Disparities in the Follow-up and Presence of Complications After Distal Hypospadias Repair

We have developed a unique hypospadias database that is fully integrated into our EPIC electronic medical record. This has allowed us to keep a close monitor on our surgical patients. We have multiple publications that aim to tease some of the specific elements of hypospadias repair. As we continue to develop and advance the database, we seek to drive down complication development after these complex surgeries.

Crude metrics of socioeconomic status, such as ZIP code, have been used in the past to identify patients who may be at a disadvantage compared to their peers. The Childhood Opportunity Index (COI) utilizes census data across education, health and environment, and social/economic factors to create a range of scores that span from low opportunity to high opportunity, with a higher score potentially representing a more favorable environment for the child and the family. We used an online scoring tool, along with the patient’s address, to calculate their COI.

We included 1,000 patients with a history of surgical repair of a distal, or mild, hypospadias. The surgical complication rate was 9%, which is less than the national average, and did not identify any difference in complications stratified by COI. Further sub-analysis based on education, health/environment, social/economic status, race, and/or primary spoken language did not identify any differences in complication development. This suggests that we are doing a satisfactory job in optimizing outcomes in all our patients.

One significant finding, however, was that patients with a lower COI have poorer follow-up and a higher rate of no follow-up compared to higher COI patients. It is possible that these patients could have developed a complication that we are yet unaware of because of a lack of follow up. To combat this disparity, we are working on further modifying our hypospadias database to automatically identify patients that are either overdue for an appointment or have been lost to follow-up.

It is clear in the literature that follow up is key for patient outcomes — not only to identify potential complications but also to counsel patients and families over time about their diagnosis and to guide their expectations as they age. We envision a “nudge” type of tool that would contact families regarding the need for follow up so they can be properly evaluated.