Overutilization of Transfer for Testicular Torsion: An Opportunity for Multilevel Policy Intervention

You have accessJournal of UrologyJU Forums1 Jan 2024Overutilization of Transfer for Testicular Torsion: An Opportunity for Multilevel Policy Intervention Emily K. Clennon, Brian Duty, and Casey Seideman Emily K. ClennonEmily K. Clennon *Corresponding Author: Emily K. Clennon, MD, MPH, Oregon Health & Science University, 3303 S Bond Ave Building 1, 10th Floor, Portland, OR 97239 ( E-mail Address: [email protected] https://orcid.org/0000-0003-0012-0785 Department of Urology, Oregon Health & Science University, Portland, Oregon More articles by this author , Brian DutyBrian Duty Department of Urology, Oregon Health & Science University, Portland, Oregon More articles by this author , and Casey SeidemanCasey Seideman Department of Urology, Oregon Health & Science University, Portland, Oregon More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003750AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail In the management of testicular torsion, there has been a gradual transition away from care within local community hospitals and toward transfer of patients to pediatric specialty centers. A nationwide analysis reported a gradual increase from 23% transfer in 2006 to 38% in 2012.1 Unpublished data from our institution show the proportion of adolescent patients transferred for torsion has increased from 66% in 2018 to 75% in 2023. The risk of testicular loss with surgical delay is widely recognized, and though delay of patient presentation is often the driving factor for orchiectomy, time spent in interhospital transfer predictably worsens outcomes. Each hour of transfer time confers a 13% increase in likelihood of testicular loss and transfer overall confers a 65% greater relative risk of testicular loss for patients presenting within 24 hours of symptom onset.2,3 In other words, this health systems–based decision may be contributing to preventable loss of testicles among adolescent patients. There are myriad potential reasons for the transfer of pediatric torsion patients to specialized centers, though most stem from institutional policy and liability rather than clinical decision-making. Some hospitals and hospital systems that do not have pediatric subspecialists/pediatric wards have policies that prevent their staff from caring for any patient under the age of 18 outside of the emergency department. Though there are rare exceptions, most torsion patients are pubertal, otherwise healthy, easily intubated, and able to be safely discharged home from the postoperative area—unlike many adult patients requiring emergent surgery. Institutional policies can and should be adaptable to allow the provision of safe and reasonable care, particularly in emergent situations. This type of adaptation was one of several recent successes to reduce transfer for torsion in Oregon. Targeting transfers within the metropolitan area, an agreement was reached with local Kaiser Permanente hospitals which previously had a policy requiring transfer of all patients <18 years old in need of emergent surgical care. Recognizing that most of these patients are pubertal and do not require admission, this policy was modified to allow treatment of patients at least 12 years old and without history or anatomy necessitating a higher level of anesthetic or surgical care. In cases where there is no policy preventing it, some local urologists or anesthesiologists choose not to provide care for minor patients given malpractice coverage limitations for this patient population. Testicular torsion is a notoriously litigious diagnosis, however most lawsuits are related to failure or delay in diagnosis with the median time to diagnosis in cases leading to malpractice claims being 3 days.4 The American Board of Urology newsletter in 2013 clarified that any board-certified urologist can perform scrotal exploration and orchiopexy for suspected testicular torsion for pediatric patients. The newsletter states that “The Board does not support the practice of urologists on call deferring routine pediatric care to subspecialty certified colleagues... there are certain conditions that are considered core to urologic training.”5 With this validation and the knowledge that treatment delay increases risk of testicular loss and provides grounds for a malpractice claim, the most logical path to reducing liability is provision of care locally. The availability of on-call urologists is another factor contributing to patient transfer. Many small hospital systems and independent hospitals lack 24/7 urology coverage, and some urologists have raised concerns that small coverage pools cannot reasonably be expected to provide emergent surgical care for all pediatric torsion patients when pediatric urologists are available relatively nearby. Potential solutions for hospitals that do not have urology coverage