A THIN database study: What are the effects of the Quality and Outcomes Framework (QOF) on assessment, diagnoses and management of erectile dysfunction and testosterone deficiency in patients with Type 2 Diabetes Mellitus in primary care?

Problem

Erectile dysfunction (ED) and testosterone deficiency (TD) are common and interlinked complications of Type 2 Diabetes Mellitus (T2DM), and independent predictors of cardiovascular disease. International guidelines recommend that men with T2DM are assessed and treated for ED and TD, which was included into the Quality and Outcomes Framework (QOF) from 2013–2014 only. We aimed to explore the effects of QOF on ED and TD diagnoses and management in patients with T2DM.

Approach

The study population included males (≥18 years) with T2DM and contributing to UK GP electronic health records from 1999–2016. Adjusted incidence rate ratios (IRRs) were estimated using multivariate Poisson regression.

Findings

In total 110 423 adult males (mean age 60 years) with T2DM were included. During follow-up, 53 003 (48%) had a recorded ED assessment, 14 355 (13%) an ED diagnosis and of these 74% had received at least one phosophodiesterase-5 inhibitor (PDE5i) prescription. ED assessments increased from 7.7 per 1000 PYAR in 2012 (95% confidence interval [CI] = 7.0 to 8.4) to 610 in 2013 (95% CI = 604 to 617) when included into QOF but dropped to 59.4 (95% CI = 56 to 63) in 2016. Compared with 2012, the adjusted incidence of recorded ED diagnoses and PDE5i prescriptions doubled in 2013 (incidence rate ratio [IRR] 2.0; 95% CI = 1.8 to 2.1) before falling to below pre-QOF levels in 2016 (IRR 0.89; 95% CI = 0.82 to 0.97). Of 1187 diabetic men diagnosed with ED or receiving a PDE5i in 2015, 213 (18%) had a minimum of one testosterone measurement, of which 45 (21%) met biochemical criteria for hypogonadism typically requiring treatment (testosterone ≤ 8nmol/l). Nine (20%) subsequently received testosterone replacement therapy (TRT). The multiple regression analysis showed a significant effect of age on ED assessment, diagnosis and PDE5i prescriptions (p < 0.001) with most assessments, diagnoses and PDE5is prescriptions completed in the 55-60y old age group. There was no effect of Townsend scores (deprivation index).

Consequences

In order to improve diagnosis and management of ED and TD in T2DM patients and thereby (cardiovascular and metabolic) health and quality of life, incorporation of guidelines into a GP framework and/or financial incentives may be required alongside solid GP education.