Circumcision of privately insured males aged 0 to 18 years in the United States

Comparing Penile Problems in Circumcised vs. Uncircumcised Boys: Insights From a Large Commercial Claims Database With a Focus on Provider Type Performing Circumcision

OBJECTIVES

To compare penile problems in circumcised relative to uncircumcised boys, and to determine which providers performing the circumcision have fewer post-circumcision problems.

METHODS

CPT codes in the 2011-2020 MarketScan database were used to identify boys who had a circumcision. Uncircumcised control subjects of the same age, state of residence, and insurance type were selected. The primary outcome was a penile problem, defined as penis-specific infection, inflammation, and urethral stricture/stenosis, among others. The secondary outcomes were procedure-related complications limited to 28 days after circumcision, and whether post-circumcision problems varied by the clinician performing the procedure. ICD-9/10 diagnostic codes were used to identify these problems.

RESULTS

We identified ∼850,000 cases and ∼850,000 matched controls. Overall, the rate of penile problems within the first five years of life was 1.7% in circumcised boys versus 0.5% in uncircumcised boys (p < 0.05). Multivariable regression models showed that the risk of penile problems was 2.9-fold higher among circumcised compared to uncircumcised males (95%CI [2.8-3], p < 0.001). Compared to males circumcised by pediatricians, those circumcised by surgeons had 2.1-fold higher penile problems in the year after circumcision (95% CI [2-2.3], p < 0.001). Procedure-related complications within 28 days of circumcision were infrequent (0.5%), with the most common being penile edema (0.2%).

CONCLUSIONS

Penile problems are very infrequent in boys in the first five years of life. However, when they occur, they are 3x more likely to occur in circumcised boys relative to uncircumcised boys. Penile problems are more likely to occur in boys circumcised by surgeons.

LEVELS OF EVIDENCE

Level II.

TYPE OF STUDY

Prognosis study.

Differential Insurance Plan Coverage and Surgeon Reimbursement of Pediatric Circumcision at an Urban, Midwestern Hospital

OBJECTIVE

To explore private vs public pediatric circumcision insurance coverage and surgeon reimbursement.

METHODS

A telephone survey about circumcision coverage (Current Procedural Terminology codes: 54150, 54161) was conducted in October 2021 with insurance plan representatives from the 12 plans that comprised ≥1% of institutional pediatric urology visits to compare plan characteristics and coverage details. Circumcision billing data were collected at one pediatric hospital to assess surgeon reimbursement (insurance+patient payment) by plan type using bivariate statistics.

RESULTS

Ten plans (5 private and 5 public) responded (83.3% response rate). All except one public plan covered newborn circumcision. For non-newborn circumcisions, most public plans (80%) had unrestricted coverage, whereas all private plans required medical necessity. Median reimbursement for newborn circumcision (CPT: 54150) was $484 for private and $78 for public plans, P < .001 while median reimbursement for non-newborn circumcision (CPT: 54161) was $314 for private and $147 for public plans, P < .001.

CONCLUSION

Private insurance plans reimburse significantly more than public plans for newborn circumcision. For non-newborn circumcision, private plans reimburse more than public but the coverage is more restricted, with a smaller differential between newborn and non-newborn circumcision. This coverage and reimbursement structure may indirectly encourage newborn circumcision for privately insured boys and non-newborn circumcision for publicly insured boys.

Outcome assessment of office Plastibell circumcision in infants utilizing interactive electronic health record

OBJECTIVE

To assess the outcomes of office-based circumcision performed using Plastibell devices in infants, utilizing the MyChart interactive electronic health record (iEHR) system to monitor the progress and identify potential complications.

METHODS

This is a prospective cohort study conducted between March 2021 to April 2022 on all infants undergoing office based Plastibell circumcision. Parents were encouraged to submit concerns via MyChart and to submit photos if the ring has not fallen by post-procedure day 7. Telehealth or in-person clinic visits were then made accordingly. Postoperative complications were collected and compared with existing literature.

RESULTS

Of the 234 consecutive infants, the average age was 33 days (9-126 days) and the average weight was 4.35 kg (2.5-7.25 kg). A total of 170 parents (73%) responded to MyChart messages. Fourteen (6%) complications necessitating local intervention were identified: excessive fussiness (1), bleeding (2), ring retention (11) including 2 incomplete skin division requiring repeat dorsal block and surgical completion, fibrinous adhesion (3), and proximal ring migration (6). The photo and messages submitted through iEHR facilitated early patient return for intervention. Additionally, 17 parents submitted photos which were expected postprocedural findings and were reassured through iEHR, thus omitting unnecessary return visits. The 2 patients with incomplete skin division occurred early in the series using the included cotton ties. Subsequent procedures were performed with double 0-Silk ties (n = 218) without similar finding.

