Lessons learnt from the variation across 6741 family/general practices in England in the use of treatments for hypogonadism

Abstract

Introduction We have previously reported rates of diagnosis of male hypogonadism in United Kingdom (UK) general practices. We aimed to identify factors associated with testosterone prescribing in UK general practice. Methods We determined for 6741 general practices in England, the level of testosterone prescribing in men and the relation between volume of testosterone prescribing and (1) demographic characteristics of the practice, (2) % patients with specific comorbidities and (3) national GP patient survey results. Results The largest volume (by prescribing volume) agents were injectable preparations at a total cost in the 12‐month period 2018/19 of £8,172,519 with gel preparations in second place: total cost £4,795,057. Transdermal patches, once the only alternative to testosterone injections or implants, were little prescribed: total cost £222,022. The analysis accounted for 0.27 of the variance in testosterone prescribing between general practices. Thus, most of this variance was not accounted for by the analysis. There was a strong univariant relation (r = .95, P < .001) between PDE5‐I prescribing and testosterone prescribing. Other multivariant factors independently linked with more testosterone prescribing were as follows: HIGHER proportion of men with type 2 diabetes(T2DM) on target control (HbA1c ≤ 58 mmol/mol) and HIGHER overall practice rating on the National Patient Survey for good experience, while non‐white ethnicity and socio‐economic deprivation were associated with less testosterone prescribing. There were a number of comorbidity factors associated with less prescribing of testosterone (such as T2DM, hypertension and stroke/TIA). Conclusion Our analysis has indicated that variation between general practices in testosterone prescribing in a well developed health economy is only related to small degree (r2 = 0.27) to factors that we can define. This suggests that variation in amount of testosterone prescribed is largely related to general practitioner choice/other factors not studied and may be amenable to measures to increase knowledge/awareness of male hypogonadism, with implications for men's health.

Clinical characteristics and comorbidities associated with testosterone prescribing in men

“…As expected, pituitary disease, testicular cancer and undescended testes were more prevalent in men prescribed TRT versus men not prescribed TRT. 7,14 However, contrary to a recent study in primary care, 10 IHD, DVT/PE and stroke were associated with a higher likelihood of prescribing TRT in our cohort. This may suggest that men with CV comorbidities are more likely to have hypogonadism.…”

“…2 A recent UK study reported that variation in testosterone prescribing across 6741 general practices is related to unidentified factors such as GP choice/preference. 10 A study using semi-structured interviews with clinicians concluded that diagnostic ambiguity of age-related hypogonadism and beliefs about the appropriateness of TRT influenced testosterone prescriptions in men. 21 Similarly, other studies have reported system-level factors We observed that men between the ages of 45-69 years were most likely to be prescribed TRT compared to other ages (highest age group 50-54 years).…”

“…It is likely that there exists substantial variability in the prescribing habits of clinicians with regard to TRT for men with symptoms of hypogonadism. 10 To better understand the factors associated with prescribing (or not prescribing) TRT, we analysed a primary healthcare database to profile the clinical characteristics and comorbidities of men who had at least one serum total testosterone level (TT) measured from a population of over 2.5 million patients registered with a general practitioner (GP) in North-West London (NWL), UK.…”

Cost‐effectiveness of testosterone treatment utilising individual patient data from randomised controlled trials in men with low testosterone levels

“…We used published data to identify the four most prescribed testosterone formulations and annualised dosing in the UK to define the percentage of men prescribed testosterone using each formulation 22 : testosterone 16.2 mg/g gel (Testogel), 29%; testosterone 2% gel (Tostran), 15%; combined testosterone esters (Sustanon 250), 8%; testosterone undecanoate 1 g (Nebido), 46%. British National Formulary and the NHS indicative prices were used to value these medicines (Table 4).…”

Male hypogonadism and general practitioners in the UK. How to increase case recognition, without compromising diagnostic accuracy?

“…1 Studies investigating the underlying reasons for generalist physician prescribing of testosterone are important to guide future clinical practice. 6 Heald et al 7 analysed data from a variety of data sources to examine factors associated with testosterone prescribing for over 6000 GP practices within England. They also provide important data on changes in formulations of testosterone prescribed over recent years; injectable forms of testosterone are becoming relatively more common, and transdermal testosterone now mostly administered using a pump-dispenser rather than sachet.…”