the menthe men’’s health centers health center
TRANSCRIPT
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The MenThe Men’’s Health Centers Health CenterComprehensive Compassionate CareComprehensive Compassionate CareCardiometabolic Urology: The Future?Cardiometabolic Urology: The Future?
Martin Miner MDMartin Miner MDCoCo--Director Director The MenThe Men’’s Health Centers Health CenterMiriam Hospital Miriam Hospital Warren Alpert School of MedicineWarren Alpert School of MedicineWarren Alpert School of MedicineWarren Alpert School of MedicineBrown UniversityBrown UniversityProvidence, RI USA Providence, RI USA
Disclosures
Research Funding: GSK; Auxilium
Consultancy: Auxilium T Registry;Merck
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Why is Men’s Health Critical?Rationale: THE EDUCATIONAL MISSION
The standard for most US family medicine residency programs is a one-month rotation encompassing:
• “Randomly-defined” exposure to various surgical subspecialty fields, which may or may not include urologyp y , y y gy
• Widely varying educational goals and objectives• NO DEFINED MEN’S HEALTH CURRICULUM
Medical students and medicine residents at Brown University have expressed educational concerns regarding:
• Lack of exposure to and training in comprehensive, multi-disciplinary men’s health (we see male patients, but…)
• Lack of adequate training in primary care (office non• Lack of adequate training in primary care (office, non-surgical) urology (Sexual health is the portal to men’s health…)
• Lack of adequate training in andrology (What’s this ?)
Project Description
The development of a men’s health curriculum is a novel concept aimed at improving theis a novel concept aimed at improving the knowledge base in various subject areas for medical students, family medicine, and internal medicine residents
Dedicated men’s health center co-led by primary care and urologyprimary care and urology
Each clinic session accommodates an average of 12-16 patients on a referral basis
Allows for re-direction to primary care emphasis
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Curriculum
The development of a men’s health curriculum to include primary care urology is novel and innovativeinnovative
The principal framework is driven by the ACGME competencies of medical knowledge:
• Patient-centered care
• Practice-based learning and improvement
• Systems-based practice
• Professionalism
• Inter-professional and communication skills
• Interdepartmental and Interspecialty Links
Multidisciplinary Outreach
Cardiology-Partnership in finding vul
Internal Medicine-TD; Male Bone Health; CMB*
MHC
Partnership in finding vul pt
Neurology-TD & Chr HA;
-ED & MS; Parkinsons
Health
Urology
Pulmonary Medicine-OSA & TD
-COPD & TD & ED
Gynecology
Psychiatry-TD &
Depression;
Sex Rx
Oncology-Chemo TD; Rad TD
-ED in all Onc popuiations
-TD; Bone Health; CVD eval
Of ED pts-FSD
*Cardiometabolic (CMB)
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Aims
Diagnose and treat male sexual dysfunction General sexual dysfunction
S l d f ti l t d t ifi Sexual dysfunction related to specific disease states
Evaluate cardiometabolic risks of men with sexual dysfunction Cardiovascular risk stratification Prevention strategies and lifestyle Prevention strategies and lifestyle
counseling The benefits and risks of male hormonal
replacement therapyPsychological Evaluation and Therapy
Establish the Miriam/Brown MHC as a national leader in the emerging field of sexual medicine and cardiometabolic health
• Research
–Outcomes based
Computerized database
–Industry and NIH support• Resident/trainee Education
–Psychology/Psychiatrysyc o ogy/ syc at y
–Urology
–Int Medicine/Family Medicine
–Medical Student
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Goals
Offer sexual health services to patient groups not currently served
• After MI or CAD intervention
• Conditions where disease or treatment affects sexual function
– Post Abdominal/Pelvic Surgical Penile Rehabilitation
– Non urologic cancer patients eg general l H d ki Di C l t l CAoncology: Hodgkins Disease; Colorectal CA
– Chronic disease statesMS, Parkinson’s, COPD, Obesity, DM, Depression
OSA and other sleep disorders
Goals