CONCLUSION

The interactive utilization of iEHR communication in the post-circumcision period identified proximal bell migration and bell trapping, allowed earlier intervention and reduced complications.

LEVEL OF EVIDENCE

Level 1.

Neonatal circumcision availability in the United States: a physician survey

BACKGROUND

A significant proportion of boys present to surgical specialists later in infancy/early childhood for elective operative circumcision despite the higher procedural risks. This study aims to assess physician perspectives on access to neonatal circumcision across the United States and identify potential reasons contributing to disparities in access.

METHODS

A cross-sectional survey was electronically distributed to physician members of the Societies for Pediatric Urology and the American Academy of Pediatrics Section on Hospital Medicine. Hospital characteristics and circumcision practices were assessed. Associations between NC availability and institutional characteristics were evaluated using chi-squared testing and multivariable logistic regression. Qualitative analyses of free-text comments were performed.

RESULTS

A total of 367 physicians responded (129 urologists [41%], 188 pediatric hospitalists [59%]). Neonatal circumcision was available at 86% of hospitals represented. On univariate and multivariate analysis, the 50 hospitals that did not offer neonatal circumcision were more likely to be located in the Western region (odds ratio [OR] = 8.33; 95% confidence interval [CI] 3.1-25 vs. Midwest) and in an urban area (OR = 4.2; 95% CI 1.6-10 vs. suburban/rural) compared with hospitals that offered neonatal circumcision. Most common reasons for lack of availability included not a birth hospital (N = 22, 47%), lack of insurance coverage (N = 8, 17%), and low insurance reimbursement (N = 7, 15%). Institutional, regional, or provider availability (68%), insurance/payment (12.4%), and ethics (12.4%) were common themes in the qualitative comments.

CONCLUSIONS

Overall availability of neonatal circumcision varied based on hospital characteristics, including geography. Information from this survey will inform development of interventions designed to offer neonatal circumcision equitably and comprehensively.

Longitudinal Sociodemographic Analysis of Operative Circumcisions at Children's Hospitals

OBJECTIVE

To characterize elective, post-neonatal operative circumcision at US children's hospitals, in the context of established sociodemographic disparities in access to neonatal circumcision.

METHODS

A retrospective cohort study was performed of boys undergoing elective, operative circumcision at the 23 Pediatric Health Information System (PHIS) hospitals who contributed data from 2004-2018. Boys > = 36 months' and those with congenital anomalies of the penis were excluded. Bivariate statistics were used to compare the circumcision cohort to a referent cohort of boys undergoing other ambulatory surgery or having an observational hospital stay.

RESULTS

The annual median number of operative circumcisions per hospital increased during the study (72 [IQR 54-162] to 136 [IQR 88-266], P = .003). Boys undergoing circumcision were mostly non-Hispanic White (46.7%) or non-Hispanic Black (30.9%), in the lowest income quartile (26.6%), from the Southern US (51.5%), and publicly-insured (60.5%). When compared to the reference cohort, boys undergoing circumcision were more likely to be non-Hispanic Black (30.9 vs 15.7%, P = .001) and publicly-insured (60.5 vs 45.9%, P = . 001).

CONCLUSION

The number of post-neonatal operative circumcisions performed at US children's hospitals nearly doubled from 2004 to 2018. Study findings suggest an emerging healthcare disparity, with non-Hispanic Black boys of lower socioeconomic status undergoing more post-neonatal operative circumcisions that are more expensive and higher risk.

Retractable foreskin reduces urinary tract infections in infant boys with vesicoureteral reflux

BACKGROUND

Uncircumcised males are at higher risk of urinary tract infection (UTI) in the first year of life and circumcision is recommended as an option for males with vesicoureteral reflux (VUR). Uncircumcised males treated successfully with topical corticosteroid cream have decreased risk of UTI but the role of preputial management has not been explored previously in males with VUR.

OBJECTIVE

We hypothesized that among uncircumcised boys with VUR, those with retractable foreskin would be at reduced risk of UTI compared to those with non-retractable foreskin.

STUDY DESIGN

Males less than one year of age with primary VUR were prospectively enrolled. Patients with concomitant urologic diagnoses or less than one month of follow-up were excluded. Phimosis severity was graded on a 0-5 scale. Primary outcome was UTI during follow-up. Patients were divided into three groups for analysis: circumcised, low grade phimosis (grades 0-3) and high grade phimosis (grades 4-5). Multivariable Cox proportional hazards regression was used to estimate UTI risk adjusting for risk factors.

