Readmission characteristics of elective pediatric circumcisions using large-scale administrative data
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.
Section snippets
Data source
Data for this study were obtained from the Pediatric Health Information System (PHIS), an administrative database that contains inpatient, emergency department, ambulatory surgery, and observation data from 43 not-for-profit, tertiary care pediatric hospitals in the United States. Included hospitals are affiliated with the Children's Hospital Association, a business alliance of children's hospitals. Data quality and reliability are assured through a joint effort between the Child Health
Cohort characteristics
We identified 95,046 circumcisions performed in ambulatory surgery centers from 2004 to 2013. Characteristics of the cohort are displayed in Table 1.
A total of 2906 (3.1%) of patients had an additional encounter at the same facility within 7 days. A total of 2409 (2.4%) of the encounters had an ER visit within 7 days, and 253 (0.3%) had an inpatient encounter within 7 days. One hundred and thirty-two patients (0.1%) had a reoperation related to the penis within 7 days.
Of those with repeat
Discussion
We present a descriptive study of clinical events occurring at the same tertiary children's hospital where the ambulatory surgical procedure occurred within the first 7 days following more than 95,000 elective post-neonatal circumcisions. We determined the incidence, proportion, and nature of all return visits, hospital readmissions, and reoperations. In this series, over 82% of the 2906 additional encounters occurred in the emergency department. All told, only 0.1% of patients underwent any
Conclusion
In conclusion, our study provides information regarding complications following elective post-neonatal circumcision. However, our knowledge of repeat visits has limited granularity. While we acknowledge the limitations inherent to administrative data, our cohort is large, and serves to further demonstrate that elective circumcision remains a safe procedure with a repeat encounter rate of less than 4%, and a reoperation rate of less than 0.1%. Despite this, approximately 1 in 30 patients will
Conflict of interest
None.
Funding
None.
Acknowledgments
We acknowledge the administrative support of the Departments of Urology and Pediatrics at Indiana University School of Medicine. We also acknowledge the generous support of the Children's Hospital Association (www.childrenshospitals.org) for maintaining the PHIS database.
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