Lead/Presenter: Guneet Jasuja, COIN - Bedford/Boston
All Authors: Jasuja GK (CHOIR Bedford/Boston), Engle RL (CHOIR Bedford/Boston), Skolnik A (CHOIR Bedford/Boston) Rose AJ (Department of Medicine, Section of General Internal Medicine, Boston University School of Medicine, Boston, MA) Male A (CHOIR Bedford/Boston) Reisman JI (CHOIR Bedford/Boston) Bokhour BG (CHOIR Bedford/Boston)
We examined system- and clinician-level factors that contribute to patterns of potentially inappropriate testosterone prescribing in VHA.
We conducted a qualitative study, using a positive deviance approach to understand practice variation in high and low testosterone prescribing sites. Participants included 22 primary care and specialty clinicians, key opinion leaders, and pharmacists at 3 high and 3 low testosterone prescribing sites. Semi-structured phone interviews were conducted, transcribed and coded using a priori theoretical constructs and emergent themes. Case studies were developed for each site and a cross-case matrix was created to evaluate variation across high- and low-prescribing sites.
We identified four system-level domains related to variation in testosterone prescribing: organizational structures and processes specific to testosterone prescribing, availability of local guidance on testosterone prescribing, well-defined dissemination process for local testosterone polices, and engagement in best practices related to testosterone prescribing. Two clinician-level domains were also identified: structured initial testosterone prescribing process, and well-specified follow-up protocols following testosterone prescription. The four system level domains were related systematically to level of testosterone prescribing whereas the clinician level domains were similar across all sites. The third high-prescribing site was unusual in that, at the time of our visit, it exhibited system-level domain characteristics similar to the 3 low-prescribing sites. This outlier had recognized its status as a high-prescribing site and implemented several improvement strategies in the year between selection and interviews, resulting in greatly reduced rates of testosterone prescribing.
Findings suggest that local organizational factors play an important role in influencing testosterone prescribing. Sites have the potential to transform their utilization patterns by providing access to specialty care expertise, an electronic health record-based system to facilitate guideline-concordant prescribing, well-defined dissemination processes for information, guidance from multiple sources, and clarity regarding best practices for prescribing.
The use of these system-level factors to change medication prescribing can also be extrapolated to improving other prescribing behavior, including safer prescribing of high-risk drugs and facilitating deprescribing of unnecessary and/or harmful medications.