RESULTS

One-hundred and five boys (24 circumcised and 81 uncircumcised) with VUR were included. Median age at enrollment was 4.4 months (IQR 2.2-6.6) and median follow-up was 1.1 years (IQR 0.53-2.9). Males with phimosis grades 4-5 had a higher UTI rate (29%) compared to phimosis grade 0-3 (4%). Based on Kaplan-Meier curves, boys with initial phimosis grades 4-5 were significantly more likely to develop a UTI than boys who were circumcised or had phimosis grades 0-3 (p = 0.005). On multivariable analysis, boys with phimosis grades 4-5 were significantly more likely to develop UTI when compared to boys with grades 0-3 phimosis (HR = 8.4, 95% CI: 1.1-64, p = 0.04).

DISCUSSION

Males with a retractable prepuce had a lower UTI risk compared to males with non-retractable prepuce (high grade phimosis) and this remained significant on multivariable analysis. This is concordant with prior studies demonstrating that a retractable prepuce is associated with decreased UTI risk. Limitations of our study include using phimosis grade at time of study enrollment and heterogenous prophylactic antibiotic use in our population.

CONCLUSIONS

Retractable foreskin reduces UTI risk in uncircumcised boys less than one year of age with VUR. Medical phimosis treatment to achieve a retractable prepuce offers an alternative and less invasive modality to reduce UTI risk in males with VUR.

Opioid prescribing is excessive and variable after pediatric ambulatory urologic surgery

BACKGROUND

Acute pain after surgery is one of the most frequent indications for opioid prescribing in children. Opioids are often not stored or disposed of safely after their use, placing children and others in the home at risk for accidental ingestion or intentional misuse. We currently lack evidence-based guidelines for post-operative pain management after common ambulatory pediatric urologic procedures. Thus, each surgeon must decide if and how much opioid to prescribe based on his/her own assumptions of perceived post-operative pain.

OBJECTIVES

As part of an effort to establish opioid prescribing guidelines across two academic centers, the objectives of this study were to evaluate current variability in pediatric urologists' opioid prescribing factors and identify patients at greatest risk of being prescribed high doses of opioids after common ambulatory pediatric urologic procedures.

METHODS

We retrospectively evaluated post-operative opioid prescribing patterns after common ambulatory pediatric urology procedures (circumcision, orchiopexy, and hernia/hydrocele) at two major children's hospitals. Specifically, we evaluated if and how much opioid was prescribed for all children (18 years or younger) between 2016 and 2017. Bivariate analysis was performed using Kruskal-Wallis Test and Wilcoxon Rank Sum. Multivariable logistic regression was performed to determine patient, surgeon, and procedural factors that predicted the prescription of a high dose of opioids (greater than the median number of doses prescribed for that procedure).

RESULTS

Over the two-year period, 811 circumcisions and 883 inguinal surgeries (inguinal orchiopexy and hernia/hydrocele) were performed. 94% of patients undergoing circumcision and 97% of those undergoing inguinal surgery were prescribed opioid analgesia. The median number of doses prescribed for circumcision was 20; for inguinal surgeries, 23.75% of patients received 15 opioid doses or more. Patients ages 0-2 years, who represented the largest age group (41% of all patients), received significantly more opioid doses than all other age groups, followed by those >10 years (p < 0.01). There was significant variation in opioid prescribing patterns by provider (p < 0.01) (Figure 1) On multivariable logistic regression, younger age, pill form, and earlier year were all associated with a greater number of opioid doses prescribed for all surgeries.

CONCLUSIONS

Across two institutions without a formal post-operative opioid prescribing policy for ambulatory pediatric urologic procedures, we observed considerable variability in provider prescribing patterns, with nearly all patients receiving an opioid, and those 0-2 years receiving the highest number of doses. This highlights the need for evidence-based guidelines for post-operative pain management after ambulatory pediatric urologic surgeries.

Caregiver Reported Reasons for Delay of Neonatal Circumcision

OBJECTIVES

To determine caregiver-reported reasons for delay of desired neonatal circumcision.

METHODS

Caregivers requesting elective outpatient circumcision at two urban tertiary care hospitals were surveyed from 1/2017 to 12/2018. Boys >3 years and those with abnormal penile anatomy were excluded. Patient/parent demographics, insurance status, comorbidities, birth history, family history, reasons circumcision was desired, and reasons for circumcision delay were obtained.

RESULTS

Surveys were completed by 206/229 caregivers (90% response rate). Respondents were primarily mothers (74%) who identified as African-American (62%). Eligible boys presented at a median 7.5 months [0.3-35.6] and were predominantly African-American (63%), publicly-insured at birth (83%), and publicly-insured at present (86%). 80% were full-term. 83% had no comorbidities. Most caregivers (84%) requested inpatient circumcision, primarily for penile cleanliness (75%) and infection prevention (72%). Common reasons for delay included neonatal circumcision not being performed by the birth physician/hospital (26%) and prematurity (16%). Publicly-insured boys were more likely to encounter delays related birth physician/hospital not performing circumcisions (P = .02). Non-Caucasian/mixed race boys were less likely to be eligible for circumcision without general anesthesia (P = .004). In 108 cases (52%), circumcision was requested for full-term boys without comorbidities. Of these, 72 (35% of the cohort) now require general anesthesia to undergo circumcision.

