title: Who Gets Testosterone? Patient Characteristics Associated with Testosterone Prescribing in the Veteran Affairs System: a Cross-Sectional Study.
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.
  
  
  METHODS
  Cross-sectional.
  
  
  METHODS
  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.
  
  
  METHODS
  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.
  
  
  METHODS
  Conditions and medications associated with testosterone prescription.
  
  
  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.
authors.affiliation: 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.|Department of Health Policy and Management, Boston University School of Public Health, Boston, MA, USA. guneet.jasuja@va.gov.
authors.forename: Guneet K
authors.initials: GK
authors.lastname: Jasuja
authors.affiliation: Research Program in Men's Health, Aging and Metabolism, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.|Boston Claude D. Pepper Older Americans Independence Center, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.
authors.forename: Shalender
authors.initials: S
authors.lastname: Bhasin
authors.affiliation: Center for Healthcare Organization and Implementation Research (CHOIR), ENRM VAMC, Bedford VA Medical Center, 200 Springs Road, Bedford, MA, 01730, USA.
authors.forename: Joel I
authors.initials: JI
authors.lastname: Reisman
authors.affiliation: Division of Geriatrics, Department of Medicine, School of Medicine, University of Pittsburgh, Pittsburgh, PA, USA.|Department of Pharmacy and Therapeutics, School of Pharmacy, University of Pittsburgh, Pittsburgh, PA, USA.|Center for Health Equity Research and Geriatric Research Education and Clinical Center, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, PA, USA.|Department of Epidemiology, School of Public Health, University of Pittsburgh, Pittsburgh, PA, USA.
authors.forename: Joseph T
authors.initials: JT
authors.lastname: Hanlon
authors.affiliation: Center for Healthcare Organization and Implementation Research (CHOIR), ENRM VAMC, Bedford VA Medical Center, 200 Springs Road, Bedford, MA, 01730, USA.
authors.forename: Donald R
authors.initials: DR
authors.lastname: Miller
authors.affiliation: Clinical Pharmacy Services and Healthcare Services Research, VA Pharmacy Benefits Management Services VACO, Washington DC, USA.
authors.forename: Anthony P
authors.initials: AP
authors.lastname: Morreale
authors.affiliation: Department of Veterans Affairs, New Jersey Healthcare System-Center for Healthcare Knowledge Management, East Orange, NJ, USA.|University of Medicine and Dentistry of New Jersey-New Jersey Medical School, Newark, NJ, USA.
authors.forename: Leonard M
authors.initials: LM
authors.lastname: Pogach
authors.affiliation: VA Pharmacy Benefits Management Services, Hines, IL, USA.
authors.forename: Francesca E
authors.initials: FE
authors.lastname: Cunningham
authors.affiliation: New England Veterans Engineering Resource Center, VA Boston Healthcare System, Boston, MA, USA.
authors.forename: Angela
authors.initials: A
authors.lastname: Park
authors.affiliation: Center for Healthcare Organization and Implementation Research (CHOIR), ENRM VAMC, Bedford VA Medical Center, 200 Springs Road, Bedford, MA, 01730, USA.|Department of Health Policy and Management, Boston University School of Public Health, Boston, MA, USA.
authors.forename: Dan R
authors.initials: DR
authors.lastname: Berlowitz
authors.affiliation: Center for Healthcare Organization and Implementation Research (CHOIR), ENRM VAMC, Bedford VA Medical Center, 200 Springs Road, Bedford, MA, 01730, USA.|Department of Medicine, Section of General Internal Medicine, Boston University School of Medicine, Boston, MA, USA.
authors.forename: Adam J
authors.initials: AJ
authors.lastname: Rose
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D000701:Analgesics, Opioid / Q000008:administration & dosage; D000728:Androgens / Q000097:blood / Q000627:therapeutic use*; D015992:Body Mass Index; D016022:Case-Control Studies; D015897:Comorbidity; D003430:Cross-Sectional Studies; D006801:Humans; D007006:Hypogonadism / Q000453:epidemiology; D008297:Male; D008875:Middle Aged; D009765:Obesity / Q000150:complications; D016017:Odds Ratio; D056687:Off-Label Use / Q000706:statistics & numerical data*; D010818:Practice Patterns, Physicians' / Q000706:statistics & numerical data*; D013739:Testosterone / Q000097:blood / Q000627:therapeutic use*; D014481:United States; D014493:United States Department of Veterans Affairs; D014728:Veterans / Q000706:statistics & numerical data*; D055815:Young Adult
chemical_list: D000701:Analgesics, Opioid; D000728:Androgens; D013739:Testosterone
keywords: patient; predictors; prescribing; testosterone