No abstract

INTRODUCTION AND OBJECTIVE: Policy statements from American Urologic Association and the American Academy of Pediatrics (AAP) report medical benefits of newborn circumcision (NBC) and recommend presenting it as an option. The AAP further recommends insurance coverage for those who choose it. Many newborn males (NBM) who do not undergo NBC may eventually undergo operative circumcision (OC), which carries increased medical risk and cost. We hypothesize that socio-economic factors, including race and insurance, influence access to NBC; and further believe that this results in an increased shift of potential harm to an under-represented population of our community.METHODS: We retrospectively reviewed NBM records at our hospital system from Jan 2010-Jun 2015, excluding those admitted to the NICU. Demographic information collected included race and insurance. The genital exam and reason NBC was not performed were also recorded for NBM that desired the procedure (determined by signed consent). We then reviewed males (ages 6 months-18 years) undergoing OC at our institution from Jan 2015-Dec 2019. Demographics collected included race and insurance, and indications for OC. We excluded patients with concomitant procedures, abnormal penile exams, and underlying medical conditions necessitating OC, in an effort to identify patients undergoing purely elective OC. Analysis was performed using c2, Fisher exact test, and Student's t-test.RESULTS: Of the 13,351 NBM who met criteria, 10,020 (75.1%) underwent NBC. We found a statistically significant association between NBC and insurance type (p<0.001) as well as race (p<0.001), with private insurance and white race being more likely to undergo NBC. Evaluation of the 314 eligible NBM, who desired but did not undergo NBC, revealed they were more likely to hold public insurance (p<0.001) or be of Black or African American (BAA) race (p<0.001). Of the 2,702 patients with OC, 82.6% of boys were publicly insured (p<0.001) and 73.7% were of BAA race (p<0.001). When comparing demographics between the NBC and the OC cohorts, results revealed a significant difference by race and insurance type, with BAA race (46.2% vs 73.7%, p<0.001) and public insurance (29.2% vs 82.6%, p<0.001) as the highest predictive factors of undergoing OC.CONCLUSIONS: Patients have unequal access to NBC, with rates impacted by insurance and race. We also observe those groups with less access to NBC subsequently undergoing OC, despite known increased risk and cost burden. These findings represent a disparity of care in our healthcare system.