BACKGROUND/RATIONALE:
The use of testosterone therapy increased 3-fold during the 10 year-period between 2001 and 2011in the United States. Use of this therapy in VA has been doubling every 5 years, suggesting that factors other than clinical need may be contributing to its use. There has been concern about the growing off-label use of testosterone, which has been approved for the treatment of male hypogonadism. The rapid increase in testosterone use is of immediate concern because of safety issues - particularly cardiovascular and prostate health - associated with this therapy. Understanding the context within which testosterone is prescribed in the VA, including which patients receive testosterone, which providers prescribe it, and which site-level structures and policies are associated with more or less use of testosterone may contribute to interventions to improve prescribing practices.





OBJECTIVE(S):
This CDA will first identify quantitative and qualitative patient-, provider-, and site-level correlates of sub-optimal testosterone use, and then use this information to inform the design of an intervention to improve testosterone prescribing in the VA.
Aim 1: Identify quantitative patient-, provider-, and site-level predictors of potentially inappropriate testosterone prescribing, apart from hypogonadism.
Aim 2: Examine patient, provider, and key opinion leader perceptions and system-level factors that relate to testosterone prescribing, using qualitative methods.
Aim 3: Develop and pilot test an intervention to modify current testosterone prescribing patterns and optimize appropriate use of testosterone in VA.

METHODS:
To accomplish these aims, we will use mixed methods, including secondary database analyses, semi-structured interviews, and intervention development and testing. Aim 1 will be conducted using administrative data on all male Veteran patients without HIV, who had at least one outpatient visit and one prescription fill during FY08-FY14. We will apply Generalized Linear Mixed Models to examine our putative predictors at the patient- (e.g. depression), provider- (e.g. older age) and site-level (e.g. academic affiliation). For Aim 2, we will conduct semi-structured interviews with patients, providers, and site-level thought leaders to gain additional insight into how their perceptions, as well as site factors, may influence testosterone prescribing. To effect meaningful change in prescribing, the results of the first two research aims will be combined with relevant findings in the literature to develop and pilot test a multi-faceted intervention (Aim 3) to promote appropriate use of testosterone in the VA.

FINDINGS/RESULTS:
Not yet available.

IMPACT:
The research proposed here will improve quality of care by limiting testosterone therapy to those patients most likely to benefit and least likely to be harmed. Investigating the context of testosterone prescribing and factors that contribute to suboptimal prescribing practices would be an important preparatory step before designing and implementing interventions to optimize testosterone therapy for those men in whom it is medically indicated. Lessons learnt from this study will also serve as an exemplar for other medications, which embody similar characteristics, including high cost and potential safety issues.

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External Links for this Project

NIH Reporter

Grant Number: IK2HX001553-01
Link: https://reporter.nih.gov/project-details/8783909

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PUBLICATIONS:

Journal Articles

1. Engle RL, Bokhour BG, Rose AJ, Reisman JI, Jasuja GK. Characterizing patient attitudes and beliefs towards testosterone therapy in Veterans Affairs: A qualitative study. Patient education and counseling. 2023 Jan 1; 106:201-207. [view]
2. Jasuja GK, Reisman JI, Weiner RS, Christopher ML, Rose AJ. Gender differences in prescribing of zolpidem in the Veterans Health Administration. The American journal of managed care. 2019 Mar 1; 25(3):e58-e65. [view]
3. Jasuja GK, Ameli O, Reisman JI, Rose AJ, Miller DR, Berlowitz DR, Bhasin S. Health Outcomes Among Long-term Opioid Users With Testosterone Prescription in the Veterans Health Administration. JAMA Network Open. 2019 Dec 2; 2(12):e1917141. [view]
4. Jasuja GK, Bettano A, Smelson D, Bernson D, Rose AJ, Byrne T, Berlowitz DR, McCullough MB, Miller DR. Homelessness and Veteran Status in Relation to Nonfatal and Fatal Opioid Overdose in Massachusetts. Medical care. 2021 Apr 1; 59(Suppl 2):S165-S169. [view]
5. Jasuja GK, Ameli O, Miller DR, Land T, Bernson D, Rose AJ, Berlowitz DR, Smelson DA. Overdose risk for veterans receiving opioids from multiple sources. The American journal of managed care. 2018 Nov 1; 24(11):536-540. [view]
6. Jasuja GK, Bhasin S, Rose AJ. Patterns of testosterone prescription overuse. Current opinion in endocrinology, diabetes, and obesity. 2017 Jun 1; 24(3):240-245. [view]
7. Jasuja GK, Bhasin S, Rose AJ, Reisman JI, Hanlon JT, Miller DR, Morreale AP, Pogach LM, Cunningham FE, Park A, Wiener RS, Gifford AL, Berlowitz DR. Provider and Site-Level Determinants of Testosterone Prescribing in the Veterans Healthcare System. The Journal of clinical endocrinology and metabolism. 2017 Sep 1; 102(9):3226-3233. [view]
8. Jasuja GK, Engle RL, Skolnik A, Rose AJ, Male A, Reisman JI, Bokhour BG. Understanding the Context of High- and Low-Testosterone Prescribing Facilities in the Veterans Health Administration (VHA): a Qualitative Study. Journal of general internal medicine. 2019 Nov 1; 34(11):2467-2474. [view]
9. Jasuja GK, Bhasin S, Rose AJ, Reisman JI, Skolnik A, Berlowitz DR, Gifford AL. Use of testosterone in men infected with human immunodeficiency virus in the veterans healthcare system. AIDS Care. 2018 Oct 1; 30(10):1207-1214. [view]
10. Jasuja GK, Bhasin S, Reisman JI, Hanlon JT, Miller DR, Morreale AP, Pogach LM, Cunningham FE, Park A, Berlowitz DR, Rose AJ. Who Gets Testosterone? Patient Characteristics Associated with Testosterone Prescribing in the Veteran Affairs System: a Cross-Sectional Study. Journal of general internal medicine. 2017 Mar 1; 32(3):304-311. [view]

DRA: Health Systems Science, Cardiovascular Disease
DRE: Technology Development and Assessment
Keywords: Best Practices
MeSH Terms: none