Racial and ethnic disparities in timing of pediatric urology procedures
Jennifer J. Ahn, MD, MS1, Michelle M. Garrison, PhD2, Adam B. Goldin, MD, MPH1, Paul A. Merguerian, MD, MS1, Margarett Shnorhavorian, MD, MPH1.
1Seattle Children's Hospital, Seattle, WA, USA, 2University of Washington, Seattle, WA, USA.
BACKGROUND: Health disparities exist across the continuum of care in the United States and there is growing evidence suggesting inequities in surgical care particularly with respect to race and ethnicity. Timing of surgery is important in pediatric urology, and there are recommendations for early repair of cryptorchidism and hypospadias. Timing may also be important for conditions like urinary incontinence, which impact quality of life. In this study, we sought to evaluate the association of race and ethnicity with age at surgery for cryptorchidism, hypospadias, and urinary incontinence. We hypothesized that non-Hispanic black and Hispanic patients undergo surgery at later ages than non-Hispanic white patients.
METHODS: The NSQIP-Pediatric Participant Use Data Files from 2012-2016 were queried to identify all individuals undergoing orchiopexy (CPT 54640, 54650, 54692), hypospadias repair (54322, 54324, 54326, 54328, 54332, 54336), and continence procedures including catheterizable channel, bladder neck procedures, bladder augmentation, and continent diversion (51800, 51840, 51845, 51990, 51992, 50845, 50825). Those with malignancy were excluded as the presence of cancer could influence timing of surgery. Individuals undergoing concurrent procedures with greater morbidity were also excluded to restrict the cohort to those primarily undergoing the above procedures of interest. Primary outcome of interest was age at time of surgery, and the primary exposure of interest was race/ethnicity. Secondary outcome was likelihood of undergoing orchiopexy and hypospadias by 18 months of age. Additional exposures of interest were BMI, sex, surgical risk score, spina bifida, and developmental delay. Generalized linear models (GLM) were created using the modified Park test and link test for the primary outcome. Logistic regression models were created for the secondary outcome. All analyses were performed using Stata 14.
RESULTS: A total of 4230 orchiopexies were performed at a mean age of 3.0 years (SD 3.4), with 2178 (51%) undergoing orchiopexy by 18 months of age. On adjusted analyses, Hispanic and non-Hispanic black race/ethnicity were associated with older age at surgery, compared with non-Hispanic white, by 0.4 and 0.6 years, respectively (Table 1). Likelihood of orchiopexy by 18 months was significantly lower in these groups, as well as American Indian and Alaska Natives, and those with developmental delay. A total of 10,954 primary hypospadias repairs were captured, 90% of which were distal. Similar delays were seen, with non-Hispanic whites undergoing earlier repairs by at least 6 months (Table 1). Urinary continence surgery was performed in 1322 individuals at a mean age of 9.5 years (SD 4.0). There was no association of race/ethnicity with age at surgery on bivariate and multivariate analyses.
CONCLUSIONS: Race and ethnicity were associated with age at time of orchiopexy and hypospadias repair, but not with continence surgery. Non-Hispanic whites were most likely to undergo surgery in accordance with current recommendations. Future studies will investigate the factors contributing to these concerning disparities.
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