Provider and Site-Level Determinants of Testosterone Prescribing in the Veterans Healthcare System.

CONTEXT

Testosterone prescribing rates have increased substantially in the past decade. However, little is known about the context within which such prescriptions occur.

OBJECTIVE

We evaluated provider- and site-level determinants of receipt of testosterone and of guideline-concordant testosterone prescribing.

DESIGN

This study was cross-sectional in design.

SETTING

This study was conducted at the Veterans Health Administration (VA).

PARTICIPANTS

Study participants were a national cohort of male patients who had received at least one outpatient prescription within the VA during fiscal year (FY) 2008 to FY 2012. A total of 38,648 providers and 130 stations were associated with these patients.

MAIN OUTCOME MEASURE

This study measured receipt of testosterone and guideline-concordant testosterone prescribing.

RESULTS

Providers ranging in age from 31 to 60 years, with less experience in the VA [all adjusted odds ratio (AOR), <2; P < 0.01] and credentialed as medical doctors in endocrinology (AOR, 3.88; P < 0.01) and urology (AOR, 1.48; P < 0.01) were more likely to prescribe testosterone compared with older providers, providers of longer VA tenure, and primary care providers, respectively. Sites located in the West compared with the Northeast [AOR, 1.75; 95% confidence interval (CI), 1.45-2.11] and care received at a community-based outpatient clinic compared with a medical center (AOR, 1.22; 95% CI, 1.20-1.24) also predicted testosterone use. Although they were more likely to prescribe testosterone, endocrinologists were also more likely to obtain an appropriate workup before prescribing compared with primary care providers (AOR, 2.14; 95% CI, 1.54-2.97).

CONCLUSIONS

Our results highlight the opportunity to intervene at both the provider and the site levels to improve testosterone prescribing. This study also provides a useful example of how to examine contributions to prescribing variation at different levels of the health care system.