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Understanding the Context of High- and Low-Testosterone Prescribing Facilities in the Veterans Health Administration (VHA): a Qualitative Study
- Source :
- J Gen Intern Med
- Publication Year :
- 2019
- Publisher :
- Springer Science and Business Media LLC, 2019.
-
Abstract
- BACKGROUND: Inappropriate testosterone use and variations in testosterone prescribing patterns exist in the Veterans Health Administration (VHA) despite the presence of clinical guidelines. OBJECTIVE: We examined system and clinician factors that contribute to patterns of potentially inappropriate testosterone prescribing in VHA. DESIGN: Qualitative study using a positive deviance approach to understand practice variation in high- and low-testosterone prescribing sites. PARTICIPANTS: Twenty-two interview participants included primary care and specialty clinicians, key opinion leaders, and pharmacists at 3 high- and 3 low-testosterone prescribing sites. APPROACH: 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. CONCLUSIONS: 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. ELECTRONIC SUPPLEMENTARY MATERIAL: The online version of this article (10.1007/s11606-019-05270-6) contains supplementary material, which is available to authorized users.
- Subjects :
- Male
medicine.medical_specialty
Best practice
Specialty
Inappropriate Prescribing
Context (language use)
01 natural sciences
03 medical and health sciences
0302 clinical medicine
Interim
Internal Medicine
medicine
Humans
Testosterone
030212 general & internal medicine
Practice Patterns, Physicians'
0101 mathematics
Positive deviance
Qualitative Research
Original Research
Veterans
business.industry
010102 general mathematics
Opinion leadership
Testosterone (patch)
Organizational Culture
United States
United States Department of Veterans Affairs
Family medicine
Androgens
Guideline Adherence
business
Qualitative research
Subjects
Details
- ISSN :
- 15251497 and 08848734
- Volume :
- 34
- Database :
- OpenAIRE
- Journal :
- Journal of General Internal Medicine
- Accession number :
- edsair.doi.dedup.....fe520c46c918fd0881c792aff2801361