Opting out of the Quality and Outcomes Framework (QOF) and impact on practices' performance

Background

Financial incentives are being increasingly adopted to help improve standards of care within general practice. However their effects on care quality are unclear. This study aimed to evaluate the impact of practices opting out of the Quality and Outcomes Framework (QOF), a financial incentive scheme in UK general practice.

Study design

A retrospective before and after study of all practices in Tower Hamlets, east London.

Methods

Practices were given an option by local commissioners of opting out of QOF without a financial penalty and instead opting for a locally designed financial incentive scheme that promoted more holistic care. We compared those practices which opted out of QOF to those which continued. We used national, publicly available QOF achievement data from 2016/17 and 2017/18. We undertook a sub-analysis of 16 QOF indicators to better understand the impact of the intervention.

Results

Of the 36 practices in Tower Hamlets, 7 decided to continue with QOF and 29 opted out. The intervention resulted in a small but statistically significant reduction in the total QOF achievement scores of practices which opted out of QOF. The sub-analysis of 16 QOF indicators showed statistically significant reductions in most of achievement scores net of exceptions for the practices that opted out. The differences in performance between the two cohorts of practices became smaller when exceptions were included.

Conclusions

The removal of QOF financial incentives can result in a reduction in achievement of QOF-related indicators but the size of the effect seems to depend on the QOF exception rates. An alternative incentive scheme that promotes a more holistic approach to care seems to be welcomed by general practices.

Social needs screening in primary care: A tool in the fight for health equity?

Progress on addressing health inequalities is slow and in many places around the world the gap between the privileged and the disadvantaged is widening. This is driven largely by an unfair and unequal distribution of the social determinants of health. While upstream policy and agenda commitment is needed to improve social determinants of health at a population level, healthcare also has a role. Currently social information is sporadically collected and used in healthcare. Improving our understanding of social problems is crucial in targeting services and to reduce the overreliance on area-level measures of deprivation. This has the potential to improve patient care as well as more accurately capture socio-economic disadvantage. Here we argue that there is a role for primary care in screening for social needs to help address inequalities. Social needs screening, more commonly used in North America than Europe, aims to systematically collect social information in health and care settings. Healthcare professionals ask patients about social issues including employment, finances, housing, education and social isolation and this information is used to prompt referral to community services to address any need identified. Social needs screening has potential to address negative impacts of social determinants of health at an individual and population level. Providing a reliable measure of social need, screening gives healthcare professionals an opportunity to tailor and improve quality of care for patients and offer individualised support. It has been shown to improve individual social and health outcomes and positively impact healthcare utilisation. At a population level, social needs screening can improve the data on social determinants of health and therefore support policy makers and service delivery leaders to target resources and services more effectively to the communities most in need. Implementing social needs screening must take account of local healthcare service capacity and available community resources but where sustainable, effective programmes can be introduced, the potential benefits are manifold. While primary care alone cannot solve the root causes of health inequalities, we argue it could be a powerful actor in the fight for health equity.

Prognostic Value of Weekly Delta-Radiomics during MR-Linac Radiotherapy of Glioblastoma

PURPOSE/OBJECTIVE(S)

MRI after chemoradiotherapy (chemoRT) shows areas of presumed tumor growth in ≤ 50% of glioblastoma (GBM) patients, which can be true progression (TP) - tumor growth with poor treatment response, or pseudoprogression (PP) - edema and tumor necrosis with favorable treatment response. Patients with TP have median overall survival (OS) of only 7 months, while patients with PP have median OS of 36 months. However, on imaging, TP and PP are usually not discernible during treatment, making it difficult to adapt radiation for poor responders. The purpose of this study was to investigate the prognostic value of delta radiomic features from MR-Linac for GBM.

MATERIALS/METHODS

Using an IRB-approved prospective cohort of GBM patients undergoing 30 fractions of chemoRT to 60 Gy on a 0.35T MR-Linac, 2 regions of interest (ROI) were contoured on daily T2-weighted treatment set-up scans: 1) tumor/edema (lesion) and 2) post-surgical resection cavity (RC). The lesion ROI were used to calculate texture features: second order radiomics features based on the gray-level co-occurrence matrix (GLCM), gray-level size zone matrix (GLSZM), gray-level run length matrix (GLRLM), and neighborhood gray-tone difference matrix (NGTDM). Each of these describe the probability of spatial relationships of gray levels occurring within the ROI. Features from fraction 1 (pre-radiation) were subtracted from fractions 5, 10, 15, 25, and 30 to create delta features at 5 timepoints (D5-D30). Patient response was retrospectively defined as no progression (NP), TP, or PP. Supervised machine learning was utilized using a 500-tree random forest (RF) classification model with TP or PP as the outcome. Variable importance analysis was conducted by calculating the out-of-bag errors with multiple bootstrapped data sets. The most prognostic features were selected using the RF importance scores.

