Preliminary Evaluation of an Order Template to Improve Diagnosis and Testosterone Therapy of Hypogonadism in Veterans

Background: 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.

Methods: 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.

Results: 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.

Conclusions: 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.