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Study Suggests Veterans Do Not Receive Appropriate Testing for Testosterone Therapy within VA Healthcare System

BACKGROUND: Testosterone therapy is approved for the treatment of male hypogonadism (inability to produce sufficient testosterone), which is based upon the presence of symptoms in addition to two or more low testosterone levels (measured in the morning). Testosterone prescriptions in the U.S. have increased markedly over the past decade, and an increasing number of articles raise concerns about the growing off-label use of testosterone in men who may not be hypogonadal. This study evaluated whether the dispensing of testosterone therapy in the VA healthcare system was preceded by an appropriate diagnostic evaluation of testosterone deficiency. Using VA data, investigators identified 111,631 male Veterans who received VA outpatient care during FY2009 through FY2012, and who had not previously received testosterone from VA. [Veterans with HIV were excluded because testosterone therapy is controversial for this condition.] Investigators also assessed the records of Veterans enrolled in Medicare for testosterone testing outside VA during the year before dispensing within VA. Diagnostic codes during the year before the index date of testosterone prescription were examined for documented hypogonadism, as well as any contraindications to testosterone therapy, including prostate cancer, breast cancer, and obstructive sleep apnea.

FINDINGS:

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• Only a small proportion of male Veterans receiving testosterone in the VA healthcare system underwent appropriate testing: 3% of men who received testosterone met the criteria for an “ideal” evaluation, with two or more low testosterone levels in the morning, measurement of luteinizing hormone (LH) and follicle-stimulating hormone (FSH) levels, and no contraindications; while 17% did not have their testosterone level checked at all. Moreover, 52% of Medicare-enrolled Veterans who did not have any testosterone testing within VA also had no testing outside VA.
• Some Veterans received therapy despite important contraindications: 8% had obstructive sleep apnea, 4% had elevated hematocrit at baseline, and 1% had prostate cancer.
• New testosterone dispensing in VA increased from 20,437 in FY2009 to 36,394 in FY2012 – a 78% increase, while the number of male VA patients increased by 5% during the same period.

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IMPLICATIONS:

• While there are currently no official VA guidelines on testosterone prescribing, promotion of a more uniform application of clinical guidelines on testosterone therapy may help limit the therapy to those who are most likely to benefit and least likely to be harmed.

LIMITATIONS:

• This study relied on data from VA’s electronic medical record and Medicare’s administrative claims data, which may be affected by inconsistencies in coding and limited clinical information.
• There is considerable heterogeneity in the level of total testosterone that is considered “low,” but investigators chose a level (300 ng/dL) that is widely regarded as low.

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AUTHOR/FUNDING INFORMATION: Drs. Jasuja, Berlowitz, and Rose, and Mr. Reisman are part of HSR&D’s Center for Healthcare Organization and Implementation Research located in Bedford and Boston, MA.

Jasuja G, Bhasin S, Reisman J, Berlowitz D, and Rose A. Ascertainment of Testosterone Prescribing Practices in the VA. Medical Care. September 2015;53(9):746-752.

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