|By Islam, Saleem|
Circumcision remains a controversial operation. Most procedures are performed in the neonatal period and avoid general anesthesia. Legislation driven by policy statements from the
DESPITE ITS ANCIENT history, circumcision is today controversial in
In our clinical practice, we noted a recent increase in the numbers of referrals for circumcision among young boys, in particular those aged 2 to 5 years of age. Parents often explained that they were unable to pay for the procedure after the child was born. We hypothesized that neonatal circumcisions were deferred among families in lower socioeconomic classes because public funding was not available. Circumcisions would then be done when the child was older, a costlier procedure requiring general anesthesia in an outpatient surgical facility. To test this contention, we used state health agency databases to determine rates of circumcisions in the neonatal and nonneonatal age groups. We found that publicly funded nonneonatal circumcision has significantly increased in recent years.
The database identifies procedures by Current Procedural Terminology code (CPT; Table 1). All patients 0 to 17 years of age over a 5-year period (2003 to 2008) undergoing circumcision were identified, including their demographic characteristics, facility charges, and insurance status. Professional fees are not included in the reported charge data. Ages are reported as an integer (0, 1, 2, 3, etc.) and no dates of birth are given. We therefore chose to define nonneonatal circumcision as those occurring in patients aged 1 year old or older; neonatal circumcision occurring in patients here the age was reported as ''0.'' Imputation analysis was not required for this study.
We collected and analyzed patient information from our practice for 2010, including basic demographic data, insurance information, reason for the procedure, complications, and clinic and operative day show rates.
Data were grouped into years and analyzed using Student's t tests and Fisher's exact test for proportions. Prevalence and incidence are estimated using the numerator only because total birth rates were not considered in the analyses.
Public agencies covered payment for 55.3 per cent of circumcisions, 65.2 per cent of which were in patients aged 1 year and older. Numbers of publicly funded circumcisions more than doubled (114.7% increase) during the study period, a rate of increase 6.4 times the rate observed of private insurance-funded circumcisions (P < 0.0001). For both public and private payers, nonneonatal circumcisions were consistently more common each year compared with neonatal circumcision.
Procedural Charge Analysis
Average facility charges for public and privately funded circumcisions were
Circumcisions among blacks had the largest rate of increase among all racial groups, increasing by 77 per cent over the study period (P 4 0.003); Hispanics, 33 per cent (P 4 0.083); and whites, 29 per cent (P 4 0.021). By total number of procedures, whites ranked first in the total number of circumcisions performed for the first 4 years, but in the fifth year, blacks assumed the top spot. Half of the number of publicly funded nonneonatal circumcisions was in blacks, 50 per cent; whites, 34 per cent; and Hispanics, 15 per cent. Numbers of publically funded nonneonatal circumcisions among all racial groups showed relative increases greater than privately funded procedures (Fig. 3).
In a single year (2010), 311 nonneonatal circumcisions were performed: 83 per cent were publically funded, 78 per cent were black, and the most common age group was 1 to 5 years. There was a 24 per cent no show rate for the preoperative assessment and a 12 per cent absence on the operative day, excluding those who called to cancel a scheduled operation for a bona fide reason such as illness or missed transportation.
Our data show the cost of nonneonatal circumcisions in
The current neonatal circumcision rate in
As currently practiced, neonatal circumcision is a safe bedside procedure not needing general anesthesia. There is general agreement that newborns perceive pain and adequate regional anesthetic block is required for the procedure.13 Morris et al. supports infancy as the optimal time for neonatal circumcision under local anesthesia because of the low cost, quick healing, and a superior cosmetic result.14, 15 Reviews that compare complications from neonatal and nonneonatal circumcisions show a higher complication rate (0.2 to 0.6 vs 1.5 to 3.8%, respectively) with the older age group.16, 17 The cost of neonatal circumcisions ranges from
Our study is unique in that the database used captured outpatient circumcisions, a limitation of federal administrative databases such as the Kids' Inpatient Database that focus on inpatient procedures. Thus, we found increasing state expenditures for the procedures, the unintended result of state agencies deciding not to fund neonatal circumcisions. It is important to recall that our data only include the facility fee; therefore, the actual charge is significantly higher when one considers the provider fees for the surgeon and anesthesiologist. Publicly funded circumcisions increased, whereas the numbers for the procedure paid by private insurance stayed stable. We speculate the increase was among patients with lower socioeconomic status who depend on publically funded health care. The disparity in circumcisions among families below the poverty line has been shown by others.8, 9, 20 To our knowledge, the present study is the first to analyze the funding for and demographic distribution of nonneonatal circumcision on a statewide basis.
There are several limitations of our study. Administrative databases lack specific information so conclusions necessarily are general. The
1. Bailey RC, Moses S, Parker CB, et al. Male circumcision for HIV prevention in young men in Kisumu,
2. Bronselaer GA, Schober JM, Meyer-Bahlburg HFL, et al. Male circumcision decreases penile sensitivity as measured in a large cohort. BJU Int 2013
3. Nelson CP, Dunn R,Wan J,Wei JT. The increasing incidence of newborn circumcision: data from the nationwide inpatient sample. J Urol 2005;173:978-81.
4. Circumcision policy statementAmerican
5. Jagannath VA, Fedorowicz Z, Sud V, et al. Routine neonatal circumcision for the prevention of urinary tract infections in infancy. Cochrane Database Syst Rev 2012;11:CD009129.
6. Andrews AL, Lazenby GB, Unal ER, Simpson KN. The cost of
8. Leibowitz AA, Desmond K, Belin T. Determinants and policy implications of male circumcision in
9. Leibowitz AA,
10. Witmer MT, Margo CE. Analysis of ophthalmology workforce and delivery of emergency department eye care in
11. Quayle SS, Coplen DE, Austin PF. The effect of health care coverage on circumcision rates among newborns. J Urol 2003;170: 1533-6.
13. Paix BR, Peterson SE. Circumcision of neonates and children without appropriate anaesthesia is unacceptable practice. Anaesth Intensive Care 2012;40:511-6.
14. Banieghbal B. Optimal time for neonatal circumcision: an observation-based study. J Pediatr Urol 2009;5:359-62.
15. Morris BJ, Waskett JH, Banerjee J, et al. A 'snip' in time: what is the best age to circumcise? BMC Pediatr 2012;12:20.
16. Cathcart P, Nuttall M,
17. Kacker S, Frick KD, Gaydos CA, Tobian AAR. Costs and effectiveness of neonatal male circumcision. Arch Pediatr Adolesc Med 2012;166:910-8.
18. Ortenberg J, Roth CC. Projected financial impact of noncoverage of elective circumcision by Louisiana Medicaid in boys aged 0-5. J Urol 2013 Feb 19 [Epub ahead of print].
19. Robinson JD, Ortega G, Carrol JA, et al. Circumcision in
20. Neiberger RE. Are we becoming a two-class society based on neonatal circumcision? Pediatrics 1990;86:1005.
From the *
Presented at the
Address correspondence and reprint requests to
|Copyright:||(c) 2013 Southeastern Surgical Congress|