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RESEARCH OBJECTIVE: Inappropriate testosterone use and variations in testosterone prescribing patterns exist in the Veterans Health Administration (VHA) despite the presence of clinical guidelines. Understanding the context within which testosterone prescribing occurs is key to planning successful interventions to improve guideline‐concordant prescribing. We examined system‐ and clinician‐level factors that contribute to patterns of potentially inappropriate testosterone prescribing in VHA. STUDY DESIGN: We conducted a qualitative study using a positive deviance approach to understand practice variation in high‐ and 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. POPULATION STUDIED: Twenty‐two interview participants included primary care and specialty clinicians, key opinion leaders, and pharmacists at 3 high‐ and 3 low‐testosterone prescribing sites. These high‐ and low‐testosterone‐prescribing sites were located in six states and all four regions of the United States. PRINCIPAL FINDINGS: 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. At all sites, most testosterone prescriptions were initiated by patient request and clinicians varied in their adherence to guideline‐concordant prescribing. 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. CONCLUSIONS: In this study, we found that low‐prescribing sites shared some common features, including easier access to specialty care expertise, existence of an electronic health record‐based system to facilitate guideline‐concordant prescribing, well‐defined dissemination processes for information, availability of guidance from multiple sources, and clarity regarding what constitutes best practices for prescribing. 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. IMPLICATIONS FOR POLICY OR PRACTICE: 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. Lessons learned from this study will serve as an exemplar for any site aiming to improve its testosterone‐prescribing practices and prescribing in general beyond testosterone. PRIMARY FUNDING SOURCE: Department of Veterans Affairs.

Use of nonbenzodiazepine sedative hypnotics, especially zolpidem, has grown substantially, raising concerns about safety. Gender‐specific guidelines have been recommended for appropriate zolpidem prescribing to address patient safety concerns. In line with an FDA recommendation in 2013, the Veterans Health Administration (VHA) issued a similar directive to lower the doses of zolpidem in women in 2013. However, little is known about zolpidem prescribing patterns in the VHA in general. Therefore, the goal of this study was to examine utilization trends and inappropriate prescribing of zolpidem in accordance with VHA guidelines in male and female veterans in the VHA. A cross‐sectional study of veterans receiving zolpidem in the outpatient setting from October 1, 2011, to September 30, 2016. We examined 2 outcomes related to inappropriate zolpidem prescribing: high‐dose and overlap with benzodiazepines. The study population consisted of 500 332 zolpidem users (58 598 women and 441 734 men) and a random 10% sample (n = 631 449) of nonusers. Across the VHA, 7.1% of men and 10.0% of women received zolpidem at least once during the study period. In 2016, 29.7% of female veterans received an inappropriately high guideline‐discordant dosage compared with 0.1% of male veterans (P