BACKGROUND: Circumcision is the most common pediatric surgery performed in the United States (US) with >50% of infant boys undergoing newborn circumcision (NC). While NCs are most often performed by obstetricians and pediatricians, the proportion performed by other clinicians, such as pediatric urologists and advanced practice providers, has been growing. Quantifying NC complication and revision rates is challenging due to the rarity of such events and lack of an appropriate pediatric longitudinal database. Thus, this study investigated recent trends in NC complications and subsequent secondary procedures utilizing longitudinal commercial health insurance claims data. METHODS: The MerativeTM MarketScan® Commercial Database was queried for claims between 2010 and 2022. Current Procedural Terminology (CPT®) code 54150 identified NCs. Neonates with an age greater than 365 days and claims with multiple specialties or a concurrent CPT® code of 54160 or 54161 were excluded.Covariates included NC clinician specialty, US Census Bureau region, and insurance plan type. Thirty-day complications included anatomical abnormality, bleeding, infection, trauma/injury, wound, or other complications. Secondary procedures included lysis/excision of adhesions (CPT® 54162), circumcision revision (54163), frenulotomy (54164), penoplasty (54300), and foreskin manipulation (54450). Multivariable logistic regressions adjusted for age at NC, region, insurance plan type, and year. RESULTS: A total of 976976, 441498, and 155838 neonates had continuous insurance coverage after NC for thirty days, two years, and five years, respectively. Most NCs occurred in the inpatient setting (58.4%-62.6%), the South (40.5%-44.4%), urban settings (82.7%-87.4%), and were performed by obstetricians (44.5%-48.0%) or pediatricians (32.7%-32.9%). Most held fee for service insurance (68.2%-69.7%).A total of 9336 (0.96%) patients had a thirty-day complication, with infection being the most common complication (0.47%). 11461 (2.60%) and 5053 (3.24%) patients underwent a secondary procedure at two and five years, respectively, with foreskin manipulation being the most common procedure. Two- and five-year circumcision revision rates were 0.68% and 0.92%, respectively, and revision consistently comprised one-fourth of all secondary procedures (Figure). The figure also illustrates the downward trend in two- and five-year rates of all secondary procedures (p=0.003 and p=0.014, respectively).Compared to NCs performed by obstetricians, the odds of a circumcision revision within two years were lower for NCs performed by pediatricians (OR 0.46 [0.42-0.51]), urologists (OR 0.29 [0.19-0.44]), pediatric urologists (OR 0.38 [0.22-0.66]), pediatric surgeons (OR 0.60 [0.36-0.98]), and other clinicians (OR 0.59 [0.52-0.66]). These findings were similar at five years. NCs in the West compared to the Northeast were also associated with lower odds of revision at two (OR 0.64 [0.54-0.75]) and five (OR 0.73 [0.58-0.92]) years.
CONCLUSIONS: Less than 1% of patients have a thirty-day NC complication, and the rate of secondary procedures following NC is falling. Circumcision revisions comprise one-fourth of all secondary procedures and the rate has not changed over time.
