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Disparities in ED diagnosis and referral across clinics who serve varying demographics


To examine the disparities of ED diagnosis and referral, Denise Asafu-Adjei, MD, MPH, and a team of investigators conducted a study involving 2 outpatient urology settings who serve communities with varying demographics.

Denise Asafu-Adjei, MD, MPH

Denise Asafu-Adjei, MD, MPH

Although erectile dysfunction (ED) affects a significant number of patients, only some of these patients go forward with seeking treatment.

To examine the disparities of ED diagnosis and referral, Denise Asafu-Adjei, MD, MPH, and a team of investigators conducted a study involving 2 outpatient urology settings who serve communities with varying demographics. This study was presented at the 2021 American Urological Association Annual Meeting.¹ Asafu-Adjei is a urologist and medical director of male reproductive medicine at Loyola University, Chicago, Illinois.

Please discuss the background for this study.

This study, which was sponsored through the AUA Urology Care Foundation and the Sexual Medicine Society of North America joint grant, was seeking to look at access to care for erectile dysfunction services. The main goal of the project was to characterize what we were doing at our primary men's clinic at UCLA, and look to see how that care, in terms of the pathways and the access, compared to another UCLA site, more of a community hospital setting. We compared how the patients are getting into each system.

The overarching goal was for us to determine, essentially, what are the best practices or the best ways that we can get men seen for this disease process, and how we can eventually move toward standardizing care. The reason we care about erectile dysfunction is because it is what we call a gateway disease, so a lot of the men that come to see us typically have some form of cardiovascular comorbidity like diabetes, hypertension, obesity, etc. A lot of times, however, we know that men don't go to the doctor as often as women do. As urologists, we are seeing men in these settings, and it really gives us a unique position to be able to pivot our patients to other primary care doctors and other places where they really need essential care. So, we see it as a public health issue to address ED and that was the motivation behind studying this.

What were some of the notable findings? Were any of them surprising to you and your co-authors?

What was surprising to us is when we compared men presenting to the system based on their referral patterns. We found that a lot of men in our more underserved community hospital setting were actually coming to the system via self-referrals, whereas most of the patients at our mental health clinic, our flagship site at UCLA, were coming to us for the most part through referrals from other physicians or more formal referrals. So, that was really screaming to us that the men in the community hospital were essentially not getting directly linked to us, but eventually were finding their way. And I think it really spoke to the fact that outside of just being urologists, we really have to think about the other mechanisms and how people are coming to us to be seen for erectile dysfunction. Primary care physicians really play a big role in being able to ask those questions regarding family history or social history for any kind of middle-aged patient, and even younger ones. We really have to ask, "How are your erections?" because we know that it's uncomfortable, but it also allows us to think about other health conditions. So, it was pretty surprising looking at those referral patterns. We have such a big population at UCLA, and I think we definitely got to see a fair amount of younger men as well. The data showed us that a lot of young men are coming in for ED, and we can't really think of it as just a disease of older men. It can affect you at any age.

What can be done to address the disparities observed in this study?

We are in the process of formally writing this up for publication, but I think 1 thing that stood out to us was thinking about the different providers along the pathways for patients, and how we can be more proactive with asking about this. It was clear from our study that if men are self-referring themselves, who knows how long they've had this issue where nobody was sending them to a specialist? They may have been screaming at the top of their lungs, "My erections are a problem!" Society is so focused on making sure your diabetes is controlled or your hypertension is controlled. Not that those aren’t important issues, but if we're going to capture men who typically don't present to the health care system in a timely fashion, this could be another avenue for us to treat even more men with those diseases. So, I think the first thing is just thinking about education amongst non-urologists, and even amongst some of our own urology colleagues, too. If it's not within your specialty, it may not be the first thing you ask about, but it really should be for any middle aged 40-plus man. It should be on our roster of questions so that we can ensure that we're addressing quality of life issues, as well as some other hidden big medical problems.

What is the take-home message for the practicing urologist?

The take-home is ED is alive and well out there in our patients, and I think we need to be asking about it. Even if it is not your cup of tea or area of interest, please ask your patients if they're being affected by this because it does unroof a lot of other medical issues that we may be ignoring or that the patient may not mention. So, figuring out a good, comfortable way to bring that conversation up will really pay dividends in other parts of the health care system. It will also allow more people to appropriately get funneled to urology to better address it.

Is there anything else you feel our audience should know about the findings?

We've now figured out that these are some of the gaps in care in terms of how patients are getting to the system, but now the next step is going to be figuring out how we better design our clinical care pathways so that everyone is getting to see a specialized urologist or getting into the system in an equitable way.

In terms of our findings, if we know that younger guys are a problem population in terms of getting them in for a check-up, maybe we need to be more aggressive about getting them in for a follow-up or getting them in sooner, so that we don't lose them to the system. When we think about different hospital settings as well, our men's center had a sub specialized urologist who was seeing all of this, and in a lot of other hospitals you either have a general urologists or other providers. So, I really think that it would be best to think about how all those different [providers] play into the system so that we can more effectively make sure that our patients are being seen, having things taken care of in a timely fashion and having ED addressed and escalated as needed.


1. Asafu-Adjei D, Santamaria A, Eleswarapu S, et al. Disparities in diagnosis and referral patterns for erectile dysfunction in outpatient settings: an analysis between academic and community based practices. Paper presented at: 2021 American Urological Association Annual Meeting; September 10-13, 2021; virtual. Abstract LBA01-10

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