An Analysis of a Commercial Database on the Use of Erectile Dysfunction Treatments for Men With Employer-Sponsored Health Insurance

Gap in Sexual Dysfunction Management Between Male and Female Patients Seen in Primary Care: An Observational Study

BACKGROUND

Female sexual dysfunction (FSD), defined as clinically distressing problems with desire, arousal, orgasm, or pain, affects 12% of US women. Despite availability of medications for FSD, primary care physicians (PCPs) report feeling underprepared to manage it. In contrast, erectile dysfunction (ED) is frequently treated in primary care.

OBJECTIVE

To describe differences in patterns of FSD and ED diagnosis and management in primary care patients.

DESIGN

Retrospective observational study.

SUBJECTS

Primary care patients with an incident diagnosis of FSD or ED seen at a large, integrated health system between 2016 and 2022.

MAIN MEASURES

Sexual dysfunction management (referral or prescription of a guideline-concordant medication within 3 days of diagnosis), patient characteristics (age, race, insurance type, marital status), and specialty of physician who diagnosed sexual dysfunction. We estimated the odds of FSD and ED management using mixed effects logistic regression in separate models.

KEY RESULTS

The sample included 6540 female patients newly diagnosed with FSD and 16,591 male patients newly diagnosed with ED. Twenty-two percent of FSD diagnoses were made by PCPs, and 38% by OB/GYNs. Forty percent of ED diagnoses were made by PCPs and 20% by urologists. Patients with FSD were managed less frequently (33%) than ED patients (41%). The majority of FSD and ED patients who were managed received a medication (96% and 97%, respectively). In the multivariable models, compared to diagnosis by a specialist, diagnosis by a PCP was associated with lower odds of management for FSD patients (aOR, 0.59; 95% CI, 0.51-0.69) and higher odds of management (aOR, 1.52; 95% CI, 1.36-1.64) for ED patients.

CONCLUSIONS

Primary care patients with FSD are less likely to receive management if they are diagnosed by a PCP than by an OB/GYN. The opposite was true of ED patients, exposing a gap in the quality of care female patients receive.

Early Versus Late Periprosthetic Joint Infection After Total Knee Arthroplasty: Do Patient Differences Exist?

BACKGROUND

Periprosthetic joint infection (PJI) is a devastating complication following total knee arthroplasty (TKA). Little evidence exists comparing those with early versus late PJI. The purpose of the study was to determine comorbidity profile differences between patients developing early and late PJI.

METHODS

There were 72,659 patients undergoing primary TKA from 2009 to 2021, who were identified from a commercial claims and encounters database. Subjects diagnosed with PJI were categorized as either 'early' (within 90 days of index procedure) or 'late' (> 2 years after index arthroplasty). Non-infected patients within these periods served as control groups following 4:1 propensity score matching on other extraneous variables. Logistic regression analyses were performed comparing comorbidities between groups.

RESULTS

Patients were significantly younger in the late compared to the early infection group (58.1 versus 62.4 years, P < .001). When compared to those with early PJI, patients who had chronic kidney disease (13.3 versus 4.1%; OR [odds ratio] 5.17, P = .002), malignancy (20.4 versus 10.5%; OR 2.53, P = .009), uncomplicated diabetes (40.8 versus 30.6%; OR 2.00, P = .01), rheumatoid arthritis (9.2 versus 3.3%; OR 2.66, P = .046), and hypertension (88.8 versus 81.6%; OR 2.17, P = .04), were all significant predictors of developing a late PJI.

CONCLUSIONS

When compared to patients diagnosed with early PJI following primary TKA, the presence of chronic kidney disease, malignancy, uncomplicated diabetes, rheumatoid arthritis, and hypertension, were independent risk factors for the development of late PJI. Younger patients who have these comorbidities may be targets for preoperative optimization interventions that minimize the risk of PJI.

