Relationship between socioeconomic disparities and hypospadias repair: outcome analysis
Vinaya Pavithra Bhatia, MD1, Shannon Cannon, MD1, Aimee Teo Broman, MA1, Christina Kim, MD, FAAP2, Ruthie Su, MD, MS1, Walid Farhat, MD, FRCSC, FACS1.
1University of Wisconsin, Madison, WI, USA, 2Connecticut Children's Medical Center, Hartford, CT, USA.
Background: Timing of hypospadias repair is often recommended prior to 18 months of age to allow recovery in a period of decreased genital awareness. Though several studies have examined the epidemiology, natural history, and surgical outcomes of hypospadias (HS), few have examined the effect of racial, ethnic, and socioeconomic disparities on care delivery and surgical outcome. We hypothesized that patients from an area of higher socioeconomic disadvantage (SED) would experience a higher rate of post-operative complications.
Methods: We performed a retrospective chart review of all patients who underwent any hypospadias repair performed from 2017-2021 at a single large tertiary care referral center. We excluded any patients who had prior HS surgery at an outside institution. We collected demographic data, surgical data, and the area deprivation index (ADI), a validated measure of SED on a state and national level. A state decile of greater than 5 and a national centile of greater than 50 were defined as a higher level of SED according to previously published values. Outcomes of interest included number of complications, age at initial surgery, and loss to follow-up following initial surgery, if any. Loss to follow-up was defined as a patient not following up within 3 months of the surgeon's suggested follow-up time point. Demographic data were recorded. Socioeconomic variables such as parental employment, English as a primary language, developmental delay, and physical disability had a large proportion of missing values and were excluded from our analysis.
We measured the association of low ADI (state and national level), race, ethnicity, and insurance type on the outcomes of interest through cross-tabulation and Chi-square or Fisher's exact tests. We used Hochberg (1988) adjustment to correct the p-value for the multiple tests performed per outcome.
Results: There were 116 patients seen for primary hypospadias repair. Age at first surgery ranged from 0.5 to 13.4 years, median age = 1.02, IQR= [0.77, 1.34] years. Contrary to our original hypothesis, SED, minority race, and minority ethnicity were not associated with a higher complication rate (Table 1), a delay in receiving surgical care, or loss to follow-up. However, when examining insurance type, public insurance or self-pay were more likely to have at least one complication following surgery (p-value=0.019, adjusted p-value 0.11).
Conclusions: In our cohort, SED was not associated with a higher rate of complications as hypothesized. However, insurance status may be associated with a higher risk of post-operative complications. Insurance status is known to be associated with several potential concerns that could increase the risk of post-operative complications, including health literacy and poor access to care. These findings merit careful consideration in large, multi-center datasets, which will allow us to validate the clinical significance of our findings and examine the effects of disadvantage more critically on care delivery and outcomes in hypospadias.
Table 1. Association between Any Complication (Yes/No) and Potential Disadvantage
| No | Yes | P-Value | P-Adjusted | ||
| Age Categories (years) | (0.5 - 1] | 43 (46.7%) | 12 (52.2%) | 0.66 | 1 |
| (1 - 1.5] | 33 (35.9%) | 6 (26.1%) | |||
| (1.5 - 14] | 16 (17.4%) | 5 (21.7%) | |||
| White Race | No | 8 (8.8%) | 2 (8.7%) | 1 | 1 |
| Yes | 83 (91.2%) | 21 (91.3%) | |||
| Hispanic Ethnicity | Yes | 10 (10.8%) | 3 (13%) | 0.72 | 1 |
| No | 83 (89.2%) | 20 (87%) | |||
| ADI State Decile > 5? | No | 56 (60.2%) | 15 (65.2%) | 0.84 | 1 |
| Yes | 37 (39.8%) | 8 (34.8%) | |||
| ADI National Centile > 50? | No | 42 (45.2%) | 8 (34.8%) | 0.51 | 1 |
| Yes | 51 (54.8%) | 15 (65.2%) | |||
| Insurance | Private | 82 (88.2%) | 15 (65.2%) | 0.019 | 0.11 |
| Public/None | 11 (11.8%) | 8 (34.8%) |
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