RESULTS

Thirty-six patients were screened for inclusion: 9 were excluded due to no T2 lesion (RC ROI only). Of the remaining 27 patients: 10 had NP, 11 had TP, and 6 had PP. Thirty-nine texture features, plus lesion volume and mean lesion intensity (for a total of 41 variables per time point) were calculated and included in the model. Of the 10 most prognostic features, 6 were from D10, suggesting that prognostic changes in the underlying lesion microenvironment are occurring within the first 10 fractions of treatment. The model selected GLSZM high gray-level zone emphasis (HGZE) D10, IBSI code 5GN9, as the most prognostic feature. The receiver operator characteristic (ROC) area under the curve (AUC) for GLSZM HGZE D10 was 0.94 (95% CI = 0.81-1.00).

CONCLUSION

Delta radiomic features extracted from MR-Linac imaging may predict between PP and TP in GBM patients during treatment, which is earlier than current methods. This could allow physicians to adapt/intensify treatment in real time for poorly responding patients. Future directions include analysis with a larger patient cohort and with additional MRI contrasts (MR-Linac multiparametric MRI).

Evaluation of the national governmental efforts between 1997 and 2010 in reducing health inequalities in England

OBJECTIVES

The pandemic has compounded existing inequalities. In the UK, there have been calls for a new cross-government health inequalities strategy. This study aims to evaluate the effectiveness of national governmental efforts between 1997 and 2010, referred to as the National Health Inequalities Strategy (NHIS).

STUDY DESIGN

population-based observational study.

METHODS

Using Global Burden of Disease data, age-standardised years of life lost due to premature mortality (YLL) rates per 10,000 were extracted for 150 Upper Tier Local Authority (UTLA) regions in England for every year between 1990 and 2019. The slope index of inequality was calculated using YLL rates for all causes, individual conditions, and risk factors. Joinpoint regression was used to assess the trends of any changes which arose before, during or after the NHIS.

RESULTS

Absolute inequalities in YLL rates for all causes remained stable between 1990 and 2000, before decreasing over the following 10 years. After 2010, improvements slowed. A similar trend can be observed amongst inequalities in YLLs for individual causes, including ischaemic heart disease, stroke, breast cancer and lung cancer amongst females, and ischaemic heart disease stroke, diabetes and self-harm amongst males. This trend was also observed amongst certain risk factors, notably blood pressure, cholesterol, tobacco and dietary risks. Inequalities were generally greater in males than in females; however, trends were similar across both sexes. The NHIS coincided with significant reductions in inequalities in YLLs due to ischaemic heart disease and lung cancer.

CONCLUSIONS

The findings suggest that the NHIS coincided with a reduction in health inequalities in England. Policy makers should consider a new cross-government strategy to tackle health inequalities drawing from the success of the previous NHIS.

Clinical Evaluation of Scout Accelerated Motion Estimation and Reduction Technique for 3D MR Imaging in the Inpatient and Emergency Department Settings

BACKGROUND AND PURPOSE

A scout accelerated motion estimation and reduction (SAMER) framework has been developed for efficient retrospective motion correction. The goal of this study was to perform an initial evaluation of SAMER in a series of clinical brain MR imaging examinations.

MATERIALS AND METHODS

Ninety-seven patients who underwent MR imaging in the inpatient and emergency department settings were included in the study. SAMER motion correction was retrospectively applied to an accelerated T1-weighted MPRAGE sequence that was included in brain MR imaging examinations performed with and without contrast. Two blinded neuroradiologists graded images with and without SAMER motion correction on a 5-tier motion severity scale (none = 1, minimal = 2, mild = 3, moderate = 4, severe = 5).

