Compliance of Current Orchiopexy Guidelines Over Time
David Weatherly, MD, Benjamin Whittam, MD, Rosalia Misseri, MD, Martin Kaefer, MD, Richard Rink, MD, Mark Cain, MD, William Bennett, Jr., MD.
Indiana University, Indianapolis, IN, USA.
BACKGROUND: Undescended testicle is a common congenital anomaly present in 3-5% of full-term male infants, but a majority will descend by 6 months of age. Current AUA guidelines recommend performing orchiopexy between 6 and 18 months of age. Previous work analyzing large- scale administrative data has demonstrated overall poor utilization of the guidelines, with a minority of patients receiving the operation in this window. We hypothesized that there would be an improvement in the proportion of patients undergoing orchiopexy during the recommended time interval over time.
METHODS: We used the Pediatric Health Information System to analyze all orchiopexy operations from 2004 through 2014. Patients were excluded if they were diagnosed with retractile testes or had torsion, or if they had other urological procedures at the time of operation, as described previously by Nelson, et al. We built a mixed effects regression model with hospital and physician as random effects and ethnicity, race, and insurance status as fixed effects.
RESULTS: 64,924 patients met our search criteria. The overall mean age at orchiopexy was 4.7 years and the median was 3.3 years. Interestingly, the median age at orchiopexy has consistently increased over the past 11 years, beginning at 2.69 years in 2004 and rising to 3.76 years in 2014. The proportion of patients who had orchiopexy performed between the optimal age range of 6 months and 18 months declined: from 38.3% in 2004 to 33.4% in 2014. Inter-hospital variation was high, and did not change over time. After analysis with a mixed effects regression model, we found that patients of African American race (OR 0.81, p < 0.001) and Hispanic ethnicity (OR 0.84, p <0.001) were less likely to receive orchiopexy in the appropriate window. Insurance status did not appear to impact optimal timing of the operation. We also plotted the age distribution by year. Most of the change in distribution occurred with an increased proportion of patients aged 2-10 years. As such, we did not think a change in referral patterns (such as increased referral of teenaged patients in lieu of adult urologists) affected our results.
CONCLUSIONS: Despite new guidelines and multiple publications calling attention to both low utilization and implementation of the guideline and racial/ethnic disparities, not only is there no improvement; the average age has actually been increasing over time at large American children's hospitals. Racial and ethnic disparity remains high, with patients of color less likely to receive optimal care. This is an example for increased need for primary care education regarding timing of referral for patients with urologic disease.
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