Promoting a more uniform application of clinical guidelines may facilitate appropriate use of testosterone.