RESULTS

The median SAMER reconstruction time was 1 minute 47 seconds. SAMER motion correction significantly improved overall motion grades across all examinations (P < .005). Motion artifacts were reduced in 28% of cases, unchanged in 64% of cases, and increased in 8% of cases. SAMER improved motion grades in 100% of moderate motion cases and 75% of severe motion cases. Sixty-nine percent of nondiagnostic motion cases (grades 4 and 5) were considered diagnostic after SAMER motion correction. For cases with minimal or no motion, SAMER had negligible impact on the overall motion grade. For cases with mild, moderate, and severe motion, SAMER improved the motion grade by an average of 0.3 (SD, 0.5), 1.1 (SD, 0.3), and 1.1 (SD, 0.8) grades, respectively.

CONCLUSIONS

SAMER improved the diagnostic image quality of clinical brain MR imaging examinations with motion artifacts. The improvement was most pronounced for cases with moderate or severe motion.

1215 IMPROVING THE QUALITY OF ANTICIPATORY CARE PLANNING FOR PATIENTS WITH RECURRENT ASPIRATION PNEUMONIA

Introduction

Recurrent episodes of aspiration pneumonia (RAP) are a significant problem in frail patients leading to high re-hospitalization and mortality. Anticipatory care planning (ACP) enables improved quality of life and end of life care. We reviewed the assessment, ACP discussions and communication with Primary Care in these patients.

Methods

We used a PDSA methodology, reviewing 116 patients with RAP referred to Speech and Language Therapy (SLT) in Elderly Medicine wards over six months, including the winter. Educational interventions were implemented. An illustrative case and pre-intervention results were presented at an online hospital-wide seminar and subsequently at an online departmental medical staff teaching session. Post-intervention analysis of 10 patients with RAP admitted over two summer months was conducted. The second round of interventions included departmental induction teaching for newly rotated doctors and creating an electronic ACP document (RAP ACP) for inclusion within the medical record.

Results

Baseline data was collected from 116 patients (mean age 85, 47% female). After the educational interventions, data was collected from 10 patients (mean age 88, 70% female). Data is being collected from winter months after the second intervention. This will be available before the conference. Baseline data demonstrated the need for improvements in documentation of Mental Capacity Assessment (MCA) specific to feeding (21.5%), ACP completion (26.7%) and flagging patients suitable for the Gold Standards Framework (GSF) on discharge (15%). Following educational interventions, there was a substantial improvement in MCA documentation (80%). Furthermore, there was a marked improvement in the completion of ACP discussions (70%). Communication of patients eligible for GSF was similar (14.2%) post-intervention.

Conclusions

Educational interventions substantially improved the quality of individualised care provided to patients with RAP. Mortality was high in both groups, yet documentation of eligibility for GSF was low, prompting further interventions targeting discharge communication.

Reducing health inequalities through general practice in the UK: a realist review (EQUALISE)

Background

In the UK, chronic conditions such as cancer, heart disease, stroke, and chronic obstructive pulmonary disease are driving health inequalities in life expectancy and were responsible for two-thirds of premature mortality in 2017. Voices that stress the importance of primary care in reducing health inequalities have been strengthening during the last decade. However, defining the most effective strategies to reduce health inequalities through general practice remains a challenge.

Aims

This study examines the evidence on interventions in primary care that are likely to decrease inequalities in NCDs and especially cancer, diabetes, cardiovascular and chronic obstructive pulmonary disease and will provide healthcare organisations with guiding principles on what should be commissioned.

Methods

The study is a realist review following Pawson's model. Based on a programme theory, we screened systematic reviews of interventions delivered in primary care and through their references, we identified primary studies reporting on inequalities across PROGRESS-Plus criteria. The data were analysed in light of the initial program theory and organised in a model informed by Collins’ Domains of Power framework.

Results

Out of 251 included reviews we retrieved 6,555 primary studies which resulted in 333 studies for data extraction. We found that there are five guiding principles operating simultaneously across four different domains which can reduce health inequalities in General Practice. The principles include flexibility, continuity, inclusivity, intersectionality, and community and operate simultaneously across the domains of structures and policies; narratives and ideas; rules and practices; and relationships and experience.

Conclusions

Flexibility, continuity, inclusivity, intersectionality, and community are the five principles which should guide the design and delivery of General Practice for the reduction of health inequalities.

Key messages

• Flexibility, continuity, inclusivity, intersectionality, and community are the five principles which should guide the design and delivery of General Practice for the reduction of health inequalities.

