Assessment of Surgical Access among Patients with Undescended Testes in a Universal Healthcare System.
Elaine J. Redmond, MD, Andrew E. MacNeily, MD, Kourosh Afshar, MD, Soojin Kim, MD.
BC Children's Hospital, Vancouver, BC, Canada.
BACKGROUND: One of the key goals of a universal healthcare system is to achieve equity of access. However, even in the setting of free universal care, systemic factors may persist which can prevent timely access to care. Undescended testes (UDT) is an ideal condition to investigate healthcare inequity among pediatric urology patients because it is screened at birth and its occurrence appears to be unaffected by socioeconomic status. Left untreated, UDT is associated with an increased risk of testicular cancer and potential fertility complications. American Urological Association and European Association of Urology guidelines recommend surgical intervention before 18 months of age. The aim of our study was to evaluate access to surgery among patients with UDT in Canada.METHODS: The prospectively maintained Canadian Institute of Health Information (CIHI) database was analysed for all patients in Canada (excluding Quebec) with a diagnosis of UDT who underwent orchidopexy or orchiectomy from March 2010-March 2019. Patients with premature birth, congenital anomalies, retractile testis, re-do orchidopexy, testicular pain, torsion or tumour were excluded. Variables collected included age, type of treating institution, type of surgeon, institutional case volume, year of surgery, province, and distance from hospital. Statistical analysis was performed to assess the association between age at UDT surgery and recorded covariates. The primary outcome was surgery before 18 months of age.
RESULTS: There were 19,385 surgeries for UDT performed during the study period. A total of 78.8% of cases were performed in academic hospitals (n=15,284), and 62% were performed in a designated pediatric hospital (n=12,012). There was a large variation in the annual volume of UDT surgery between institutions (median 135 cases/year (range:1-632)). Overall, 27.1% of patients had surgery before 18 months of age (n=5,261). The proportion of cases preformed at <18 months varied significantly by province (0-33.3%, p=<0.001). Hospitals with a UDT volume in the lowest (4th) quartile (<46cases/year) were significantly less likely to perform surgery at <18 months compared to institutions in the 1-3rd quartiles (>46cases/year) (15.2% vs 31.1%, p=<0.001). Designated pediatric hospitals and academic institutions were more likely to perform orchidopexy prior to 18months than non-pediatric and non-academic institutions. (30.5% vs 21.7%, p=<0.001 and 30.6% vs 14.1% p=<0.001). Pediatric surgeons were significantly more likely to adhere to UDT age recommendations than pediatric urologists, urologists and general surgeons (39.5% vs 28.1%, 19.2% and 27.2% respectively, p=<0.001). Distance from treating institution and year of surgery did not influence age at UDT surgery (p=0.9 and p=0.66 respectively).
CONCLUSIONS: Less than 30% of UDT surgeries were performed before 18 months of age in Canada. Higher volume institutions, children’s hospitals and teaching hospitals were more likely to perform surgery within the recommended timeline. Centralising referrals to such institutions may help to improve national adherence to treatment guidelines. Despite free universal healthcare in Canada, our findings suggest there are systemic barriers to timely surgical care among pediatric urology patients. Further evaluation of local diagnosis-referral-treatment pathways are required to elucidate the reasons for this.
Back to 2021 Abstracts