The Impact of Targeted Education of American Urological Association Cryptorchidism Guidelines in a Rural State: Improvement Still Needed

Abstract

Background The American Urological Association published guidelines in 2014 regarding management of undescended testicles (UDT). Despite these guidelines, prior studies have indicated discordance between guidelines and actual practice, especially in rural states. This study aims to identify if educating referring providers improves management of UDT. Methods Patients with UDT referred to our institution were divided into two groups: those referred prior to (Group 1) and after (Group 2) targeted education. A retrospective review was performed to compare the groups in terms of age at time of referral and surgery, laterality, specialty, and practice setting of referring provider, and whether or not ultrasound (US) was performed prior to referral. Results A total of 100 patients were identified in Group 1 and 168 in Group 2. No significant differences were noted between groups regarding age, variability of referring provider, or those receiving US prior to referral. Median age at referral was 20.7 months (range=0–194) and 33 months (range=0–205.1) in Groups 1 and 2, respectively ( p =0.26). Sixty-two (37%) patients underwent surgical evaluation within 18 months of age or younger in Group 1 compared to 39 (39%) in Group 2 ( p =0.73). Private practice pediatricians comprised the majority of referring providers in both cohorts. US was performed prior to referral in 41% of patients in Group 1 compared to 35.8% in Group 2 ( p =0.51). The number of US ordered prior to referral significantly decreased from 10 (50%) to six (19%) following education among academic providers ( p =0.02). No significant difference was found following education for private practice physicians ( p =0.27). Conclusion Targeted education did not improve age at referral in the short-term, which may reflect suboptimal healthcare access. Additionally, more research is needed to evaluate whether more diverse targeted education provided on a regular basis to both physician and mid-level providers would have a meaningful impact.

How Effective Was the 2014 AUA Cryptorchidism Guideline? A Multi-institutional Evaluation

“…Regarding the utilization of prereferral ultrasound, despite the AUA Guidelines and Choosing Wisely Campaign which attempts to decrease medical cost and overutilization of unnecessary diagnostics, we found no significant decrease or difference of ultrasound utilization in the literature. 10,12,16 It has been well documented that ultrasounds have poor sensitivity and specificity in the diagnosis of cryptorchidism. 16 Furthermore, ultrasound does not aid treatment decisions in the management of cryptorchidism.…”

“…In this study, private providers were less likely to change their practice compared with academic providers. 12 This study has multiple strengths. As a multi-institutional study, it represents 4 Midwestern academic centers producing a large sample size and heterogenous patient and referring provider populations.…”

“…In the cohorts at all 3 time points, less than a quarter of patients were evaluated by a pediatric urologist prior to 12 months of age, despite the median time from referral to initial pediatric urology visit being 1 month (IQR: 0-1 months). There were no significant differences between cohorts in the number of patients evaluated prior to 12…”

“…6,10,11 Furthermore, studies report that around 29%-40% of cryptorchid patients are evaluated with scrotal ultrasound prior to referral. 10,12 This study aims to determine the impact of the 2014 AUA Guidelines and assess if they reduced the age of referral and the utilization of ultrasound in boys with cryptorchidism. Due to both published patterns on care in cryptorchidism as well as our own clinical experience, we hypothesize that the majority of boys with cryptorchidism are still being referred to specialty care after 6 months of age and that utilization of ultrasound prior to referral remains unchanged even after publication of these guidelines.…”

“…6,10,11 Furthermore, studies report that around 29%-40% of cryptorchid patients are evaluated with scrotal ultrasound prior to referral. 10,12…”