• Action to reduce health inequalities should be taken simultaneously across the domains of structures and policies; narratives and ideas; rules and practices; and relationships and experience.

Changing life expectancy in Europe 1990-2019: Global Burden of Disease Study 2019

 

Improvements in life expectancy have slowed in high income countries, with uncertain causes. We assessed the contribution of different causes of death to changes in life expectancy, and changes in population exposure to major risk factors in 16 European Economic Area countries plus the 4 nations of the United Kingdom from 1990-2013 and 2013-2019, using the Global Burden of Disease Study. After decades of steady improvements in life expectancy, all countries experienced smaller annual improvements after 2013. Norway experienced the smallest mean annual rate of change in improvement from pre 2013 to post 2013 of 0.03 years, and Northern Ireland (followed closely by Scotland and England) experienced the largest annual reduction from pre to post 2013 of 0.25 years. The cause of death responsible for the largest reductions in life expectancy improvements after 2013 was cardiovascular disease, followed by neoplasms. The largest reductions in deaths from cardiovascular disease were attributable to seven major risk factors: high LDL cholesterol, tobacco, dietary risks, high fasting plasma glucose, high systolic blood pressure, high body mass index, and low physical activity. The risk factors for deaths from neoplasm were similar. Exposure to tobacco remains a high risk but exposure declined steadily. Exposure to the other risks generally worsened after 2013, particularly for BMI and high fasting plasma glucose. The European countries that had better maintained reductions in deaths from cardiovascular disease and neoplasms also experienced larger improvements in life expectancy. These changes were underpinned by changing exposure to major risks. Policy responses to the slowdown in life expectancy improvements should include reducing population exposure to major risks, including the broader risks from diet and low physical activity, through prevention and addressing the broad social and commercial determinants of health as well as adequate funding for health services.

Key messages

A Multicenter, Prospective, Observational, Cohort-Controlled Study of Clinical Outcomes Following Coronavirus Disease 2019 (COVID-19) Convalescent Plasma Therapy in Hospitalized Patients With COVID-19

BACKGROUND

The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic has caused high inpatient mortality and morbidity throughout the world. COVID-19 convalescent plasma (CCP) has been utilized as a potential therapy for patients hospitalized with coronavirus disease 2019 (COVID-19) pneumonia. This study evaluated the outcomes of hospitalized patients with COVID-19 treated with CCP in a prospective, observational, multicenter trial.

METHODS

From April through August 2020, hospitalized patients with COVID-19 at 16 participating hospitals in Colorado were enrolled and treated with CCP and compared with hospitalized patients with COVID-19 who were not treated with convalescent plasma. Plasma antibody levels were determined following the trial, given that antibody tests were not approved at the initiation of the trial. CCP-treated and untreated hospitalized patients with COVID-19 were matched using propensity scores followed by analysis for length of hospitalization and inpatient mortality.

RESULTS

A total of 542 hospitalized patients with COVID-19 were enrolled at 16 hospitals across the region. A total of 468 hospitalized patients with COVID-19 were entered into propensity score matching with 188 patients matched for analysis in the CCP-treatment and control arms. Fine-Gray models revealed increased length of hospital stay in CCP-treated patients and no change in inpatient mortality compared with controls. In subgroup analysis of CCP-treated patients within 7 days of admission, there was no difference in length of hospitalization and inpatient mortality.

CONCLUSIONS

These data show that treatment of hospitalized patients with COVID-19 treated with CCP did not significantly improve patient hospitalization length of stay or inpatient mortality.

Allied health professionals: A promising ally in the work against health inequalities- A rapid review

Objectives

Allied Health Professionals (AHPs) have a crucial role in reducing health inequalities. However, there is a lack of evidence regarding the ways they can fulfil this role. This rapid review explores the ways in which AHPs can decrease health care or health outcome inequalities; address inequalities in the social determinants of health; and support disadvantaged groups at an individual, organisational and system level.

Study design

Rapid review following Cochrane criteria and narrative synthesis.

Methods

MEDLINE, EMBASE, CINAHL, Web of Science and AMED were searched combined with grey literature, to identify quantitative or qualitative review articles published between January 2010 and February 2021.

