Addressing Health-Care System Inequities in the Management of Erectile Dysfunction: A Call to Action

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.

Racial and socioeconomic disparities in surgical care for post-prostate cancer treatment complications: A nationwide Medicare-based analysis

Objectives

To investigate the racial and socioeconomic (income) differences in receipt of and time to surgical care for urinary incontinence (UI) and erectile dysfunction (ED) occurring post-radical prostatectomy (RP) and/or radiation therapy (RT).

Materials and Methods

Utilizing the Medicare Standard Analytical Files (SAF), a retrospective cohort study was performed on data of patients diagnosed with prostate cancer (PCa) from 2015 to 2021. Patients who underwent RP and/or RT and who subsequently developed UI and/or ED were grouped into four cohorts: RP-ED, RP-UI, RT-ED and RT-UI. County-level median household income was cross-referenced with SAF county codes, classified into income quartiles, and used as a proxy for patient income status. The rate of surgical care was compared between groups using two-sample t-test and log-rank test. Cox proportional hazards modelling was used to determine covariate-adjusted impact of race on time to surgical care.

Results

The rate of surgical care was 6.8, 3.61 3.07, and 1.54 per 100 person-years for the RP-UI, RT-UI, RP-ED, and RT-ED cohorts, respectively. Cox proportional 'time-to-surgical care' regression analysis revealed that Black men were statistically more likely to receive ED surgical care (RP-ED AHR:1.79, 95% CI:1.49-2.17; RT-ED AHR:1.50, 95% CI:1.11-2.01), but less likely to receive UI surgical care (RP-UI AHR:0.80, 95% CI:0.67-0.96) than White men, in all cohorts except RT-UI. Surgical care was highest among Q1 (lowest income quartile) patients in all cohorts except RT-UI.

Conclusions

Surgical care for post-PCa treatment complications is low, and significantly impacted by racial and socioeconomic (income) differences. Prospective studies investigating the basis of these results would be insightful.

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.

Deafening Silence of Male Infertility

Think about 6 loved ones of reproductive age in your life. Now imagine that 1 of these 6 individuals is suffering from infertility. Perhaps they feel alone and isolated, unable to discuss their heartbreak with their closest friends, family, and support network. Suffering in silence. In this editorial, we discuss the infertility journey through the lens of the patients, the providers, and the scientists who struggle with infertility each and every day. Our goal is to open a dialogue surrounding infertility, with an emphasis on dismantling the longstanding societal barriers to acknowledging male infertility as a disease. Through education, communication, compassion, and advocacy, together we can all begin to break the deafening silence of male infertility.

The Epidemic of COVID-19-Related Erectile Dysfunction: A Scoping Review and Health Care Perspective

INTRODUCTION

COVID-19 infection is expected to be associated with an increased likelihood of erectile dysfunction (ED). Considering the high transmissibility of COVID-19, ED may be a concerning consequence for a large segment of the population.

AIMS

To (1) summarize existing published evidence for the impact of COVID-19 on the prevalence, severity, treatment, and management of ED; and (2) identify health-related trends in the emerging literature and identify gaps in the existing research literature and make recommendations for future research needs in the area.

METHODS

A scoping literature search was conducted on April 27, 2021. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews (Preferred Reporting Items for Systematic Reviews and Meta-Analyses-ScR) checklist was followed. The literature search was performed in PubMed using the terms: COVID-19, erectile, sexual, and dysfunction. A total of 693 publications were screened for relevance. Studies were appraised for their level of evidence based on study design and the rigor of methodology.

RESULTS

The evidence that COVID-19 infection causes or impacts ED is compelling. Four topics emerged regarding the nature of the association between COVID-19 and ED: (1) the biological impact of COVID-19 infection on ED; (2) the mental health impact of COVID-19 on ED; (3) the impact of COVID-19 on the management of ED and access to ED treatment; and (4) health disparities and the impact of COVID-19 on ED. Long-term and well-designed studies are needed to clarify the extent of the impact of COVID-19 on ED. The pandemic exposed several vulnerabilities within worldwide healthcare and social systems.

CONCLUSION

COVID-19 has a uniquely harmful impact on men's health and erectile function through biological, mental health, and healthcare access mechanisms. As the pandemic wanes, strategies to identify long-term effects and additional health care support may be needed to adequately mitigate the impact of COVID-19 on men's health. Hsieh T-C, Edwards NC, Bhattacharyya SK, et al.The Epidemic of COVID-19-Related Erectile Dysfunction: A Scoping Review and Health Care Perspective. Sex Med Rev 2022;10:286-310.

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.

Sexual Dysfunction and Gun Ownership in America: When Hard Data Meet a Limp Theory

Although there has been no direct empirical evidence linking sexual dysfunction (SD) with gun ownership, speculation has been widespread and persistent for decades. In this paper, we formally examine the association between SD and gun ownership. Our primary hypothesis, derived from the psychosexual theory of gun ownership, asserts that men experiencing SD are more likely to personally own guns than other men. To test this hypothesis, we used recently collected data from the 2021 Crime, Health, and Politics Survey (CHAPS), a national probability sample of 780 men, and binary logistic regression to model gun ownership as a function of SD. Our key finding is that men experiencing SD are no more likely to own guns than men without SD. This interpretation was supported across several indicators of SD (performance anxiety, erection trouble, and ED medication) and gun ownership (personal gun ownership, purchasing a gun during the pandemic, and keeping a gun in one's bedroom). To our knowledge, we are the first to have directly tested the association between SD and gun ownership in America. Our findings are important because they contribute to our understanding of factors associated with gun ownership by challenging the belief that phallic symbolism and masculinity somehow drive men with SD to purchase guns. Our results also remind us of the perils of gun culture rhetoric, which, in this case, function to discredit gun owners and to further stigmatize men with ED. We conclude by calling for more evidence-based discussions of SD and guns in society.

Socioeconomic Disparities and Risk Factors in Patients Presenting With Ischemic Priapism: A Multi-Institutional Study

OBJECTIVES

To evaluate contemporary clinical presentations of priapism, their association with socioeconomic characteristics, and the role of prescribing providers in priapism episodes in a large cohort of patients managed at 3 major academic health systems.

METHODS

We identified all consecutive patients presenting with ischemic priapism to the emergency departments of three major academic health systems (2014 -2019). Demographic characteristics, priapism etiologies, and clinical management were evaluated. Univariable and multivariable analyses were used to assess the contribution of socioeconomic characteristics and the role of prescribing providers in priapism episodes.

RESULTS

We identified 102 individuals with a total of 181 priapism encounters. Hispanic race, lower income quartile, sickle-cell disease, and illicit drug use were associated with increased risk of recurrent episodes. Of ICI users, 57% received their prescriptions from non-urological medical professionals (NUMPs); the proportion with recurrent episodes was higher for NUMPs compared to urologists (24% vs 0%, P = 0.06) with no demographic differences identified between patients treated by either group.

CONCLUSION

Socioeconomic disparities exist among patients presenting with recurrent episodes of priapism, potentially highlighting systemic issues with access to care and patient education. With most patients who developed ischemic priapism from ICI being prescribed these medications by NUMPs, further investigation is required to elucidate the prescribing and counseling patterns of these providers. Increased awareness of disparities and complications may improve patient safety.