Background: Studies suggest that surgical care in high-volume settings may improve outcomes. For rare conditions, such as cloacal anomalies, then number of such programs in the U.S. is inherently limited. Although some families travel for care in high-volume programs, families facing socioeconomic constraints may experience barriers to seeking care at these high-volume locations. We aimed to identify any socioeconomic factors associated with undergoing primary cloacal repair at a high-volume institution (≥20 cloacal repairs / 10 years).
Methods: Using the Pediatric Health Information SystemŽ (PHIS), we identified patients who underwent primary cloacal repair between 2012-2022 using ICD9/10 procedure and diagnosis codes. Age was restricted to <3 years to solely capture initial repair. We verified and refined our abstraction method by cross-referencing PHIS-identified cases with cases performed at our institution. The outcome of interest was whether primary cloacal repair occurred at a high-volume (>20 repairs / 10 years) or low volume institution (<20 repairs / 10 years). The exposures were race (non-Hispanic White vs. all other categories), insurance (public vs. private / commercial), income (>50th percentile household income vs. <50th percentile), and childhood opportunity index (favorable vs. unfavorable; COI). COI is a composite measure of 23 neighborhood variables reflecting social determinants of health. Descriptive statistics, univariable, and multivariable logistic regression were performed while adjusting for clustering. Results: Between 2012-2022, 228 patients underwent primary cloacal repair (120 at low-volume institutions, 108 at high-volume institutions). Most patients were non-Hispanic White (53%), privately insured (52%), with a median income of $35,000-70,000 (57%) and had a favorable childhood opportunity index (63%). A larger proportion of non-Hispanic White, privately insured, and higher income patients were treated at high-volume institutions (Table 1). Unadjusted logistic regression demonstrated increased likelihood of care at a high-volume center for non-Hispanic White patients with private insurance and income >50th percentile (table 1). After adjusted analysis, only income was independently associated with repair at a high-volume institution (5.2 [2.0-13.5], p < 0.001; table 1). Conclusions: A larger proportion of White non-Hispanic, privately insured, and higher income patients received primary cloacal repair at a high-volume institution. After adjusted analysis, income was the main driver of this difference and conferred 5-fold increased odds of receiving care in a high-volume institution. If we believe centers of care improve outcomes for rare conditions, our findings indicate an imperative to address income-based inequities through advocacy and policy work. Key Words: Primary Cloacal repair; Congenital Cloaca; Genital Function
| Table 1. Descriptive statistics, unadjusted and adjusted regression analysis for receipt of primary cloaca repair at a high-volume institution between 2012-2022. | |||
| Low volumeN=120 (%) | High volumeN=108 (%) | P value | |
| White Non-Hispanic | 55 (46) | 65 (60) | 0.006 |
| Non-White, Any ethnicity | 18 (15) | 10 (9.3) | |
| Private or commercial insurance | 55 (47.0) | 64 (66.0) | 0.005 |
| Public | 62 (53) | 33 (34) | |
| Income > 50th percentile | 6 (5) | 20 (21) | 0.001 |
| Income < 50th percentile | 111 (95) | 77 (79) | |
| Unfavorable COI | 45 (37) | 31 (31) | 0.338 |
| Favorable COI | 75 (63) | 68 (69) | |
| OR (95% CI) | P value | ||
| Non-White, Any ethnicity | 0.56 (0.33-0.95) | 0.031 | |
| Private or commercial insurance | 2.19 (1.26-3.84 | 0.006 | |
| Income > 50th percentile | 4.81 (1.95-13.64) | 0.001 | |
| Unfavorable COI | 0.76 (0.43-1.33) | 0.339 | |
| aOR (95% CI) | |||
| Non-White, Any ethnicity | 0.61 (0.34-1.11) | 0.106 | |
| Private or commercial insurance | 1.57 (0.79-3.13) | 0.191 | |
| Income > 50th percentile | 5.22 (2.02-13.45) | 0.001 | |
| Unfavorable COI | 1.34 (0.72-2.5) | 0.360 | |
| COI = childhood opportunity index, OR = odds ratio, aOR = adjusted odds ratio | |||