Results

From 8727 references, 36 met the inclusion criteria. The methodological quality of the studies was assessed with the AMSTAR tool and was generally low. Meta-analysis was not possible due to the heterogeneity of the studies, and a narrative synthesis was produced. Three themes emerged at patient and organisational level: 1) access to AHP services; 2) quality of care; and 3) social determinants of health. Two themes emerged at system level: 1) unequal workforce distribution and 2) lack of inclusive clinical guidelines.

Conclusions

This rapid review offers a broad range of evidence on the ways AHPs can contribute to the reduction of inequalities in health care, both in terms of access and quality of care and in health outcomes. More research is needed to further understand the impact of AHPs on inequalities affecting specific groups and their contribution to equitable distribution of social determinants of health.

At a Glance: An Update on Neuroimaging and Retinal Imaging in Alzheimer's Disease and Related Research

Neuroimaging serves a variety of purposes in Alzheimer's disease (AD) and related dementias (ADRD) research - from measuring microscale neural activity at the subcellular level, to broad topological patterns seen across macroscale-brain networks, and everything in between. In vivo imaging provides insight into the brain's structure, function, and molecular architecture across numerous scales of resolution; allowing examination of the morphological, functional, and pathological changes that occurs in patients across different AD stages (1). AD is a complex and potentially heterogenous disease, with no proven cure and no single risk factor to isolate and measure, whilst known risk factors do not fully account for the risk of developing this disease (2). Since the 1990's, technological advancements in neuroimaging have allowed us to visualise the wide organisational structure of the brain (3) and later developments led to capturing information of brain 'functionality', as well as the visualisation and measurement of the aggregation and accumulation of AD-related pathology. Thus, in vivo brain imaging has and will continue to be an instrumental tool in clinical research, mainly in the pre-clinical disease stages, aimed at elucidating the biological complex processes and interactions underpinning the onset and progression of cognitive decline and dementia. The growing societal burden of AD/ADRD means that there has never been a greater need, nor a better time, to use such powerful and sensitive tools to aid our understanding of this undoubtedly complex disease. It is by consolidating and reflecting on these imaging advancements and developing long-term strategies across different disciplines, that we can move closer to our goal of dementia prevention. This short commentary will outline recent developments in neuroimaging in the field of AD and dementia by first describing the historical context of AD classification and the introduction of AD imaging biomarkers, followed by some examples of significant recent developments in neuroimaging methods and technologies.

P–106 The evaluation of dietary score representing the overall effect of men’s diet to semen quality on couple’s fertility

Study question

Is men’s diet associated with assisted reproductive technology (ART) outcomes?

Summary answer

An empirical dietary score representing the overall effect of men’s diet on semen quality was unrelated to ART outcomes.

What is known already

Multiple studies have related various aspects of men’s diet to semen quality. Generally, healthier foods, such as fish, vegetables, and fruits, have been related to better semen quality, whereas unhealthy foods, like processed and red meats, have had the opposite relationship. Nevertheless, while bulk semen parameters are important biomarkers of male fertility and a diagnostic cornerstone for male factor infertility, they are imperfect predictors of a couple’s fertility.

Study design, size, duration

Couples presenting to the Massachusetts General Hospital Fertility Center between April 2007 and April 2018 were invited to participate in the Environment and Reproductive Health (EARTH) study, a prospective cohort study. Men’s diet was assessed with a previously validated food frequency questionnaire. A dietary score reflecting the overall relation of men’s food intake with semen quality parameters was empirically derived using reduced rank regression (RRR). The resulting dietary score was related to ART outcomes.

Participants/materials, setting, methods

We used information from 349 men (908 semen samples) to derive the empirical diet pattern and data from 231 couples (407 ART cycles). The primary outcome was the probability of live birth per treatment cycle; secondary outcomes were semen quality, and fertilization, implantation, and clinical pregnancy rates. We evaluated the association between the dietary score and these outcomes using logistic generalized linear mixed models to account for repeated cycles while adjusting for confounders.

