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

Summary

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.

Introduction

Elective post-neonatal circumcision is a common procedure, and as many as 13% of uncircumcised neonates eventually undergo a circumcision. Nearly 50% of these boys will have the operation before 1 year of age [1]. This simple outpatient procedure is considered safe and is associated with minimal morbidity [2]. However, few data exist evaluating the rates of emergency department visits, readmission, and need for reoperation following elective childhood circumcision. Circumcision is one of the most commonly performed surgical procedures in the United States [1], yet little has been published about its immediate complication rate and the risk of reoperation. No study has focused solely on return visits, postoperative readmission early reoperation rates after just post-neonatal circumcision, or if any demographic risk factors exist to predict readmission or reoperation.

In a cohort of 65,740 patients, 9.1% of patients aged 1–9 years experienced an adverse event and 5.3% of patients older than 10 years experienced an adverse event following elective post-neonatal circumcision [3]. Although this study did look at correctional procedures performed by age range, it did not analyze data regarding readmission rates, emergency room visits, or reoperations. Another study showed that 2.6% of 4097 patients returned to the emergency department following pediatric urological procedures, with a majority of these procedures being circumcisions [4].

Immediate complications associated with post-neonatal circumcisions include uncontrolled bleeding, hematoma, infection, inflammation, postoperative fever, and aspiration pneumonia [2], [3]. While some of these complications can be related to anesthesia rather than the surgical procedure itself, the overall complication rate is important when counseling parents about post-procedure expectations and risks. The most traumatizing complication to patients and parents is significant hemorrhage or hematoma requiring urgent surgical exploration to control bleeding or evacuate hematoma.

However, it is unclear if risk factors exist to predict patients at increased risk for reoperation. Most pediatric urologists consider older patients, particularly teenagers, at higher risk for bleeding and reoperation. However, this association has never been confirmed in the literature. Emergency room and physician office visits after elective post-natal circumcision are costly and time consuming to the family, as are readmission, following these visits. Readmission rates are thought to be low despite frequent secondary encounters in the emergency room and physician office.

It is a well-known phenomenon that pediatric emergency department (ED) encounters peak in the late winter and early spring months secondary to increased respiratory illnesses [5]. It is unclear if these increased ED visits would also correlate to an increased rate of postoperative ED encounters because of increased pulmonary complications related to anesthetics during these months. In addition, elective procedures in the pediatric population tend to peak in summer months and during school breaks. However, elective neonatal circumcisions may not be seasonal as most of these cases occur in preschool age children who do not need to wait for school breaks to undergo surgery. There are no studies to our knowledge reporting on seasonal variations in complications following elective circumcision.

We sought to define the rates of repeat encounters, readmission, and reoperation in the first 7 days following circumcision to accurately inform families about the risks of this elective procedure. We hypothesized that readmission and reoperation after outpatient post-neonatal circumcision are rare, and that increased age is a risk for reoperation.