• Expand management breadth where services exist
– General male sexual dysfunctionsGeneral male sexual dysfunctions• ED• Premature Ejaculation• Testosterone deficiency• Links to Obesity Treatment, Nutrition
Education, & Reintroduction of Exercise
After prostate cancer therapy– After prostate cancer therapy• Penile rehabilitation• Urinary Incontinence Pelvic Floor
Strengthening/Conditioning PT Specialist
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Goals • Expand the evaluation to include underlying risks
associated with sexual dysfunction– Cardiovascular disease (CAD)
P t A t i l A i A ti Stiff C t l– Premature Arterial Aging: Aortic Stiffness Central Arterial Pressure; Pulse Wave Velocity
• SphygmoCor• EndoPat: measure Endothelial Function
– Metabolic syndrome (Individual components)– Diabetes Mellitus– Obesity– Dyslipidemia (Inc TG/ Dec HDL)– Psychological Evaluation for anxiety, depression,
relational disorders esp performance anxiety
MHC: Multidisciplinary Approach• Psychology
– John Wincze PhD• Elected Member/ Former President• International Academy of Sex Research Therapistsy f p
• Medicine– Martin Miner MD
• Fellow Sexual Medicine Society of North America• Fellow Am Academy of Family Practice
• Urology– Mark Sigman MD Nutrition– Kathleen Hwang MD -- Mary Flynn PhD
• Urology/Andrology• Male Pelvic Floor Therapy
-- Christy Cielsa PT
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MHC: Age Range of Patients
MHC: Current Referral Base
Referring Practices
40
60
80
100
120
140
160
180
Nu
mb
er o
f P
atie
nts
Ref
erre
d
60% Urology30% Int Med10% Other
0
20
Ob/
Gyn
Orth
oped
ics
Car
diol
ogy
Psyc
hiat
ryEn
docr
inol
ogy
Pulm
onar
y
Onc
olog
ySe
lf R
efer
ral
Inte
rnal
Med
icin
e
Uro
logy
Type of Practice
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Men’ s Health
Why is the relation between ED and CVD important?
The size of the problem
The number of men with ED will increase from152 million men in 1995 to 322 million men by 2025
North America 9.1 million
South/CentralAfrica
19 3 million
Europe 11.9 million
Asia 113 million
152 million men in 1995 to 322 million men by 2025
South/CentralAmerica andCaribbean
15.6 million
19.3 million
Oceania 0.9 million
Adapted from McKinlay JB. Int J Impot Res. 2000;12(suppl 4):S6-S11.
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ED is a remarkably common condition.
ED in a substantial majority of men is
The Prevalence of EDThe Prevalence of ED
majority of men is due to underlying vascular causes.
ED is highly Associations Between ED
and Various Comorbid StatesAssociations Between ED
and Various Comorbid States
n=2536, ED 18.5 %n=2536, ED 18.5 %
prevalent in men with vascular risk factors for CVD.
Christopher S Saigal, Hunter Wessells, Jennifer Pace, Matt Schonlau, Timothy J Wilt. Predictors and
prevalence of erectile dysfunction in a racially diverse population. Arch Intern Med. 2006;166:207-212 *
Christopher S Saigal, Hunter Wessells, Jennifer Pace, Matt Schonlau, Timothy J Wilt. Predictors and
prevalence of erectile dysfunction in a racially diverse population. Arch Intern Med. 2006;166:207-212 *
Prevalence of ED in Patients With CV Pathologic Conditions or RisksPrevalence of ED in Patients With CV Pathologic Conditions or Risks
Condition Condition Estimated Prevalence Estimated Prevalence
of ED, % of ED, % ReferencesReferences
Age >40 yAge >40 y 33–89 Bacon et al, Bai et al, Chew et al, Feldman et al, Moreira et al, Morillo et al, Safarinejad, Shiri et al
Type 2 diabetesType 2 diabetes 2020––8686 Alonso et al, Klein et al, McCulloch et al, Siu et al, Yamasaki et al
HypertensionHypertension 27–68 Burchardt et al, Cuellar et al, Jensen et al
CADCAD 42–75 Dhabuwala et al, Diokno et al, Kloner et al, Montorsi et al, Solomon et al, Wabrek et al
Heart failureHeart failure 75 Jaarsma et al
DepressionDepression 25–90 Araujo et al
ObesityObesity Increased prevalence Esposito and Giugliano, Esposito et al, Gunduz et al
HyperlipidemiaHyperlipidemia Increased prevalence Nikoobakht et al, Saltzman et al, Wei et al
SmokingSmoking Increased prevalence Gades et al, Mannino et al, Mirone et al
MedicationMedication Increased prevalence Derby et al
CAD, coronary artery disease; CV, cardiovascular; ED, erectile dysfunction.