Main results and the role of chance

Men had a median baseline age and BMI of 36.8 years and 26.9 kg/m2, respectively. The empirical diet pattern was significantly associated with all semen parameters. One standard deviation increase in the empirical diet pattern was associated with lower volume (–0.10 standard units [95% CI: –0.17 to –0.04]) and to higher sperm total sperm count (0.13 standard units [0.06 to 0.20]), concentration (0.17 standard units [0.10 to 0.24]), total motility (0.14 standard units [0.07 to 0.20]), progressive motility (0.08 standard units [0.01 to 0.15]), and normal morphology (0.18 standard units [0.11 to 0.25]). Couples with men in the lowest quartile of the empirical score were more likely to have a diagnosis of male infertility than couples with men in the highest quartile (49% vs 24%). Despite the association with semen parameters, the empirical diet score was not related to any clinical outcome of infertility treatment with ART. The adjusted probabilities of implantation, clinical pregnancy and live birth in the lowest and highest quartile of the empirical score were 0.62 (0.50–0.73) and 0.55 (0.45–0.66), 0.57 (0.46–0.69) and 0.50 (0.40–0.61), and 0.49 (0.37–0.62) and 0.36 (0.25–0.48), respectively. Analyses excluding couples with a diagnosis of male factor infertility yielded similar results.

Limitations, reasons for caution

We evaluated the relationship only among couples presenting to a fertility center and therefore it is unclear whether findings can be generalized to couples trying to conceive without ART.

Wider implications of the findings: Given ART is a robust intervention including stringent sperm selection procedures, any effect that empirical diet may have on a couple’s chances of conceiving through assisted reproduction is unlikely to reflect the effect of these factors on bulk semen quality parameters.

Trial registration number

The project was funded by ES009718, ES022955, ES026648, and ES000002 from the National Institute of Environmental Health Sciences, and P30DK46200 from the National Institute of Diabetes and Digestive and Kidney Diseases

P–716 The relationship of men’s adherence to the Mediterranean diet with sperm parameters and outcomes of assisted reproductive technologies

Study question

Is men’s adherence to the Mediterranean diet (MD) associated with sperm parameters and couples’ outcomes of assisted reproductive technologies (ART)?

Summary answer

Higher men’s adherence to the MD was associated with an increased probability of clinical pregnancy and live birth among couples undergoing ART.

What is known already

There is growing literature supporting the hypothesis that some nutrients, foods, and dietary patterns may be related to sperm quality and fertility. However, no previous studies analyzed the relationship of men’s adherence to the Mediterranean diet with sperm parameters and ART outcomes in the same cohort.

Study design, size, duration

The Environmental and Reproductive Health (EARTH) Study is a prospective preconception cohort of couples seeking fertility treatment at the Massachusetts General Hospital Fertility Center (Boston, USA). This analysis includes 314 men and their female partner, who underwent 791 ART cycles (2007–2020). Diet intake was measured by a validated semi-quantitative food frequency questionnaire completed prior to ART. Men’s adherence to the MD was estimated using the Trichopoulou score.

Participants/materials, setting, methods

Primary outcomes included: conventional sperm parameters (volume, sperm count, concentration, motility, and morphology), and ART outcomes (implantation, clinical pregnancy, and live birth). We estimated the marginal means and 95% confidence interval (95%CI) for semen parameters and the probability of ART (95%CI) by employing generalized linear mixed models while adjusting for several potential confounders. Sensitivity analyses by changing the cut-off points of adherence to the MD were tested.

Main results and the role of chance

At baseline, men had a median (IQR) age of 35.6 (32.6, 38.8) years and a BMI of 26.7 (24.0, 29.4) kg/m2. Female partner age median (IQR) was 35.0 years (32.0, 38.0) and BMI 23.3 (21.3, 26.6) kg/m2. Couples were mostly white and had never smoked. Men’s adherence to the MD was not associated with seminal parameters in the multivariable-adjusted models but it was related to a higher probability of clinical pregnancy and live birth. The predicted marginal proportions and confidence intervals among men in the lowest compared with the highest quartile of adherence to the MD were 0.25 (0.14, 0.40), 0.55 (0.41, 0.68) for clinical pregnancy (P-trend=0.005), and 0.19 (0.10, 0.32), 0.42 (0.30, 0.55) for live birth (P-trend=0.014). Male partner MD dietary pattern scores were unrelated to the probability of implantation. Sensitivity analyses using tertiles and quintiles of men’s adherence to the MD showed similar associations.

Limitations, reasons for caution

Although we have adjusted our models by several potential confounding factors, residual confounding cannot be ruled out, and therefore our results should be interpreted with caution. The findings may not be generalizable to other populations or couples attempting conception without ART.

Wider implications of the findings: According to our knowledge, this is the first study suggesting that adherence to MD could be suitable dietary guidance for men whose partners are undergoing infertility treatment.

Trial registration number

Not applicable