include utilization of general surgery or pediatric surgery service lines, as well as considering transfer to closer hospital systems with 24/7 coverage rather than a pediatric specialty center if there is a significant distance required. To help cover pediatric torsions in rural Oregon, one pediatric surgery group that does not include pediatric urology began covering testicular torsions. This coverage prevents 2 hours of travel time for patients in central and southern Oregon and alleviates the lack of 24/7 urology coverage for many rural communities. Our institution has also developed a map of all hospitals in the state with their urology coverage (no coverage, daytime only, limited/variable, 24/7). This map will be distributed to rural hospitals to promote efficient interhospital collaboration and minimization of transfer distance. These successes are not sufficient to allow or promote local care of all pediatric testicular torsion in our state, but they are clear demonstrations of what can be achieved with a diverse, multilevel approach to policymaking and collaboration. We have outlined recommendations for a more comprehensive approach to this issue in the Table—including efforts to define the standard of care as local surgical intervention to protect rural providers from malpractice claims—and hope individuals in other states and in relevant leadership positions consider working to improve this area of pediatric urologic care. Table. Examples of Policy Changes or Multi-Institutional Collaborations at Different Levels of the Health System to Promote Local Care of Pediatric Testicular Torsion Patients Health system level Recommended action Individual/individual surgical practice Educational sessions/collaborations with local adult urologists, pediatric surgeons, or general surgeons about surgical care of pediatric testicular torsion and recommendation for local provision of care Hospital/hospital system In systems with policies preventing care of minors, petition relevant leadership to adapt policies for torsion patients State Educational sessions at state urologic and/or general surgery association meetings about surgical care of pediatric testicular torsion and recommendation for local provision of care Creation of publicly available maps outlining urology call coverage at hospitals throughout the state to ease identification of nearby nonpediatric centers that can provide urgent care Request statements from state medical boards affirming urgent care in local community as standard of care for pediatric torsion patients National Request statement from Societies for Pediatric Urology affirming urgent care in local community as standard of care for pediatric torsion patients REFERENCES 1. Factors affecting pediatric patient transfer in testicular torsion. J Surg Res. 2016; 203(1):40-46. Crossref, Medline, Google Scholar 2. . Improving organ salvage in testicular torsion: comparative study of patients undergoing vs not undergoing pre-operative manual detorsion. J Urol. 2017; 197(3):811-817. Link, Google Scholar 3. . Impact of hospital transfer on testicular torsion outcomes: a systematic review of meta-analysis. J Pediatr Urol. 2021; 17(3):293.e1-293.e8. Crossref, Medline, Google Scholar 4. . Testicular torsion is overrepresented among malpractice cases for gonadal torsion. J Pediatr Surg. 2023; 58(4):762-766. Crossref, Medline, Google Scholar 5. . From the desk of Gerald H. Jordan, ABU Executive Secretary. ABU Report, Issue 21. 2013:6. Google Scholar Recusal: Dr Seideman is an AUA publications online content editor and was recused from the editorial and peer review processes. Support: None. Conflict of Interest Disclosures: The Authors have no conflicts of interest to disclose. Ethics Statement: This study was deemed exempt from Institutional Review Board review. © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 211 Issue 1 January 2024 Page: 172-173 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.Metrics Author Information Emily K. Clennon Department of Urology, Oregon Health & Science University, Portland, Oregon *Corresponding Author: Emily K. Clennon, MD, MPH, Oregon Health & Science University, 3303 S Bond Ave Building 1, 10th Floor, Portland, OR 97239 ( E-mail Address: [email protected] More articles by this author Brian Duty Department of Urology, Oregon Health & Science University, Portland, Oregon More articles by this author Casey Seideman Department of Urology, Oregon Health & Science University, Portland, Oregon More articles by this author Expand All Recusal: Dr Seideman is an AUA publications online content editor and was recused from the editorial and peer review processes. Support: None. Conflict of Interest Disclosures: The Authors have no conflicts of interest to disclose. Ethics Statement: This study was deemed exempt from Institutional Review Board review. Advertisement Advertisement PDF downloadLoading ...