ACP issues guideline for testosterone treatment in adult men with age-related low testosterone

1. ACP issues guideline for testosterone treatment in adult men with age-related low testosterone

ACP’s recommendations include treating for sexual dysfunction only, discontinuing treatment if sexual function does not improve, and not initiating treatment for other reasons

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Evidence Review:

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Editorial:

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Physicians should prescribe testosterone for men with age-related low testosterone only to treat sexual dysfunction, the American College of Physicians (ACP) says in a new evidence-based clinical practice guideline. The evidence shows that men with age-related low testosterone may experience slight improvements in sexual and erectile function. The guideline is published in Annals of Internal Medicine.

ACP suggests that physicians consider intramuscular rather than transdermal formulations when initiating testosterone treatment to improve sexual function because the costs are considerably lower for the intramuscular formulation and clinical effectiveness and harms are similar. The annual cost in 2016 per beneficiary for testosterone replacement therapy was $2,135.32 for transdermal and $156.24 for the intramuscular formulation according to paid pharmaceutical claims provided in the 2016 Medicare Part D Drug Claims data. Most men are able to inject the intramuscular formulation at home and do not require a separate clinic or office visit for administration.

Physicians should discuss whether to initiate testosterone treatment in men with age-related low testosterone with sexual dysfunction who want to improve sexual and erectile function based on the potential benefits, harms, costs, and patient preferences. Physicians should reevaluate symptoms within 12 months and periodically thereafter and discontinue testosterone treatment if sexual function does not improve. Testosterone treatment should not be initiated to improve energy, vitality, physical function, or cognition because the evidence indicates testosterone treatment is not effective.

ACP’s guideline, endorsed by the American Academy of Family Physicians, applies to adult men with age-related low testosterone. It does not address screening or diagnosis of hypogonadism, or monitoring of testosterone levels.

Media contact: For an embargoed PDF or to talk to an ACP spokesperson, please contact Steve Majewski at

[email protected]

or 215-351-2514.

2. U.S. health care administration costs four times more per capita than in Canada

Rise in bureaucracy due to surging overhead of private insurers

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Health care bureaucracy cost Americans $812 billion in 2017, and represented more than one-third of total expenditures for doctor visits, hospitals, long-term care and health insurance. A study found that cutting U.S. administrative costs to Canadian levels would have saved more than $600 billion. The analysis is published in Annals of Internal Medicine.

Researchers at the City University of New York at Hunter College, Harvard Medical School and the University of Ottawa analyzed thousands of accounting reports that hospitals and other health care providers filed with regulators, as well as census data on employment and wages in the health sector to quantify 2017 spending for administration by insurers and providers. They found that health administration costs were more than four-fold higher per capita in the U.S. than in Canada ($2,479 vs. $551 per person) which implemented a single payer Medicare for All system starting in 1962. Americans spent $844 per person on insurers’ overhead while Canadians spent $146. Additionally, doctors, hospitals and other health providers in the U.S. spent far more on administration due to the complexity entailed in billing multiple payers and dealing with the bureaucratic hurdles that insurers impose. As a result, hospital administration cost Americans $933 per capita vs. $196 in Canada, where hospitals are paid lump-sum budgets by the single payer, much as fire departments are funded in the U.S. Physicians’ billing costs were also much higher in the U.S., $465 per capita vs. $87 per capita in Canada.

The authors cautioned that their estimates probably understate administrative costs, and particularly the growth since 1999. The same authors conducted a study in 1999 that included administrative spending for some items such as dental care for which no 2017 data were available. They suggest that Medicare for All could save more than $600 billion each year on bureaucracy and repurpose that money to cover America’s 30 million uninsured, and eliminate copayments and deductibles for everyone.

Media contacts: For an embargoed PDF, please contact Lauren Evans at

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To reach the lead author, David U. Himmelstein, MD, please contact Clare Fauke at

[email protected]

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3. Only 10 percent of eligible primary care providers certified to prescribe buprenorphine

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Only 10 percent of eligible primary care providers are certified to prescribe buprenorphine, a number that falls far short of what is needed to address the current opioid epidemic in the United States. Waiver certification has been much faster in areas hardest-hit by the opioid epidemic, but rural communities and communities with lower levels of secondary education are still underserved. A brief research report is published in Annals of Internal Medicine.

Expanded access to medication treatment of opioid use disorder is a critical component of the national response to the opioid crisis. From 2007 to 2017, there was roughly a four-fold increase in providers certified to prescribe buprenorphine. However, how this growth has varied by community characteristics is unclear.

Researchers from RAND Corporation studied Substance Abuse and Mental Health Services Administration and the Drug Enforcement Administration data to examine county-level growth in the number of buprenorphine-waivered prescribers and variation by county characteristics, including rurality, income, and rate of opioid-related overdose deaths in the past year. They found that the number of buprenorphine-waivered clinicians increased substantially between 2007 and 2017 and that growth was much faster in counties with higher rates of opioid-related overdose deaths in the preceding year. However, despite evidence that the opioid crisis has disproportionately affected rural counties that are socioeconomically disadvantaged, prescriber growth was markedly slower in small nonmetropolitan counties than in urban counties and was also slower in communities with lower levels of education, even after adjusting for the severity of the crisis. According to the authors, new models to increase access to care, broader scope of practice laws, and more aggressive training and financial incentives are needed to address a shortage of certified providers who are offering services.

Media contacts: For an embargoed PDF, please contact Lauren Evans at

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To reach the lead author, Ryan McBain, PhD, MPH, please contact him directly at

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4. Cardiac troponin test cannot safely rule out inducible myocardial ischemia in patients with symptomatic coronary artery disease

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In symptomatic patients with coronary artery disease (CAD), even very low high-sensitivity cardiac troponin (hs-cTn) concentrations, do not generally allow clinicians to safely rule out inducible myocardial ischemia. Findings from a cohort study are published in Annals of Internal Medicine.

Currently, clinical judgement and cardiac stress imaging are used for risk stratification in symptomatic patients with CAD and suspected inducible myocardial ischemia. The optimal noninvasive method for surveillance is unknown, but hs-cTn, a quantitative marker of cardiomyocyte injury, has recently been evaluated as a clinical tool in settings other than the diagnosis of acute myocardial infarction.

Researchers from University Hospital Basel, Switzerland studied 1,896 consecutive symptomatic patients with CAD to apply a novel approach using very low hs-cTnl concentrations less than 2.5 ng/L to determine if it could exclude inducible myocardial ischemia. Including the most sensitive hs-cTnI assay currently available (limit of detection 0.1 ng/l, they used three different assaysto measure hs-cTnI and hs-cTnT in blood samples that had been taken before stress testing and processed by personnel blinded to clinical data. The researchers found that the diagnostic accuracy of hs-cTnI and hs-cTnT to identify inducible myocardial ischemia was low, and no cutoff level achieved the predefined performance characteristics for the safe exclusion of inducible myocardial ischemia.

Media contacts: For an embargoed PDF, please contact Lauren Evans at

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To reach the lead author, Christian Mueller, MD, please contact

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Also new in this issue:

Celiac Disease

Joshua Elliott Rubin, MD; Sheila E. Crowe, MD

In The Clinic

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