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Choosing Wisely® is a cooperative initiative of the American Board of Internal Medicine, Consumer Reports®, and multiple medical specialty societies that advances a national dialogue on avoiding wasteful or unnecessary tests and/or treatments. In 2013, Choosing Wisely® and the American Urologic Association released an evidence based statement on cryptorchidism recommending that ultrasounds should not be performed for boys with cryptorchidism. In this study, we evaluate the hypothesis that rates of diagnostic imaging for cryptorchidism improved after the release of the Choosing Wisely® recommendation.
Materials & Methods:
All boys who had surgery for cryptorchidism at our institution between January 2005 and August 2015 by the Urology service were included. Demographics and clinical data were collected including height, weight, race, insurance, use of pre-referral imaging studies, location of testis at time of surgery, type of surgery performed, and ZIP code distance from our medical center. Pearson’s Chi-Squared test was utilized to evaluate use of ultrasound before and after the Choosing Wisely® recommendation. The influence of other clinical and socioeconomic factors on imaging utilization was also evaluated using Pearson’s Chi-Squared, logistic regression, and Mann-Whitney U test where appropriate.
Results
1,084 patients were identified. Median age at surgery was 4.12 years. 42% had private insurance, 52% were publicly insured, and 6% were uninsured. 237 (22%) patients had diagnostic imaging for cryptorchidism prior to referral. 232 patients underwent an ultrasound study and 5 patients underwent an axial imaging study (CT or MRI). There was increased utilization of pre-referral diagnostic imaging in patients with public insurance compared to private insurance (p = .037). Patients who underwent imaging where more likely to live in ZIP codes closer to the medical center (median 13.5 miles vs 16.3 miles, p = .03). Intra-abdominal testis location (p = .052) compared to inguinal, and BMI >50th percentile (p=.248) were associated with increased utilization of imaging but these trends did not meet statistical significance. Overall rates of diagnostic imaging utilization increased over time with considerable variability from year to year. Imaging rates actually increased in the time period after the release of the Choosing Wisely Recommendation (p = .032).
Conclusions
The Choosing Wisely® Campaign has not improved rates of inappropriate imaging use in boys with cryptorchidism in our referral area. Insurance status and proximity to the medical center have some association with imaging utilization. These patients continue to receive unnecessary imaging studies prior to referral despite our efforts and the release of the Choosing Wisely® recommendation. We call for increased efforts to spread the message to primary care providers about these evidence-based recommendations and promote more cost-effective and quality care of boys with cryptorchidism.