Optimizing Testosterone Prescribing in the VA

 描述（由申请人提供）： 这是第二次提交VA HSR&D CDA提案，为Guneet K提供五年的工资支持。Jasuja博士朝着她成为VA独立调查员和药物处方研究专家的目标前进。Jasuja博士是HSR&D医疗保健组织和实施研究中心（CHOIR）的研究健康科学家。该提案描述了研究和培训目标，这些目标将使Jasuja博士成熟为独立的卫生服务研究人员，同时有助于提高退伍军人的护理质量。 第一个目的是阐明定量的患者，供应商，和网站水平的预测可能不适当的睾酮处方，迄今尚未探讨。将使用所有男性退伍军人患者的管理数据进行分析，这些患者在FY 08-FY 14期间至少有一次门诊就诊和一次处方配药。我们将应用广义线性混合模型来检查我们在患者（例如抑郁症），提供者（例如老年人）和站点级别（例如学术联系）的假定预测因素。第二个目的是检查 患者，供应商和关键意见领袖的看法和系统层面的因素，与睾酮处方，使用定性方法。对于本研究，我们将对患者、提供者和研究中心层面的思想领袖进行半结构化访谈，以进一步了解他们的看法以及研究中心因素如何影响睾酮处方。为了在处方方面实现有意义的改变，前两项研究的结果旨在 将结合文献中的相关研究结果，开发和试点测试多方面的 干预，以促进在VA中适当使用睾酮。 这里提出的研究将通过将睾酮治疗限制在那些最有可能受益和最不可能受到伤害的患者身上来提高护理质量。在设计和实施干预措施以优化医学上有指征的男性的睾酮治疗之前，调查睾酮处方的背景和导致次优处方实践的因素将是一个重要的准备步骤。这些研究的结果将产生迄今为止未知的关于潜在的不适当的睾酮处方的几个关键方面的信息，使未来的HSR&D研究建议，以解决类似的药物处方问题。从这项研究中吸取的经验教训也将作为其他药物的典范，这些药物具有类似的特征，包括高成本和潜在的安全问题。 结合拟议的研究目标，CDA将解决关键的培训目标，将进一步发展博士Jasuja的研究能力。这些培训目标将在定性和实施研究方法方面提供正式的实践教育。精心挑选的导师团队，选择他们的知识和经验，在方法和内容领域的建议，致力于促进博士。Rose博士和Bhasin博士作为Jasuja博士VISN 1 CDA的现任导师建立了工作关系，Bokhour博士和Gifford博士多年来一直提供指导和建议。所有人都致力于Jasuja博士的职业发展和保护研究时间的需要，如他们所附的信件中所述。CHOIR还承诺提供资源来实现提案中的目标。 Jasuja的最初贡献将是了解导致VA中睾酮变化和过度使用的因素。从长远来看，她将把这些技能更广泛地应用于减少其他护理领域的变化和过度使用。长期结果将是安全，有效和高质量的药物处方的显着改善，以减少退伍军人的不良后果。

 DESCRIPTION (provided by applicant): This is the second submission of a VA HSR&D CDA proposal to provide five years of salary support to Guneet K. Jasuja, PhD toward her goal of becoming a VA independent investigator and expert on medication prescribing research. Dr. Jasuja is a research health scientist in the HSR&D Center for Healthcare Organization and Implementation Research (CHOIR). This proposal delineates the research and training objectives that will lead to Dr. Jasuja's maturation into an independent health services researcher while contributing to the quality of care for Veterans. The first aim is to elucidate quantitative patient-, provider-, and site-level predictor of potentially inappropriate testosterone prescribing that to date have not been explored. Analyses will be conducted using administrative data on all male Veteran patients without HIV, who had at least one outpatient visit and one prescription fill during FY08-FY14. We will apply Generalized Linear Mixed Models to examine our putative predictors at the patient- (e.g. depression), provider- (e.g. older age) and site-level (e.g. academic affiliation). The second aim is to examine patient, provider, and key opinion leader perceptions and system-level factors that relate to testosterone prescribing, using qualitative methods. For this study, we will conduct semi- structured interviews with patients, providers, and site-level thought leaders to gain additional insight into how their perceptions, as well as site factors, may influence testosterone prescribing. To effect meaningful change in prescribing, the results of the first two research aims will be combined with relevant findings in the literature to develop and pilot test a multi-faceted intervention to promote appropriate use of testosterone in the VA. The research proposed here will improve quality of care by limiting testosterone therapy to those patients most likely to benefit and least likely to be harmed. Investigating the context of testosterone prescribing and factors that contribute to suboptimal prescribing practices would be an important preparatory step before designing and implementing interventions to optimize testosterone therapy for those men in whom it is medically indicated. Findings from these studies will yield heretofore unknown information about several key aspects of potentially inappropriate testosterone prescribing, enabling future HSR&D research proposals to address similar medication prescribing issues. Lessons learnt from this study will also serve as an exemplar for other medications, which embody similar characteristics, including high cost and potential safety issues. In conjunction with the proposed research aims, the CDA will address key training objectives that will further develop Dr. Jasuja's research capabilities. These training objectives will provide formal and hands-on education in qualitative and implementation research methods. The carefully chosen mentorship team, selected for their knowledge and experience in the methodologies and content areas addressed in the proposal, is dedicated to fostering Dr. Jasuja's successful transition to an independent investigator. Drs. Rose and Bhasin have an established working relationship as current mentors on Dr. Jasuja's VISN 1 CDA, and Drs. Bokhour and Gifford have provided guidance and advice for several years. All are committed to the career development of Dr. Jasuja and the need for protected research time, as described in their attached letters. CHOIR has also committed resources to accomplish the objectives in the proposal. Dr. Jasuja's initial contribution will be to understand the factors that contribute to variation and overuse in testosterone across VA. In the long term, she will apply these skills more generally to the issue of reducing variation and overuse in other areas of care. The long-term outcome will be significant improvements in safe, effective, and high-quality medication prescribing to reduce adverse outcomes for Veterans.