Narla Radhika, Mobley Daniel, Nguyen Ethan H K, Song Cassandra, Matsumoto Alvin M
is an Assistant Professor in the Division of Endocrinology, Metabolism and Nutrition at University of Washington School of Medicine, Seattle. is a Pharmacist; is the Pharamaceconomics Program Manager in Pharmacy; is the Formulary Program Manager; all at the US Department of Veterans Affairs Puget Sound Health Care System. is Professor Emeritus of Medicine in the Division of Gerontology and Geriatric Medicine and at the University of Washington School of Medicine.
Fed Pract. 2021 Mar;38(3):121-127. doi: 10.12788/fp.0103.
Testosterone therapy is indicated for the treatment of hypogonadism. Evidence-based guidelines recommend testosterone treatment only for men with symptoms and signs of testosterone deficiency and consistently low serum testosterone concentrations; luteinizing hormone (LH) and follicle-stimulating hormone (FSH) measurements and discussion of risks and benefits of testosterone prior to therapy. However, the US Department of Veterans Affairs (VA) Office of the Inspector General (OIG) report found that health care providers were adhering poorly to guideline recommendations for the diagnosis and treatment of men with hypogonadism.
A prior authorization drug request (PADR) testosterone order template was implemented at VA Puget Sound Health Care System. A retrospective chart review was conducted in veterans who were prescribed testosterone and had no previous prescription in the prior year. Eligible veterans were evaluated 6 months before (pretemplate) and after (posttemplate) implementation of the template, and 3 months after removal of alternative testosterone ordering pathways (posttemplate/no alternative ordering pathways) that were discovered after PADR template implementation. We assessed the proportion of eligible veterans with documented symptoms of testosterone deficiency; appropriate diagnosis and evaluation of hypogonadism with ≥ 2 low serum testosterone and LH and FSH levels; and discussion of risks and benefits of testosterone treatment.
In the pretemplate period, only 20 of 80 eligible veterans (25%) had a completed PADR for testosterone. In the posttemplate period, 18 of 45 (44%) eligible veterans had a completed PADR but only 7 (17%) had the testosterone order template completed. In the posttemplate/no alternative ordering pathways period, 13 (68%) and 11 (58%) of 19 eligible veterans had a completed PADR and testosterone order template, respectively. In all 3 periods, documentation of clinical symptoms and a discussion of risks and benefits were similar. In contrast, the proportion of veterans who had ≥ 2 low testosterone levels with LH and FSH levels measured in the posttemplate and posttemplate/no alternative ordering pathways periods were higher (41% and 37%, respectively) vs the pretemplate period (23%). Veterans with documented clinical symptoms, discussion of risks and benefits, and ≥ 2 low testosterone with gonadotropin measurements were 100%, 57%, and 71%, respectively, in the posttemplate/no alternative ordering pathways period.
Implementation of a PADR order template may be a promising approach to improve the diagnosis of hypogonadism and appropriate testosterone therapy in accordance with established evidence-based clinical practice guidelines, particularly in veterans who are receiving new prescriptions.
睾酮疗法适用于性腺功能减退的治疗。循证指南建议仅对有睾酮缺乏症状和体征且血清睾酮浓度持续偏低的男性进行睾酮治疗；在治疗前测量促黄体生成素（LH）和促卵泡生成素（FSH）并讨论睾酮治疗的风险和益处。然而，美国退伍军人事务部（VA）监察长办公室（OIG）的报告发现，医疗服务提供者在性腺功能减退男性的诊断和治疗方面对指南建议的遵循情况较差。
在VA普吉特海湾医疗保健系统实施了一项预先授权药物申请（PADR）睾酮订单模板。对开具了睾酮处方且上一年无先前处方的退伍军人进行回顾性病历审查。对符合条件的退伍军人在模板实施前6个月（模板前）和实施后（模板后）进行评估，并在PADR模板实施后发现的替代睾酮订购途径取消后3个月（模板后/无替代订购途径）进行评估。我们评估了有记录的睾酮缺乏症状的符合条件退伍军人的比例；对性腺功能减退进行适当诊断并评估，血清睾酮、LH和FSH水平≥2次偏低；以及讨论睾酮治疗的风险和益处。
在模板前阶段，80名符合条件的退伍军人中只有20名（25%）完成了睾酮的PADR。在模板后阶段，45名（44%）符合条件的退伍军人中有18名完成了PADR，但只有7名（17%）完成了睾酮订单模板。在模板后/无替代订购途径阶段，19名符合条件的退伍军人中分别有13名（68%）和11名（58%）完成了PADR和睾酮订单模板。在所有3个阶段，临床症状记录和风险与益处的讨论情况相似。相比之下，在模板后和模板后/无替代订购途径阶段测量了LH和FSH水平且睾酮水平≥2次偏低的退伍军人比例（分别为41%和37%）高于模板前阶段（23%）。在模板后/无替代订购途径阶段，有记录的临床症状、风险与益处讨论以及睾酮水平≥2次偏低且有促性腺激素测量结果的退伍军人比例分别为100%、57%和71%。
实施PADR订单模板可能是一种有前景的方法，可根据既定的循证临床实践指南改善性腺功能减退的诊断和适当的睾酮治疗，特别是在接受新处方的退伍军人中。
