Carpenter Christina P, Johnston Derrick, Tourville Elizabeth, Sharadin Cynthia, Alzubaidi Ahmad N, Giel Dana W
Department of Urology, Division of Pediatric Urology, Columbia University Irving Medical Center, NewYork-Presbyterian Morgan Stanley Children's Hospital, New York, NY, USA; Department of Urology, Division of Pediatric Urology, Le Bonheur Children's Hospital, University of Tennessee Health Science Center, Memphis, TN, USA.
Arizona Pediatric Surgery and Urology, Tucson, AZ, USA.
J Pediatr Urol. 2020 Aug;16(4):462.e1-462.e6. doi: 10.1016/j.jpurol.2020.06.017. Epub 2020 Jun 19.
Cryptorchidism is one of the most common referral diagnoses to pediatric urologists. It is well recognized in the urologic community that diagnostic imaging is unnecessary in the work-up of these patients, and the Choosing Wisely® recommendation (CWR) on this subject re-emphasized this in 2013. Many boys, however, still are sent for testing prior to referral.
The purpose of our study was dual in nature. We pursued, first, to identify any factors that make patients more likely to be sent for imaging prior to referral, and second, to determine if rates of diagnostic imaging for cryptorchidism decreased after the release of the CWR.
We included all boys who had surgery for cryptorchidism by Urology at our institution between January 2007 and August 2018. Demographics and clinical data were collected including height, weight, race, insurance type, pre-referral imaging status, testis location at time of surgery, and distance from our medical center. Chi-squared analysis was utilized to compare imaging use before and after CWR. Influence of other clinical and socioeconomic factors on imaging utilization was also evaluated using chi-squared and two-sample t tests. Those found to be significant at the 0.2 level were analyzed in multivariate logistic regression. Significance was set at 0.05.
1010 boys were available for analysis. Of the 256 patients (25.3%) with pre-referral studies, 7 had axial exams (CT or MRI), and the remainder underwent ultrasounds. Children living closer to the medical center were more likely to undergo imaging (p < 0.01) as were boys with testes not found in the inguinal canal at the time of surgery (p = 0.007). Race, insurance status, age at first visit, and increased body mass index were not found to be influential. Similarly, the release of CWR had no impact on the imaging usage (p = 0.61).
Utilization of pre-referral diagnostic imaging remains inappropriately high despite evidence demonstrating the ineffectiveness of the studies. Boys living closer to the medical center and those with non-inguinal testes are more likely to undergo these studies, but no other factors were found to have an effect. Further, the Choosing Wisely® recommendation has not improved rates of inappropriate imaging use in boys with cryptorchidism in our referral area. Our findings indicate the need for increased efforts to disseminate this evidence-based guideline more widely to primary care providers in order to promote more cost-effective and timely care of boys with undescended testes.
隐睾症是小儿泌尿外科医生最常接到的转诊诊断之一。泌尿外科界普遍认为，对这些患者进行检查时无需进行诊断性影像学检查，“明智选择”（Choosing Wisely®）关于该主题的建议在2013年再次强调了这一点。然而，许多男孩在转诊前仍被送去进行检查。
我们的研究目的具有双重性。首先，我们试图确定哪些因素会使患者在转诊前更有可能被送去进行影像学检查；其次，我们要确定“明智选择”建议发布后隐睾症的诊断性影像学检查率是否有所下降。
我们纳入了2007年1月至2018年8月间在我们机构接受泌尿外科隐睾症手术的所有男孩。收集了人口统计学和临床数据，包括身高、体重、种族、保险类型、转诊前影像学检查情况、手术时睾丸位置以及距我们医疗中心的距离。采用卡方分析比较“明智选择”建议发布前后的影像学检查使用率。还使用卡方检验和双样本t检验评估了其他临床和社会经济因素对影像学检查利用率的影响。在多因素逻辑回归分析中对在0.2水平上具有显著意义的因素进行了分析。显著性设定为0.05。
1010名男孩可供分析。在256例（25.3%）转诊前接受检查的患者中，7例进行了轴向检查（CT或MRI），其余患者接受了超声检查。居住在离医疗中心较近的儿童以及手术时在腹股沟管未发现睾丸的男孩更有可能接受影像学检查（p < 0.01，p = 0.007）。未发现种族、保险状况、初诊年龄和体重指数增加有影响。同样，“明智选择”建议的发布对影像学检查使用率没有影响（p = 0.61）。
尽管有证据表明这些检查无效，但转诊前诊断性影像学检查的使用率仍然过高。居住在离医疗中心较近的男孩和睾丸不在腹股沟的男孩更有可能接受这些检查，但未发现其他因素有影响。此外，“明智选择”建议并未提高我们转诊地区隐睾症男孩不适当影像学检查使用率。我们的研究结果表明，需要加大力度向初级保健提供者更广泛地传播这一循证指南，以便为睾丸未降的男孩提供更具成本效益和及时性的护理。
