P3C112: Effect of a USNWR Metric on Racial and Socioeconomic Healthcare Disparities in Testicular Torsion

Background: On June 15, 2015, the US News and World Report (USNWR) introduced a Speed in Treating Testicular Torsion metric to its ranking of the nation’s best children's hospitals. Hospitals received partial scoring if < 90% of patients spent < 4 hours from registration to surgical exploration or complete scoring for ≥90% of patients. The metric required uniform reporting and encouraged quality improvement (QI) among partial-scoring hospitals. All partial-scoring hospitals in 2015 achieved full scoring within the next five years. We sought to identify changes in salvage rates after the implementation of this metric and to explore whether these QI efforts relieved, maintained, or widened known healthcare disparities in testis torsion.

Methods: We identified cases of testicular torsion in pediatric patients 1-18 years of age using the Pediatric Health Information System(PHIS). Inclusion was based on CPT, ICD-9, and ICD-10 codes in ranked USNWR children’s hospitals with continuous PHIS reporting from January 2010 to December 2019. Only encounters with an associated Emergency Department visit were included. Orchiopexy without orchiectomy was considered a successful testicular salvage surgery. Rates of testicular salvage surgeries were assessed before and after institution of this USNWR metric. Statistical significance was assessed with Chi-squared and regression analyses. Subgroup analysis was performed based on race, Child Opportunity Index, income, urban flag, complexity flag, and payor type. Finally, race was assessed while controlling for all other covariates.

Results: We identified 1,615 cases of pediatric torsion in initially partial-scoring hospitals and 2,335 cases in initially complete-scoring hospitals. Among hospitals with an initial complete score, there was no significant improvement in salvage post-metric (pre-metric 65.5% vs post-metric 69.1%, p=0.08). However, for hospitals with an initial partial score, testicular salvage rates improved significantly(61.0% vs 67.5%, p=0.007). But, improvements were not uniformly observed in all subgroups[Table 1].

Improvements after the metric were largest in patients with communicative barriers to care such as those with a complex chronic condition(35.3% vs 61.1%,p=0.031) or in the youngest age group(44.7% vs 55.5%, p=0.036). There were also improvements in patients with socioeconomic barriers to care: low Child Opportunity Index(56.0% vs 65.4%, p=0.008), public insurance payor(54.4% vs 63.8%,p=0.010), and income in the lowest quartile(51.2% vs 75.0%, p=0.023).

Yet, no minority races had statistically significant improvement after the metric, and the care gap between White and non-White patients increased(4.3% vs10.0%, p< 0.05). Regression analysis showed similar findings and—after controlling for other barriers to care—Black[OR 2.96, CI: (1.14-7.65)] and Asian[OR 2.16, CI: (1.44-3.22)] races were independent predictors of failed salvage in the post-metric period[Table 2].

Conclusion: Rates of testicular torsion salvage surgeries increased following efforts to achieve the maximum score on a USNWR metric. Patients with communicative or economic barriers showed markedly reduced quality gaps but disparities persisted for minority races especially Black and Asian patients.