Guneet K Jasuja1,2, Shalender Bhasin3,4, Joel I Reisman5, Joseph T Hanlon6,7,8,9, Donald R Miller5, Anthony P Morreale10, Leonard M Pogach11,12, Francesca E Cunningham13, Angela Park14, Dan R Berlowitz5,15, Adam J Rose5,16. 1. Center for Healthcare Organization and Implementation Research (CHOIR), ENRM VAMC, Bedford VA Medical Center, 200 Springs Road, Bedford, MA, 01730, USA. guneet.jasuja@va.gov. 2. Department of Health Policy and Management, Boston University School of Public Health, Boston, MA, USA. guneet.jasuja@va.gov. 3. Research Program in Men's Health, Aging and Metabolism, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA. 4. Boston Claude D. Pepper Older Americans Independence Center, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA. 5. Center for Healthcare Organization and Implementation Research (CHOIR), ENRM VAMC, Bedford VA Medical Center, 200 Springs Road, Bedford, MA, 01730, USA. 6. Division of Geriatrics, Department of Medicine, School of Medicine, University of Pittsburgh, Pittsburgh, PA, USA. 7. Department of Pharmacy and Therapeutics, School of Pharmacy, University of Pittsburgh, Pittsburgh, PA, USA. 8. Center for Health Equity Research and Geriatric Research Education and Clinical Center, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, PA, USA. 9. Department of Epidemiology, School of Public Health, University of Pittsburgh, Pittsburgh, PA, USA. 10. Clinical Pharmacy Services and Healthcare Services Research, VA Pharmacy Benefits Management Services VACO, Washington DC, USA. 11. Department of Veterans Affairs, New Jersey Healthcare System-Center for Healthcare Knowledge Management, East Orange, NJ, USA. 12. University of Medicine and Dentistry of New Jersey-New Jersey Medical School, Newark, NJ, USA. 13. VA Pharmacy Benefits Management Services, Hines, IL, USA. 14. New England Veterans Engineering Resource Center, VA Boston Healthcare System, Boston, MA, USA. 15. Department of Health Policy and Management, Boston University School of Public Health, Boston, MA, USA. 16. Department of Medicine, Section of General Internal Medicine, Boston University School of Medicine, Boston, MA, USA.
Abstract
BACKGROUND: There has been concern about the growing off-label use of testosterone. Understanding the context within which testosterone is prescribed may contribute to interventions to improve prescribing. OBJECTIVE: To evaluate patient characteristics associated with receipt of testosterone. DESIGN: Cross-sectional. SETTING: A national cohort of male patients, who had received at least one outpatient prescription within the Veterans Affairs (VA) system during Fiscal Year 2008- Fiscal Year 2012. PARTICIPANTS: The study sample consisted of 682,915 non-HIV male patients, of whom 132,764 had received testosterone and a random 10% sample, 550,151, had not. MAIN MEASURES: Conditions and medications associated with testosterone prescription. KEY RESULTS: Only 6.3% of men who received testosterone from the VA during the study period had a disorder of the testis, pituitary or hypothalamus associated with male hypogonadism. Among patients without a diagnosed disorder of hypogonadism, the use of opioids and obesity were the strongest predictors of testosterone prescription. Patients receiving >100 mg/equivalents of oral morphine daily (adjusted odds ratio = 5.75, p < 0.001) and those with body mass index (BMI) >40 kg/m2 (adjusted odds ratio = 3.01, p < 0.001) were more likely to receive testosterone than non-opioid users and men with BMI <25 kg/m2. Certain demographics (age 40-54, White race), comorbid conditions (sleep apnea, depression, and diabetes), and medications (antidepressants, systemic corticosteroids) also predicted a higher likelihood of testosterone receipt, all with an adjusted odds ratio less than 2 (p < 0.001). CONCLUSIONS: In the VA, 93.7% of men receiving testosterone did not have a diagnosed condition of the testes, pituitary, or hypothalamus. The strongest predictors of testosterone receipt (e.g., obesity, receipt of opioids), which though are associated with unapproved, off-label use, may be valid reasons for therapy. Interventions should aim to increase the proportion of testosterone recipients who have a valid indication.
BACKGROUND: There has been concern about the growing off-label use of testosterone. Understanding the context within which testosterone is prescribed may contribute to interventions to improve prescribing. OBJECTIVE: To evaluate patient characteristics associated with receipt of testosterone. DESIGN: Cross-sectional. SETTING: A national cohort of male patients, who had received at least one outpatient prescription within the Veterans Affairs (VA) system during Fiscal Year 2008- Fiscal Year 2012. PARTICIPANTS: The study sample consisted of 682,915 non-HIV male patients, of whom 132,764 had received testosterone and a random 10% sample, 550,151, had not. MAIN MEASURES: Conditions and medications associated with testosterone prescription. KEY RESULTS: Only 6.3% of men who received testosterone from the VA during the study period had a disorder of the testis, pituitary or hypothalamus associated with male hypogonadism. Among patients without a diagnosed disorder of hypogonadism, the use of opioids and obesity were the strongest predictors of testosterone prescription. Patients receiving >100 mg/equivalents of oral morphine daily (adjusted odds ratio = 5.75, p < 0.001) and those with body mass index (BMI) >40 kg/m2 (adjusted odds ratio = 3.01, p < 0.001) were more likely to receive testosterone than non-opioid users and men with BMI <25 kg/m2. Certain demographics (age 40-54, White race), comorbid conditions (sleep apnea, depression, and diabetes), and medications (antidepressants, systemic corticosteroids) also predicted a higher likelihood of testosterone receipt, all with an adjusted odds ratio less than 2 (p < 0.001). CONCLUSIONS: In the VA, 93.7% of men receiving testosterone did not have a diagnosed condition of the testes, pituitary, or hypothalamus. The strongest predictors of testosterone receipt (e.g., obesity, receipt of opioids), which though are associated with unapproved, off-label use, may be valid reasons for therapy. Interventions should aim to increase the proportion of testosterone recipients who have a valid indication.
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