Understanding the Context of High- and Low-Testosterone Prescribing Facilities in the Veterans Health Administration (VHA): a Qualitative Study

  • Guneet K. JasujaEmail author
  • Ryann L. Engle
  • Avy Skolnik
  • Adam J. Rose
  • Alexandra Male
  • Joel I. Reisman
  • Barbara G. Bokhour
Original Research



Inappropriate testosterone use and variations in testosterone prescribing patterns exist in the Veterans Health Administration (VHA) despite the presence of clinical guidelines.


We examined system and clinician factors that contribute to patterns of potentially inappropriate testosterone prescribing in VHA.


Qualitative study using a positive deviance approach to understand practice variation in high- and low-testosterone prescribing sites.


Twenty-two interview participants included 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.

Key Results

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, specifically, structured initial testosterone prescribing process and specified follow-up testosterone prescribing process. High- and low-testosterone prescribing sites systematically varied in the four system-level domains, while the clinician-level domains looked similar across all sites. The third high-prescribing site was unusual in that it exhibited the four domains similar to the 3 low-prescribing sites at the time of our visit. This site had greatly reduced its prescribing of testosterone in the interim.


Findings suggest that local organizational factors play an important role in influencing 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.


testosterone prescribing system factors qualitative 


Funding Information

The research reported/outlined here was supported by the Department of Veterans Affairs, Veterans Health Administration, Health Services Research and Development Service. Dr. Jasuja is a VA HSR&D Career Development awardee at the Bedford VA (CDA 13-265). The views expressed in this article are those of the author(s) and do not necessarily represent the views of the Department of Veterans Affairs. The funding sources had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and the decision to submit the manuscript for publication.

Compliance with Ethical Standards

The study was approved by the Institutional Review Board of the Bedford VHA Medical Center.

Conflict of Interest

The authors declare that they do not have a conflict of interest.

Supplementary material

11606_2019_5270_MOESM1_ESM.docx (18 kb)
ESM 1 (DOCX 17 kb)


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Copyright information

© Society of General Internal Medicine (This is a U.S. government work and not under copyright protection in the U.S.; foreign copyright protection may apply) 2019

Authors and Affiliations

  • Guneet K. Jasuja
    • 1
    • 2
    Email author
  • Ryann L. Engle
    • 3
  • Avy Skolnik
    • 1
  • Adam J. Rose
    • 4
  • Alexandra Male
    • 3
  • Joel I. Reisman
    • 1
  • Barbara G. Bokhour
    • 1
    • 2
  1. 1.Center for Healthcare Organization and Implementation Research (CHOIR), ENRM VAMC Bedford VA Medical CenterBedfordUSA
  2. 2.Department of Health Law, Policy and ManagementBoston University School of Public HealthBostonUSA
  3. 3.Center for Healthcare Organization and Implementation Research (CHOIR)VA Boston Healthcare SystemBostonUSA
  4. 4.Department of Medicine, Section of General Internal MedicineBoston University School of MedicineBostonUSA

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