Chronic Anticoagulation is Associated With Increased Risk for Postoperative Complications Following Aseptic Revision Total Hip Arthroplasty

BACKGROUND

With an aging global population, the incidence of revision total hip arthroplasty (rTHA) is expected to increase markedly. While patients undergoing primary total hip arthroplasty who require chronic anticoagulation (AC) have been associated with increased postoperative complications, less is known about the impact of chronic AC status on postoperative complications in the rTHA setting. This study sought to compare complication rates following aseptic rTHA between patients who were on chronic AC and those who were not.

METHODS

A large national database was utilized to retrospectively identify 9,421 patients who underwent aseptic rTHA between 2014 and 2019. Patients were divided into 2 cohorts: 1,790 patients (19.0%) were in the chronic AC cohort (ie, having an AC prescription filled within 6 months prior to and following rTHA), and 7,631 patients (81.0%) were not on chronic AC. Postoperative complications at 90-days and 2-years were compared between cohorts utilizing univariate and multivariate analyses, controlling for sex, age, and comorbidities.

RESULTS

At 90-days, chronic AC patients had increased odds of prosthetic joint infections (PJIs) (odds ratio [OR] 3.2, P < .001), surgical site infections (OR 3.6, P < .001), and mechanical prosthetic complications (OR 3.5, P < .001), which included any aseptic loosening, implant dislocation, or broken prosthetic. At 2-years, chronic AC patients had increased odds of PJI (OR 3.3, P < .001) as well as mechanical prosthetic complications (OR 3.2, P < .001). Chronic AC patients were also at increased risk for reoperation within 2 years after initial aseptic rTHA (OR 1.9, P < .001).

CONCLUSIONS

Patients on chronic AC have significantly higher odds of 90-day and 2-year complications after aseptic rTHA. This includes increased odds of PJI, surgical site infection, and mechanical prosthetic complications. Patients receiving chronic AC who undergo rTHA should be counseled on the risk-benefit ratio of their chronic AC status in a multidisciplinary setting to optimize their postoperative outcomes.

Patient out-of-pocket costs for guideline-recommended treatments for erectile dysfunction: a medicare cost modeling analysis

Patient out-of-pocket (OOP) cost represents an access barrier to erectile dysfunction (ED) treatment. We determined OOP cost for men with ED covered by Fee-for-Service Medicare. Coverage policies were obtained from the Medicare Coverage Database for treatments recommended by the 2018 American Urological Association (AUA) guidelines. OOP cost was retrieved from the 2023 Centers for Medicare & Medicaid Services Final Rule. OOP cost for treatments without Medicare coverage were extracted from GoodRx® or literature and inflated to 2022 dollars. Annual prescription costs were calculated using the published estimate of 52.2 yearly instances of sexual intercourse. Medicare has coverage for inflatable penile prostheses (IPP; strong recommendation), non-coverage for vacuum erection devices (VED; moderate recommendation) and phosphodiesterase type-5 inhibitors (PDE5i; strong recommendation), and no policies for intracavernosal injections (ICI; moderate recommendation), intraurethral alprostadil (IA; conditional recommendation), or low-intensity extracorporeal shock wave therapy (ESWT; conditional recommendation). Annual IA prescription is most costly ($4022), followed by ICI prescription ($3947), one ESWT course ($3445), IPP ($1600), PDE5i prescription ($696), and one VED ($213). PDE5i and IPP, both strongly recommended by AUA guidelines, are associated with lower OOP cost. Better understanding of patient financial burden may inform healthcare decision-making.

Periprosthetic Joint Infection Risk After Primary Total Knee Arthroplasty: Are All Preoperative Corticosteroid Injections the Same?

BACKGROUND

Previous evidence has demonstrated an increased risk of periprosthetic joint infection (PJI) following primary total knee arthroplasty (TKA) in patients receiving corticosteroid injection (CSI) within 3 months of surgery. The study aimed to determine if PJI risk after TKA varied among different corticosteroid agents.

METHODS

A total of 85,073 patients undergoing primary TKA from 2009 to 2019 were identified from a large national database. Of these, 1,092 (1.3%) received an ipsilateral, intra-articular CSI within 90 days of TKA. These patients were compared to those not receiving CSI using multivariate logistic regressions following 1:4 propensity score matching, with PJI development as the primary outcome.