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Risk Factors of ED
Traditional
• Age• High LDL• Low HDL
Underlying
• Obesity• Sedentary
lifestyle
Emerging
• Insulin resistance
• Metabolic • Hypertension• Diabetes• Smoking
• Artherogenicdiet
Syndrome
Cardiovascular DiseaseRisk Stratification in the Asymptomatic Patient The Framingham Score and National Cholesterol
Education Program Adult Treatment Panel are theEducation Program Adult Treatment Panel are the predominant methods of identifying levels of risk for CHD.
• Typically patients are stratified into 3 categories based on
10 - year risk:
– Low (less than 10%)
– Intermediate (10-20%)
– High (>20%)
• Calculations include: age, cholesterol level, HDL cholesterol, BP, smoking and diabetes
• None include ED
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Erectile Dysfunction and S b tErectile Dysfunction and S b t
Does ED Predict CVD in an Asymptomatic Male?Does ED serve as a Surrogate Measure in Preventative
Interventions for Cardiac Disease?
Subsequent Cardiovascular Disease
Thompson IM, Tangen CM, Goodman PJ, Probstfield JL
Subsequent Cardiovascular Disease
Thompson IM, Tangen CM, Goodman PJ, Probstfield JLJL, Moinpour CM, Coltman CA. JAMA. 2005;294:2996-3002.JL, Moinpour CM, Coltman CA. JAMA. 2005;294:2996-3002.
Study Population/Design Highlights
9,457 men age 55+ randomized to placebo in Prostate Cancer Prevention Trial (PCPT)Prostate Cancer Prevention Trial (PCPT)
• 8,063 (85%) men with no CVD at study entry
• 3,816 (47%) with prevalent ED, 2,420 (57%) reported incident ED after 5 y
Followed for 7 years for development of CVD255 CVD t• 255 CVD events
Thompson et al. JAMA 2005;294:2996-3002
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ED and Subsequent Cardiovascular Events Incident ED significantly
increased the risk of myocardial infarction or angina. C i t
HR( 4247)
PV l
g
2% had CV event 1 year after incident ED.
11% had CV event by 5 years after incident ED.
ED may be considered a
SmokingSmoking 1.461.46 .02.02
Family hx Family hx MIMI
1.461.46 .001.001
DiabetesDiabetes 2.342.34 <.001<.001
Covariates
(n=4247) Value
ED may be considered a harbinger of CV events in some men with an associated risk similar to current smoking, or family history of MI.
Thompson I. JAMA. 294(23):2996-3002, 2005.
DiabetesDiabetes 2.342.34 .001.001
AntiAnti--HTN RxHTN Rx 1.741.74 <.001<.001
Incident EDIncident ED 1.461.46 <.001<.001
A Population-Based,
What about the implications of ED in a broad populationWithout diabetes and CAD?
A Population Based, Longitudinal Study of Erectile Dysfunction and Future Coronary Artery Disease
Inman B, St. Sauver J, Jacobson D, McGree M, Nehra A, Jacobsen S. Mayo Clinic Proceedings; Feb. 2009
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Incidence of Coronary Artery Disease with Respect to Age and ED Status
Overall new incident CAD developed in 156 /1402 (11%) of men, followed from 1996-2005.
14 7% MI60
ars
• 14.7% MI
• 78.8% angiographic
• 6.4% sudden death
Association between ED and incident CAD declined with increasing age.
ED presence in men > 70 years old was of no prognostic10
20
30
40
50
EDNo ED
e p
er 1
000
per
son
-yea
old was of no prognostic significance.
Men with ED at age 40 had an 80% higher risk for subsequent CAD over 9 years.
