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Veterans Health Administration Primary Care Provider Adherence to Prescribing Guidelines for Systemic Hormone Therapy in Menopausal Women

Cordasco, Kristina M.; Yuan, Anita H.; Danz, Marjorie J.; Jackson, LaShawnta; Yee, Ellen F.; Tcheung, Lueng Sophia; Washington, Donna L.

The Journal for Healthcare Quality (JHQ): March/April 2019 - Volume 41 - Issue 2 - p 99–109
doi: 10.1097/JHQ.0000000000000183
Original Article

Background: Systemic hormone therapy (HT) is effective for treating menopausal symptoms but also confers risks. Therefore, experts have developed clinical guidelines for its use.

Purpose: We assessed primary care guideline adherence in prescribing systemic HT, and associations between adherence and provider characteristics, in four Veterans Health Administration (VA) facilities.

Methods: We abstracted medical records associated with new and renewal systemic HT prescriptions examining adherence to guidelines for documenting indications and contraindications; prescribing appropriate dosages; and prescribing progesterone.

Results: Average guideline adherence was 58%. Among new prescriptions, 74% documented a guideline-adherent indication and 28% documented absence of contraindications. Among renewals, 39% documented a guideline-adherent indication. In prescribing an appropriate dose, 45% of new prescriptions were guideline-adherent. Among renewal prescriptions with conjugated equine estrogen doses ≥0.625 mg or equivalent, 16% documented the dosing rationale. Among 116 prescriptions for systemic estrogen in women with a uterus, progesterone was not prescribed in 8.

Conclusions: Guideline adherence in prescribing systemic HT was low among VA primary care providers. Failures to coprescribe progesterone put women at increased risk for endometrial cancer.

Implications: Intervention development is urgently needed to improve guideline adherence among primary care prescribers of systemic HT for menopause. Similar assessments should be conducted in community settings.

For more information on this article, contact Kristina M. Cordasco,

Funders: This work was funded by VA Health Services Research & Development CREATE project #CRE-12-031, “Controlled Trial of Tele-Support and Education for Women's Health Care in CBOCs.” Data from the DWHP Assessment of Workforce Capacity were provided by Dr. Susan Frayne, MD, MPH, which was created with funding from VA Women's Health Services (Patient Care Services). The views expressed within are solely those of the authors and do not necessarily represent the views of the Department of Veterans Affairs or the United States Government.

Presented at The Society of General Internal Medicine Annual Meeting; Denver, CO, April 11, 2018.

The authors declare no conflicts of interest.

This work was reviewed for compliance with ethical standards by the Institutional Review Board of the VA Greater Los Angeles Healthcare System. Trial registration:, NCT01918072.

© 2019 National Association for Healthcare Quality
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