RESULTS

Patients given an injection of any corticosteroid within 90 days of TKA had significantly higher PJI rates compared to controls (1.6 versus 0.41%; P < .001). This finding was driven by patients receiving methylprednisolone acetate (n = 543) or betamethasone (n = 153), with prevalence rates of 1.7 and 2.6%, respectively (P = .003 and P = .01, respectively). No significant increase in the rate of PJI was observed for patients receiving triamcinolone (1.2%; P = .08; n = 342) or dexamethasone (0.0%; P = 1; n = 54) within 90 days preceding TKA. PJI risk for all agents, administered more than 90 days preoperatively normalized to control levels (0.51 versus 0.34%).

CONCLUSIONS

These results suggest that PJI risk varies with CSI type. In this large database study, only patients given methylprednisolone acetate or betamethasone injections within 90 days of surgery had significantly higher PJI rates compared to controls.

Prospective Patient Preferences for Humor in Urologists Treating Erectile Dysfunction: A Survey Study

INTRODUCTION

Men seeking treatment for sexual dysfunction can experience embarrassment as a result of stigma. This research manuscript presents the findings of a survey conducted to investigate the influence of humor on prospective patients' preferences when selecting a specialist to address erectile dysfunction (ED).

METHODS

The respondents were presented with five pairs of mock urology business cards: one professional and one humorous. A questionnaire was designed and distributed via an online survey platform. Descriptive statistics and Fisher's exact test were performed using the Statistical Package for Social Sciences (SPSS) software version 29 (IBM SPSS Statistics, Armonk, NY) to evaluate age and race associations with card preference.

RESULTS

Among the 997 participants, an average of 66.1% (a median of 71.2%) preferred professional cards. Humorous card selection rates ranged from 5.2% to 38.4% compared to 54.0% to 78.1% for professional cards. A statistically significant relationship between age and professional card choice existed in all except the fifth set of cards (p = 0.001, 0.001, 0.001, 0.001, and 0.054). The relationship between race or ethnicity and business card preference was not reported due to an imbalance in demographics, with most participants identifying as Caucasian.

DISCUSSION

A humor-centric approach may not resonate with all individuals seeking treatment for sensitive conditions such as ED. Limitations include the subjectivity of humor, the use of an online survey platform, and the hypothetical nature of this study. Real patients experiencing ED may face stigma and respond to humor differently.

CONCLUSION

This study provides insights into patient preference for professionalism over humor from their urologist but leaves room for the exploration of humor in medical contexts. Future studies could examine the impacts of humor on patient choices in real-world healthcare settings.

Trends in Costs and Professional Reimbursements for Revision Total Hip and Knee Arthroplasty

BACKGROUND

With increasing numbers of revision total hip and total knee arthroplasties (rTHAs and rTKAs), understanding trends in related out-of-pocket (OOP) costs, overall costs, and provider reimbursements is critical to improve patient access to care.

METHODS

A large database was used to identify 92,116 patients who underwent rTHA or rTKA between 2009 and 2018. The OOP costs associated with the surgery and related inpatient care were calculated as the sum of copayment, coinsurance, and deductible payments. Professional reimbursement was calculated as total payments to the principal physician. All monetary data were adjusted to 2018 dollars. Multivariate regressions evaluated the associations between costs and procedure type, insurance type, and region of service.

RESULTS

From 2009 to 2018, overall costs for rTHA significantly increased by 35.0% and overall costs for rTKA significantly increased by 32.3%. The OOP costs for rTHA had no significant changes, while OOP costs for rTKA increased by 20.1%, with patients on Medicare plans having the lowest OOP costs. Professional reimbursements, when measured as a percentage of overall costs, decreased significantly by 4.4% for rTHA and 4.0% for rTKA, with the lowest reimbursements from Medicare plans.