0
10
40 - 49 50 - 59 60 - 69 > 70
Inci
den
ce
Inman B. Mayo Clinic Proc Inman B. Mayo Clinic Proc 2009;84(2):1082009;84(2):108--113.113.
*
Can we use ED as a means of detecting cardiovascularof detecting cardiovascular disease?
Can we use ED as a means of preventing
cardiovascular disease?
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Time interval between ED onset and CADED Prevalence and Time of Onset in 300
Consecutive Men With Acute Chest Pain and CAD
InIn 67% 67% of 300 pts, symptoms of ED had started before the of 300 pts, symptoms of ED had started before the symptoms of CAD (mean 39 months)symptoms of CAD (mean 39 months) –– retrospectiveretrospectivesymptoms of CAD (mean 39 months) symptoms of CAD (mean 39 months) retrospective retrospective
studystudy
Mean age, 62.5 y ED prevalence, 49% (147/300)Mean age, 62.5 y ED prevalence, 49% (147/300)MontorsiMontorsi F, et alF, et al.. EurEur UrolUrol 20032003
I l t ll ti t ED60
80
100
, m
o
Ptrend=.016
MontorsiMontorsi P, et al. P, et al. EurEur Heart J 2006Heart J 2006
In almost all patients, ED onset on average2-5 y before CAD
1-VD 2-VD 3-VD0
20
40
Inte
rval
Clinical spectrum of coronary artery disease
CVDsCVDs2-5 years2-5 years
*
EDED
DeBusk, Erectile Dysfunction Therapy in Special Populations and Applications: Coronary Artery Disease. Am J Cardiol 2005;96: 62M–66M
DeBusk, Erectile Dysfunction Therapy in Special Populations and Applications: Coronary Artery Disease. Am J Cardiol 2005;96: 62M–66M
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The Endothelium: A Living Organ
SmoothSmoothmusclemuscle
Arteriolelumen
Endothelium
ED May Be a Sign of Endothelial Damage: Part 1
Cigarette smoking1
Poor lifestyle choices increase oxidative stress in endothelial cells, causing early injury1
High-fatmeals1
g gObesity1
Psychological stress2
Sedentarybehavior1
ImpairedImpairedImpairedImpaired
OxidativeOxidativestressstress
NO=nitric oxide.
1. Jackson G. Int J Clin Pract. 2004;58:431. 2. Hornstein C. Vertex. 2004;15(suppl):21-31. 3. Maas R et al. Vasc Med. 2002;7:213-225.
Endothelial cellEndothelial cell
Impaired Impaired NO NO
productionproduction33
Endothelial cellEndothelial cell
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ED May Be a Sign of Endothelial Damage: Part 2
Anxiety/
ED may occur with the early endothelial cell damage before other serious diseases are manifest1-3
Anxiety/ Depression4
Early endothelial damageEarly endothelial damageVascular damageVascular damage
Endothelial cell:Endothelial cell:Early endothelial damageEarly endothelial damage
Vascular damageVascular damage8,118,11
Hyperlipidemia5-7
ED3,8
Visceral Obesity 10,11 7 Diabetes5,6,9
Atherosclerotic changesAtherosclerotic changes
1. Billups KL. Curr Sexual Health Rep. 2004;1:137-141. 2. Montorsi P et al. Eur Urol. 2003;352-354. 3. Kaiser DR et al. J Am Coll Cardiol. 2004;43:179-184. 4. Broadley AJM et al. Heart. 2002;88:521-524. 5. Maas R et al. Vasc Med. 2002;7:213-225. 6. Solomon H et al. Heart.
2003;89:251-254. 7. Hurairah H, Ferro A. Int J Clin Pract. 2004;58:173-183. 8. Bocchio M et al. J Urol. 2004;171:1601-1604. 9. DeAngelis L et al. Diabetologia. 2001;44:1155-1160. 10. Jackson G. Int J Clin Pract. 2004;58:431. 11. Deedwania PC. J Am Coll Cardiol. 2000;35:67-70.
