Introduction: Endocrinologists at this institution have adhered since 2008 to a policy governing who and when to prescribe TRT, akin to Endocrine Society guidelines. The policy, which does not apply to PCPs, excludes patients with a history of VEs (MI/CAD, CVA, VTE, PVD) <1y prior (absolute contraindication [CI] to TRT), or 1-3y prior (relative CI), and recommends strict diagnostic criteria, based on ≥2 early AM T levels by LC/MS/MS, with Total T <200ng/dl, or calculated bioavailable T <100ng/dl; or free T by Equilibrium Dialysis <5ng/dl.
Data showed that 6 of 7 patients prescribed TRT by PCPs prior to 2014 (812/945 [85.9%]) did not meet criteria, and 3 of 10 had a prior VE (283/945[30.1%]). To change PCP prescribing behavior, two initiatives were implemented. One, in 7/2014, offered E-consultation to increase access to endocrinology input (EC ACCESS), and the other, in 5/2018, installed a Lab Order (LO) set with Education on how to order and interpret T levels (LO EDU).
Objective: To determine the impact of the initiatives on TRT prescribing behavior and the risk of VEs.
Methods: Retrospective cohort study of TRT prescribing behavior (adhering to diagnostic criteria and abiding by contraindications) before (2008-2014) and after implementation of EC ACCESS (2015-5/2018) and LO EDU (6/2018-6/2020) initiatives, and the impact on VE incidence.
Results: TRT prescriptions decreased from 945 Pre-ACCESS (~135/y) to 121 after EC ACCESS (~31/y; p<0.001), and 61 (~31/y) after LO EDU. Endocrine input into TRT decisions increased from 164/945 (17.4%] Pre-ACCESS to 67/121 (55.4%) with EC ACCESS, and even further to 51/61 (83.6%; p<0.001) with LO EDU.
The initiatives changed TRT prescribing behavior in 3 significant ways. First, PCPs were more likely to use ≥2 early AM T levels by LC/MS/MS when considering TRT (Pre-ACCESS: 196/945 [20.7%]; EC ACCESS: 62/121 [51.2%]; LO EDU: 47/61 [77%]; p<0.001). Second, strict diagnostic criteria were more likely to be met in those prescribed TRT (Pre-ACCESS:133/945 [14.1%]; EC ACCESS: 43/121 [35.5%]; LO EDU: 41/61 [67.2%]; p<0.001). Third, TRT was much less likely to be prescribed in those with prior VEs (Pre-ACCESS: 283/945 [30.1%]; EC ACCESS: 19/121 [15.7%]; LO EDU: 8/61 [13.1%]; p<0.001). The changes in TRT prescribing behavior effected by the EC ACCESS and LO EDU initiatives were associated with a significantly lower incidence of VEs on TRT (Pre-ACCESS: 142/945 [15%]; Post-ACCESS: 17/182 [9.3%]; p=0.043), despite a significantly longer mean (±SE) TRT duration (Pre-ACCESS: 22±0.7mo; Post- ACCESS: 26±1mo; p=0.0158)
Conclusion: Changes in TRT prescribing behavior after EC ACCESS and amplified by LO EDU resulted in a 75% reduction in total TRT prescriptions, a nearly 5-fold increase in appropriate TRT (meeting strict criteria), and a 2.5-fold decrease in contraindicated TRT (with prior VEs). These changes were associated with a significant decrease in the incidence of VEs during TRT.