CONCLUSION

Among 206 boys experiencing circumcision delay, most were full-term, African-American, and publicly-insured. Common reasons for delay included neonatal circumcision not being performed by the birth hospital/physician and prematurity. General anesthesia could have been avoided in >35% of boys if circumcision was performed at birth.

Estimation of country-specific and global prevalence of male circumcision

BACKGROUND

Male circumcision (MC) status and genital infection risk are interlinked and MC is now part of HIV prevention programs worldwide. Current MC prevalence is not known for all countries globally. Our aim was to provide estimates for country-specific and global MC prevalence.

METHODS

MC prevalence data were obtained by searches in PubMed, Demographic and Health Surveys, AIDS Indicator Surveys, and Behavioural Surveillance Surveys. Male age was ≥15 years in most surveys. Where no data were available, the population proportion whose religious faith or culture requires MC was used. The total number of circumcised males in each country and territory was calculated using figures for total males from (i) 2015 US Central Intelligence Agency (CIA) data for sex ratio and total population in all 237 countries and territories globally and (ii) 2015 United Nations (UN) figures for males aged 15-64 years.

RESULTS

The estimated percentage of circumcised males in each country and territory varies considerably. Based on (i) and (ii) above, global MC prevalence was 38.7 % (95 % confidence interval [CI]: 33.4, 43.9) and 36.7 % (95 % CI: 31.4, 42.0). Approximately half of circumcisions were for religious and cultural reasons. For countries lacking data we assumed 99.9 % of Muslims and Jews were circumcised. If actual prevalence in religious groups was lower, then MC prevalence in those countries would be lower. On the other hand, we assumed a minimum prevalence of 0.1 % related to MC for medical reasons. This may be too low, thereby underestimating MC prevalence in some countries.

CONCLUSIONS

The present study provides the most accurate estimate to date of MC prevalence in each country and territory in the world. We estimate that 37-39 % of men globally are circumcised. Considering the health benefits of MC, these data may help guide efforts aimed at the use of voluntary, safe medical MC in disease prevention programs in various countries.

Readmission characteristics of elective pediatric circumcisions using large-scale administrative data

INTRODUCTION AND BACKGROUND

Elective circumcision is a common procedure, known to be safe and associated with minimal morbidity. There are few data reporting the rates of readmission and reoperation following elective circumcision.

OBJECTIVE

We sought to define the rates of readmission and reoperation in the first 7 days following circumcision to accurately counsel families about the risks of this elective procedure.

STUDY DESIGN

The Pediatric Health Information System (PHIS) was interrogated from 2004 to 2013 for all ambulatory, elective circumcisions (ICD-9 CM code of 640). We assessed readmission with respect to age, insurance status, race, readmission diagnosis, time to readmission, and seasonal differences (due to higher rates of all-cause hospital admissions). We performed logistical regression analysis with a dependent variable of readmission within 7 days and independent variables of age, race, month of admission, and insurance status.

RESULTS

We identified 95,046 circumcisions from 2004 to 2013 performed in ambulatory surgery centers. Of those, 2906 (3.1%) of patients had an additional encounter at the same facility within 7 days. A total of 2409 (2.4%) of encounters were ER visits, and 253 (0.3%) were encounters for hospital admission or observation. One hundred and thirty-two patients (0.1%) underwent a second ambulatory procedure within the first 7 days following circumcision. Black patients (OR 1.26, p < 0.001) and patients on Medicaid (OR 1.63, p < 0.001) were more likely to seek care of any kind at the same institution within 7 days of the original circumcision operation. No difference was found with regard to time of year on logistic regression. Older age at circumcision was associated with increased likelihood of reoperation compared to children <1 year, with children 12-18 years old having an OR of 1.91 (p = 0.033).

DISCUSSION

We present a descriptive study of clinical events occurring at the same tertiary children's hospital within the first 7 days following more than 95,000 elective postneonatal circumcisions. Limitations include a cohort generated from a single set of ICD-9 codes, and a follow-up of 7 days.

CONCLUSION

Elective circumcision remains a safe procedure with a readmission rate of 0.3%, and a reoperative rate of 0.1%. However, a relatively high percentage of patients (3.1%) will have a secondary encounter within the first 7 days following circumcision, most of them seeking care in an ER, although not necessarily for circumcision-related reasons. These may be useful data when counseling patients.