Atherosclerotic changesAtherosclerotic changes
Early endothelial dysfunction may lead to atherosclerosis and vascular remodeling10,11
Early endothelial dysfunction may lead to atherosclerosis and vascular remodeling10,11
ED and Probability of Future CADED and Probability of Future CAD
18
16
14
12
10
8
6
10
-Ye
ar
CH
D r
isk
, %(M
ea
n, 9
5%
Cl)
CAD, coronary artery disease; CHD, coronary heart disease; CI, confidence interval; ED, erectile dysfunction; IIEF, International Index of Erectile Function; IIEF5, International Index of Erectile Function-5 questionnaire.
Reproduced with permission from Ponholzer A et al. Eur Urol. 2005;48(3):512-518.
Severe EDIIEF: 5-7
n=56
6
Moderate EDIIEF: 8-16
n=94
Mild EDIIEF: 17-21
n=495
No EDIIEF: 22-25
n=1213
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Why ED occurs before other vascular diseases?
The small diameter of theEarly Late
PenileThe small diameter of the cavernosal arteries.
The penis is a vascular organ, sensitive to changes in oxidative stress and NO levels.
The high content of endothelium and smooth muscle on a per
ED
angina/infarction
Stroke
Penile1-2 mm
Coronary3-4 mm
Carotid5-7 mm
**
and smooth muscle on a per gram tissue basis (compared to other organs).
Claudication
Femoral6-8 mm
Montorsi et al. The Artery Size Hypothesis: A Macrovascular Link Between Erectile Dysfunction and
Coronary Artery Disease. Curr Opin Urol. Am J Cardiol 2005;96:19M–
23M.
Montorsi et al. The Artery Size Hypothesis: A Macrovascular Link Between Erectile Dysfunction and
Coronary Artery Disease. Curr Opin Urol. Am J Cardiol 2005;96:19M–
23M.
Atherosclerosis in Coronary Vessels
Atherosclerosis in Penile Arteries
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Conclusions ED and CHD frequently coexist, especially in
ld (> 70)older men (> 70)
ED may occur in the absence of coronary symptoms ie. ED precedes coronary ishemia perhaps even more so in younger men (<60)
ED may precede a CAD event by years (ave 2-5)
Aggressive CVD risk reduction should be considered for all men with organic ED and no cardiac symptoms
Conclusion
“These data could serve as a basis for preventing life‐threatening events by risk factor management and lifestyle modification in men with ED”
Ponholzer A et al Eur Urol2005;48:512-8
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Testosterone Therapy: Where Have We BeenWhere Have We Been,Where Are We Going?
0
Survival of Treated Versus Untreated Testosterone-Deficient Men in VA Population
• 1031 Men aged > 40 yrs, Testosterone < 250 ng/dL • Mortality: 10.3% treated, 20.7% untreated (p<0.0001)
urv
ival
by
Test
ost
ero
ne
Trea
tmen
t, %
Log rank P=.029
1.00
0.90
Untreated
VA, US Department of Veterans Affairs.
Shores MM et al. J Clin Endocrinol Metab. 2012 Apr 11 [Epub ahead of print].
Su
0.80
0 12 24 36 48Time Since Testosterone Test Date, mo
1016 639 557 496 19315 301 321 323 146
UntreatedTreated
At risk, n
Treated
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TRT Improves Survival in Men With T2DM
• Six year follow up study• Six year follow-up study• N=587
• Effect of baseline T and TRT on all-cause
mortality in hypogonadal men with
T2DMT2DM• Low T predicts
increased mortality by hazard ratio of ~2.0
(20% vs 10%)Muraleedharan V, Jones H et al. Early Online 2012 Diabetes Care
TRT Improves Survival in Men with T2DM-results Mortality rate was significantly higher in patients with low
TT without TRT compared to patients with normal TTp p
Low TT patients with TRT had lower mortality rate
510152025
ort
alit
y R
ate p=0.001
p=0.049
0
Muraleedharan V, Jones H et al. Diabetes Care 2012
Normal TT (>10.4 nmol/L)(300 ng/dL) (31/338)Low TT (≤10.4 nmol/L) without TRT(36/182)Low TT receiving TRT for ≥2 y (5/58)
Mo
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Testosterone Therapy Effects on Diabetes TIMES2 Study
• A 12-month, multicenter, prospective, randomized, double-blind, placebo-controlled study
Study Design
• 220 hypogonadal men with T2DM and MetSPopulation
• Significantly improved:• Insulin resistance in all patients by 15.2% at 6
months; 16.4% at 12 months• HDL -0.049 mmol/L and LDL cholesterol -0.210
mmol/L, lipoprotein a -0.31 mmol/L in selected groups
• Erectile Function increase of 4.8 on IIEF-5
Results
Jones TH et al. Diabetes Care. 2011;34(4):828-837.
