Addressing inequities in cryptorchidism care: The impact of social determinants on timely & true undescended testis referrals - A six-year study from a high-volume referral center.

Abstract

Introduction: The American Urological Association (AUA) recommends urology referral and surgery for undescended testicle (UDT) before 18 months of age, but it has been shown that many referrals occur later, influenced by social factors.

Objective: This study aims to identify key social factors that impact UDT referral timing and appropriateness.

Study design: Pediatric patients referred to our institution for UDT management from 2018 to 2023 were analyzed. Referral appropriateness was assessed by whether the child had a true UDT, defined as undergoing orchiopexy. Timeliness was defined as referral before 15 months of age, accounting for median 3 months interval to surgery. Demographics and socioeconomic data were gathered, including health literacy index (HLI), area deprivation index (ADI), and provider training (physician vs. advanced practice provider [APP]).

Results: Of 1821 patients, 45.6 % of patients had bilaterally descended testicles, and the median referral age was 2.5 years (IQR: 1.2-6.6), with only 27.3 % referred before 15 months. Taken together, 15.3 % of referrals were both appropriate and timely. Multivariate analysis identified three significant factors for true UDT referrals: APP referrals (OR 1.37, p = 0.028), higher ADI percentile (OR 1.005, p = 0.021), and Black race compared to non-Hispanic White (OR 1.80, p < 0.001). Hispanic children more likely to be referred late on multivariate analysis (OR 1.53, p = 0.029); upon random evaluation of approximately 10 % of our study population, 16.5 % had pre-referral ultrasounds, with more APPs ordering these ultrasounds. Sensitivity analysis confirmed less true and timely referrals for APP referrals and Hispanic and Black races.

Discussion: This study is limited by retrospective nature and unmeasured confounders such as parental knowledge or healthcare-seeking behaviors. However, our findings corroborate the disparity also noted from racial differences in analyses of the PHIS database and Cerner Real-World Data. In addition, APP referrals and higher ADI percentile emerged as independent predictors of inappropriate or delayed referrals, underscoring the systemic inequities previously reported.

Conclusions: Our findings highlight that nearly half of the children referred for UDT have normally descended or retractile testicles not necessitating referral, and two-thirds are referred late. Significant disparities in referral quality and timing are associated with race, socioeconomic factors, and provider type. Targeted educational interventions focusing on APPs, high-ADI communities, non-White populations, or broader campaigns may help address these disparities effectively.