CONCLUSION

From 2009 to 2018, total costs related to rTHA and rTKA significantly increased. The OOP costs significantly increased for rTKA, and professional reimbursements for both rTHA and rTKA decreased relative to total costs. Overall, these trends may combine to create greater financial burden to patients and the healthcare system, as well as further limit patients' access to revision arthroplasty care.

Access to inflatable penile prosthesis surgery as indicated by distances traveled among US men with Medicare

Background

The significance of geographic barriers to receiving inflatable penile prosthesis (IPP) treatment is uncertain according to the existing medical literature.

Aim

To describe the travel patterns of men with erectile dysfunction (ED) in the United States who underwent IPP surgery.

Methods

This retrospective cohort study utilized data from the 100% Medicare Standard Analytical Files. Men aged ≥65 years with an ED diagnosis who underwent IPP surgery between January 2016 and December 2021 were identified from the database. Federal Information Processing Series codes from the National Bureau of Economic Research's County Distance Database were used to determine geographic distances from patients' homes to the facilities at which surgery was performed.

Outcomes

Evaluations included the proportions of men who traveled outside their county of residence or state for IPP treatment and the average distances in miles traveled.

Results

Among 15 954 men with ED undergoing IPP treatment, 56.4% received care out of their county for IPP, at a mean distance of 125.6 miles (range, 3.8-4935.0). Although patients aged ≥80 years were less likely to travel outside their county as compared with men aged 65 to 69 years (48.1% vs 57.1%, P < .001), if they traveled, they were likely to travel farther (mean, 171.8 vs 117.7 miles; P < .001). South Dakota had the highest proportion of men traveling outside their county for IPP treatment (91.3%; mean, 514.2 miles), while Vermont had the highest proportion traveling outside their home state (73.7%).

Clinical Implications

By unveiling disparities in access, this study will potentially lead to tailored interventions that enhance patient care and health outcomes.

Strengths and Limitations

Strengths include the uniqueness in (1) evaluating the proportions of patients who travel out of their county of residence or home state for IPP treatment and (2) quantifying the average distances that patients traveled. An additional strength is the large sample size due to the retrospective design and database used. The analysis did not capture all Medicare enrollees; however, it did encompass all traditional Medicare enrollees, representing approximately half of all men in the US aged ≥65 years. Limitations include not being generalizable to entire population of the US, as the study examined only Medicare enrollees. In addition, the study period includes the pandemic, which could have affected travel patterns. Furthermore, the coding and accuracy of the data are limitations of using administrative claims data for research.

Conclusion

Study findings showed that many men with Medicare and ED traveled from their home geographic location for IPP treatment.

Safety profile and signal detection of phosphodiesterase type 5 inhibitors for erectile dysfunction: a Food and Drug Administration Adverse Event Reporting System analysis

Background

Phosphodiesterase type 5 inhibitors (PDE5Is) are generally well tolerated but have been associated with uncommon and significant adverse events (AEs).

Aim

This study aims to investigate and compare the characteristics of AEs associated with PDE5Is used for erectile dysfunction and identify any safety signals in a postmarketing surveillance database between 2010 and 2021.

Methods

A descriptive analysis was conducted for all AEs reported to the Food and Drug Administration Adverse Event Reporting System for 4 PDE5Is-avanafil, sildenafil, tadalafil, and vardenafil-indicated for erectile dysfunction between January 2010 and December 2021. The frequency of the most reported AEs and outcomes were identified. A disproportionality analysis based on proportional reporting ratio (PRR) and reporting odds ratio (ROR) was conducted for the most common and clinically important AEs to identify signals to gain insights into potential differences in safety profiles.

Outcomes

The outcome measures of the study are frequency of reported AEs and outcomes following AE.