Testosterone Therapy
In late 1980s, rarely used and almost not at all in urologyin urology
Reserved for men with unequivocal or severe testosterone deficiencies
• Absent testes
• Pituitary/hypothalamic tumors or resection
• Genetic abnormalities, eg, Klinefelter syndrome
Not recognized as useful in otherwise healthy men with sexual or other symptoms
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Current Status of Testosterone Therapy
Growing awareness of benefits for men who are symptomatic and testosterone deficientsymptomatic and testosterone-deficient
• ED
• Diminished libido
• Chronic fatigue
• Poor bone mineral density
• Decreased sense of vitality and well-being
Ongoing debate about usefulness for mid-life blues or male menopause
ED, erectile dysfunction.
Conclusions
A relationship exists between TD and MetS d it i di id l t i il and its individual components; similar cross-
sectional studies have demonstrated an association between TD and T2DM
Prospective studies have demonstrated that a low T at baseline can predict the development of T2DM
Visceral adiposity induces hypogonadotrophic hypogonadism
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Conclusions
TRT appears to improve insulin sensitivity and potentially glycemic control in TD men with T2DMpotentially glycemic control in TD men with T2DM
Men with erectile dysfunction, diminished desire, impaired orgasmic function, and metabolic diseases including MetS and T2DM should be screened for TD and treated with TRT
The issue of TRT in preventing CVD needs further study.
New Topics of T Repletion:
Emerging data that testosterone therapy may no longer be contraindicated for men with localized prostate cancer
Testosterone therapy may provide benefits for voiding despite conventional belief that higher testosterone levels cause BPH growth
T and Bone Health in Men
Testosterone may improve insulin resistance, ameliorate early type 2 DM, improve CVD and all cause mortalityy yp , p y
Provocative, no consensus
Will be fascinating to see what we learn in next 5-10 years
BPH, benign prostatic hyperplasia.
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The Future
Testosterone therapy for general health and longevity?and longevity?
Several publications showing associations between low testosterone and atherosclerosis, risk of diabetes and metabolic syndrome, and increased mortality
Ca sal relationship ers s mere association? Causal relationship versus mere association?
Barriers to Success of Men’s Health Center Unclear boundaries and newly recognized fears regarding
cardiometabolic risk screening crossing specialties and increasing costs (PCP vs ED spec; Inc $ testing)
Ensure receptivity and lack of threat to referring providers Ensure receptivity and lack of threat to referring providers-Refer back to PCP with faxed evaluation and non-threatening evidence-based recommendations
Must “vette” cardiometabolic workup with local and national preventative cardiologists: the workup must be evidence-based, cost-effective, and individualized to each patient
Establishing a computerized data base from the start E i b h i d d i id ll Engaging both community and academic providers as well as
allowing self-referral Ensure timely access Ensure cross-specialty patient discussions at weekly meeting
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What is the offer to our patients?
• A relevant issue: the value of a holistic approachto their health including sexual medicineto their health including sexual medicine
• It is 180* different from sports-page penileinjection clinic (Boston Medical)
• It is a coherent message: everything is linkedand all should be taken into account
• Patients are investing in quality of lifeg q y• One-stop Shopping: Links to Exercise; Diet;
Preventative Medicine
Who are our patients-clients?Why a Men’s Health Center?
Men above 35 y.oy
Worried about their health
Want to improve their global performance
Want to prevent age-related problems
Want to be active and healthy
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Future Long-term Goals of Men’s Health Center:
Incorporate Female Sexual Dysfunction and Partners for therapy beyond couplesPartners for therapy beyond couples counseling
Develop referral algorithms/links for other specialties: oncology; cardiology; pulmonary (COPD & OSA)
Establish the service of Male Bone Health Establish the service of Male Bone Health
Publish outcomes research