Low complication rates for procedures performed by advanced practice providers
A circumcision clinic led by nurse practitioners (NPs) had a 5-year complication rate of 4.1% as compared with 3.4% for circumcisions performed by physicians. Neither the overall rate nor any of the rates for specific types of complications differed significantly between NPs and MDs, reported Jonathan A. Gerber, MD, of Texas Children’s Hospital (TCH) in Houston, at the American Urological Association annual meeting.
The second study showed a 3-year complication rate of about 5% for circumcisions performed by a specially trained physician assistant (PA). That compared with complication rates of 4%-5% in published reviews of physician-performed circumcisions. The PA-performed circumcisions also generated substantial revenue for the urology practice, said Kaity Colon-Sanchez, PA-C, of Nemours Children’s Hospital in Orlando.
“We felt that utilization of advanced practice providers in our newborn services clinic has allowed pediatric urologists to focus their attention on the most complicated cases in the practice, while the more simple newborn circumcisions are being performed safely and effectively by advanced practice providers,” said Gerber. “Additionally, the results suggest that the longstanding age and weight cutoffs for newborn circumcisions need to be reconsidered, because our study shows similar outcomes in older and heavier children.”
About 70%-80% of newborn male infants undergo circumcision, making it the most common urologic procedure. An ongoing shortage of pediatric urologists has created a significant imbalance between the need for circumcision and the resources to provide the service. To address the problem, TCH established an APP-led newborn circumcision clinic, said Gerber.
One previous study documented results of a service wherein NPs performed minor urologic procedures, but the procedures all occurred in an operating room. The TCH service is provided in an outpatient setting.
Pediatric urologists trained APPs to perform Gomco clamp circumcisions. The training consisted of observing 10 newborn circumcisions, assisting in 10 procedures, and then performing 10 circumcisions under direct supervision of a pediatric urologist. Thereafter, a pediatric urologist was on call for all APP-performed circumcisions. APPs were limited to performing circumcisions for infants <30 days old and weighing <10 lbs.
Investigators retrospectively reviewed records for circumcisions performed over a 5-year period, which allowed for comparison of outcomes before and after implementation of the APP-led clinic.
Gerber reported data for 314 APP-performed circumcisions and 237 performed by pediatric urologists. The analysis focused primarily on complications. The study population had a mean age of 23.8 days and mean weight of 8.6 pounds. Physicians performed circumcisions on older (28.4 vs 20.3 days, P<0.0001) and heavier (8.9 vs 8.4 lb, P<0.0063) infants and used more lidocaine per procedure (0.96 vs 0.8 mL).
Overall, 21 complications occurred, with no significant differences between the APP and physician procedures:
- Total: 13 (4.1%) vs 8 (3.4%)
- Revision circumcision: 1 each
- 30-day return to emergency department (ED): 2 vs 0
- Other penile surgery: 2 vs 4
- Intraprocedure bleeding: 11 vs 4
The data showed no difference in outcomes for patients <30 vs ≥30 days or weight <10 vs ≥10 lbs, the traditional age and weight cutoffs for uncomplicated circumcision.
Colon-Sanchez reported her 3-year experience performing clinic-based circumcision in a pediatric urology service. She evaluated 371 infants for neonatal circumcision. They had a mean age of 7.8 weeks (range of 1 to 13 weeks) and weighed an average of 5.2 kg (11.4 lbs) and had a weight range of 3.2-7.5 kg. Subsequently, 95 infants did not undergo circumcision, 91 because of an abnormal genital exam. Colon-Sanchez performed 272 circumcisions with the Plastibell device and four with the Gomco device.
The clinic charged $366 for families that paid for the procedures themselves, and billed $722 when procedures were covered by insurance. Colon-Sanchez noted that the 95 patients excluded from the analysis did not represent lost revenue, as the office visit was considered billable and many of the patients required additional surgery.
Records revealed a complication rate of 6.43%, consisting of retained Plastibell device in 1.80% of cases, swelling in 1.40%, adhesions in 1.10%, cosmesis issues in 0.73%, and ED visits for bleeding in 1.40%.
The results compared favorably with those from studies of circumcisions performed by physicians, said Colon-Sanchez. A study of more than 1,000 circumcisions performed by pediatricians and ob/gyns showed an acute complication rate of 3.9%, all involving bleeding. A study of 9,000 surgeries at a pediatric urology service showed that 4.7% of the procedures involved late complications of circumcisions. Additionally, 7.4% of visits to the pediatric urology outpatient clinic during a 1-year period involved concerns related to newborn circumcisions.
“Well-trained physician urology physician assistants can perform neonatal circumcisions,” said Colon-Sanchez. “The data support low complication rates with well-trained PA providers. Urologist back-up is readily available. Office-based neonatal circumcisions provides an additional revenue stream.”
In response to a question, she described a training program similar to the one the APPs in Gerber’s study completed. She said she felt comfortable with her abilities after about 30 procedures.
Gerber and Colon-Sanchez disclosed no relevant relationships with industry.
This story was originally posted on MedPage Today.
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