Results

A total of 29 236 AEs were reported for PDE5Is during the study period. The most reported AE was "drug ineffective" with 7115 reports (24.3%). Eight safety signals were detected across the 4 drugs. Key signals were sexual disorders (PRR, 3.13 [95% CI, 2.69-3.65]; ROR, 3.24 [95% CI, 2.77-3.79]) and death (PRR, 3.17 [2.5-4.01]; ROR, 3.211 [2.52-4.06]) for sildenafil, priapism (PRR, 3.63 [2.11-6.24]; ROR, 3.64 [2.12-6.26]) for tadalafil, and drug administration error (PRR, 2.54 [1.84-3.52]; ROR, 2.6 [1.86-3.63]) for vardenafil. The most reported outcomes were other serious events with 6685 events (67.2%) and hospitalization with 1939 events (19.5%).

Clinical Implications

The commonly reported AEs and detected signals may guide clinicians in treatment decision making for men with erectile dysfunction.

Strengths and Limitations

This is the first comprehensive report and disproportionality analysis on all types of AEs associated with PDE5Is used for erectile dysfunction in the United States. The findings should be interpreted cautiously due to limitations in the Adverse Event Reporting System, which includes self-reports, duplicate and incomplete reports, and biases in reporting and selection. Therefore, establishing a causal relationship between the reported AEs and the use of PDE5Is is uncertain, and the data may be confounded by other medications and indications.

Conclusion

PDE5Is demonstrate significantly increased risks of reporting certain clinically important AEs. While these events are not common, it is imperative to continually monitor PDE5I use at the levels of primary care to national surveillance to ensure safe utilization.

Out-of-Pocket and Total Costs for Common Hand Procedures From 2008 to 2016: A Nationwide Claims Database Analysis

PURPOSE

Rising patient out-of-pocket (OOP) costs and financial distress have been associated with reduced access to and delays in care. We evaluated whether OOP and total costs for common hand procedures have increased from 2008 to 2016 and identified key drivers of these costs.

METHODS

Using the IBM MarketScan Research Databases, we identified patients who underwent trigger finger release, open carpal tunnel release, thumb carpometacarpal joint arthroplasty, cubital tunnel release, or open treatment of distal radius fracture in the outpatient setting between 2008 and 2016. Patient OOP costs included copayment, coinsurance, and deductible payments. Costs not directly related to medical care, such as transportation and childcare costs, were not included. The overall cost was defined as the sum of the patient OOP cost and insurer reimbursements. We calculated changes in OOP and total overall costs over the study period. We also performed multivariable linear regressions to evaluate the associations between costs and procedure type, insurance type, region, and site of service.

RESULTS

The mean patient OOP cost increased by 55% to 71% and the total overall cost increased by 20% to 45%, depending on the procedure, between 2008 and 2016. Facility overall costs increased by 38%, whereas professional overall costs increased by 9%. Procedures performed in an office-based setting were associated with the lowest patient OOP and total overall costs, whereas high-deductible health plans were associated with the highest OOP costs.

CONCLUSIONS

Patient OOP and total overall costs increased for the most common hand procedures between 2008 and 2016, driven by a substantial increase in facility costs. Office-based procedures were associated with the lowest costs.

CLINICAL RELEVANCE

To alleviate the rising patient cost burden, hand surgeons could incorporate OOP cost considerations into shared decision-making tools, identify patients who may benefit from financial counseling, and shift procedures to an office-based setting.

Cost of Lost Productivity Due to Erectile Dysfunction and Impact of Employer Benefit Exclusion of Penile Prosthesis Implantation Treatment

OBJECTIVE

We examined the cost of lost productivity due to erectile dysfunction (ED) and employer benefit exclusion of penile prosthesis implantation (PPI) among men with employer-sponsored health insurance.

METHODS

A decision-analytic model was developed using administrative claims data, US Bureau of Labor Statistics, and published literature. The economic impact of ED productivity loss and PPI benefit exclusion was reported in 2019 USD.

RESULTS

Men with ED had an additional 282.7 hours/year of work impairment compared to men without ED, resulting in annual incremental costs of $7,270. US employers excluding PPI benefits could lose $9.3 billion/year of work due to additional work impairment from ED.

CONCLUSIONS

Productivity loss due to ED and PPI benefit exclusion have considerable economic impacts on men with ED and their employers. Continuous advocacy for benefit exclusion removal is needed to ensure appropriate patient access.