The Effect of Inpatient versus Outpatient Location on Postoperative Healthcare Utilization After Circumcision

Background: Access to male circumcision for all families who desire the procedure is recommended by the American Academy of Pediatrics. When performed during the newborn stage, circumcision has less complications and decreased cost. However, there has been a trend toward outpatient circumcision over the last few decades to reduce length of inpatient hospitalizations and costs. Performing the procedure outpatient may delay circumcision, lead to potentially inadequate access to care, and increased hospital utilization as an outpatient. This study aimed to compare the healthcare utilization rates after neonatal circumcision performed both in the immediate post-birth inpatient and outpatient settings.

Methods: We performed a retrospective cohort study comparing 30-day postoperative healthcare utilization of full-term, healthy, infants who underwent an inpatient versus outpatient circumcision within 30-days of birth from 2015-2020. Healthcare utilization was defined as having an ED visit, unplanned office visit, or readmission pertaining to the circumcision. Length of stay (LOS) of the original hospital admission at birth as well as direct patient costs between groups were also compared. Statistical analyses included Chi-square tests, multivariable adjusted logistic regression models, and adjusted negative binomial regression when appropriate.

Results: 3,137 infants were included, 1426 (45.5%) had an outpatient circumcision, 1711 (54.5%) inpatient. Children who underwent circumcision as an outpatient had similar overall healthcare utilization rates (5.7% vs. 5.6%, p=0.933). They required a similar number of emergency department (ED) visits (1.5% vs 0.8%, p=0.055), office visits (4.5% vs. 5.1%, p=0.437), and readmission (0.2% vs. 0.0%, p=0.058). However, infants with inpatient circumcisions had longer lengths of stay after adjusting for age, ethnicity and delivery type (Cesarean versus vaginal) with an incident rate ratio of 1.97 (95% confidence interval 1.84-2.11, p<0.001). On average, outpatient circumcision cost $372 more than inpatient.

Conclusion: The setting of neonatal circumcision in healthy, full-term males does not affect healthcare utilization rates. The ability to offer the procedure outpatient may lead to a shorter hospital stay following birth. However, outpatient circumcisions do have an increased cost based on hospital charge data and may require an additional outpatient visit. Therefore, choice of location should be left to parental preference when resources are available.