Neonatal Circumcision Availability in the United States: A Physician Survey

Neonatal Circumcision Availability in the United States: A Physician Survey | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Neonatal Circumcision Availability in the United States: A Physician Survey Ushasi Naha, Hans Arora, Ryan Walton, Ilina Rosoklija, Lindsay Skibley, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-812059/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 8 You are reading this latest preprint version Abstract Background : A significant proportion of boys present to surgical specialists later in infancy/early childhood for elective operative circumcision despite the higher procedural risks. This study aims to assess physician perspectives on access to neonatal circumcision (NC) across the United States and identify potential reasons contributing to disparities in access. Methods : A cross-sectional survey was electronically distributed to physician members of the Societies for Pediatric Urology and the American Academy of Pediatrics Section on Hospital Medicine. Hospital characteristics and circumcision practices were assessed. Associations between NC availability and institutional characteristics were evaluated using chi-squared testing and multivariable logistic regression. Qualitative analyses of free-text comments were performed. Results : A total of 367 physicians responded (129 urologists [41%], 188 pediatric hospitalists [59%])). NC was available at 86% of hospitals represented. On univariate and multivariate analysis, the 50 hospitals who did not offer NC were more likely to be located in the Western region (odds ratio [OR]=8.33; 95% confidence interval [CI]=3.1-25 vs Midwest) and in an urban area (OR=4.2; 95% CI=1.6-10 vs suburban/rural) compared with hospitals that offered NC. Most common reasons for lack of availability included not a birth hospital (N=22, 47%), lack of insurance coverage (N=8, 17%), and low insurance reimbursement (N=7, 15%). Institutional, regional, or provider availability (68%), insurance/payment (12.4%), and ethics (12.4%) were common themes in the qualitative comments. Conclusions : Overall availability of neonatal circumcision varied based on hospital characteristics, including geography. Information from this survey will inform development of interventions designed to offer NC equitably and comprehensively. Urology & Nephrology neonatal circumcision access pediatrics pediatric urology Figures Figure 1 Figure 2 Figure 3 Introduction Circumcisions are the most commonly performed pediatric surgical procedure.[ 1 ] For families who seek circumcision for their sons, health benefits include the decreased risk of urinary tract infections, sexually transmitted infections and penile cancer. These benefits are greatest for boys when the circumcision is performed in the neonatal period.[ 2 ] When circumcisions are done beyond the neonatal period, there are higher complication rates,[ 3 ] and general anesthesia is required, leading to increased risks[ 4 – 8 ] and costs.[ 9 , 10 ] Over time, neonatal circumcision rates in the United States have modestly declined overall. However, boys with public insurance have had lower rates of circumcision compared to those with private insurance, even when controlling for demographics, geographic region, hospital and year of birth. Additionally, boys from lower-income families have lower rates of circumcision in comparison to boys from families with higher income.[ 11 ] This suggests that there are barriers in access underlying the differing rates of neonatal circumcision. Indeed, a study of free-standing children’s hospitals found that 28% of boys undergoing delayed surgical circumcisions were Black/African-American, and 68% of boys had public insurance.[ 12 ] After the defunding of Medicaid coverage for circumcision, state-specific rates of neonatal circumcision decreased by around 20%. In states and years without Medicaid coverage, Black infants had lower odds of undergoing neonatal circumcision.[ 13 ] Though prior data indicate differences in neonatal circumcision access by demographic factors including income, insurance type, and race, the precise reasons for these differences have not been identified. Differences in availability and efficiency of neonatal circumcision at birth hospitals may be one factor contributing to the apparent disparity in access to neonatal circumcision. The present study aims to assess physician perspectives on access to neonatal circumcision at hospitals throughout the United States, and identify potential underlying reasons contributing to disparities in access to the procedure. Our hypothesis is that neonatal circumcision availability will differ based on the geographic location and by hospital characteristics. Methods Survey Development A 21-question survey was developed to ascertain hospital characteristics and circumcision practices of institutions that care for newborns across the United States (Supplement 1). Hospital characteristics assessed included the teaching and metropolitan status, geographic region and whether the institution was public or private. We also assessed whether hospitals had a standard circumcision protocol used during the birth encounter. Availability of circumcision, including details of time, dates, payment options and specialties that perform circumcisions, as well as circumcision exclusion criteria, were collected. The last question was a free-text question where respondents could add any further comments about the availability of neonatal circumcisions at their institution or in their region. The study was approved by the Ann & Robert H. Lurie Children’s Hospital of Chicago Institutional Review Board and the need for obtaining informed consent from subjects was waived (IRB 2020–3505). Survey Distribution A cross-sectional, anonymous survey was electronically distributed to physician members of the Societies for Pediatric Urology (SPU) and the American Academy of Pediatrics (AAP) Section on Hospital Medicine through organizational email lists. Responses were collected starting on March 31 until May 12, 2020. One reminder email was sent to AAP members and two reminder emails were sent to the SPU email lists. Survey responses were recorded and stored without participant identifiers using REDcap.[ 14 ] Analysis Descriptive statistics were used to summarize survey respondents and characteristics at institutions that perform circumcisions. Univariate comparisons of hospital characteristics and circumcision practices between institutions that do and do not perform circumcisions were performed using Pearson chi-square tests. Multivariable logistic regression was performed to assess adjusted associations between institutional characteristics and circumcision availability. Covariates were initially determined a priori, taking into account the statistical significance of covariates in the univariate analysis. Covariates in the regression model included geographic region, private versus public institution, metropolitan status and teaching status. Regression analyses were displayed using forest plots. All statistical analyses were performed using R 4.0.0 (R Foundation for Statistical Computing, Vienna, Austria) using 95% confidence intervals with two-sided p-values < 0.05 considered significant. An inductive, qualitative analysis of free-text comments about neonatal circumcision availability was performed, and key themes were summarized. Results Cohort Characteristics A total of 367 physicians (165 pediatric urologists [45%], 202 pediatric hospitalists [55%]; Table 1 ) responded to the survey, with an estimated response rate of 9.5% (pediatric hospitalists: 6%; pediatric urologists: 23%). Response rates were estimated based on the number of clinicians on the organizational email lists. Most respondents (317/367 [86%]) reported neonatal circumcision availability at their institution. The geographic distribution by US region was relatively even (South: 31%, Midwest: 28%, West: 23%, Northeast: 17%). Most respondents worked at private, non-profit institutions (66%) in urban settings (66%) that were teaching hospitals (82%). Table 1 Univariate Analysis of Respondents and Hospital Characteristics Total (N = 367) Circumcisions offered (N = 317) Circumcisions not offered (N = 50) p-value Region < 0.001* Midwest 101 (27.5%) 95 (30.0%) 6 (12.0%) Northeast 62 (16.9%) 61 (19.2%) 1 (2.0%) South 114 (31.1%) 102 (32.2%) 12 (24.0%) West 85 (23.2%) 58 (18.3%) 27 (54.0%) Other 4 (1.1%) 1 (0.3%) 3 (6.0%) No response 1 (0.3%) 0 (0.0%) 1 (2.0%) Type of Institution 0.307 Private for Profit 36 (9.8%) 29 (9.1%) 7 (14.0%) Private Non-profit 243 (66.2%) 206 (65.0%) 37 (74.0%) Public 69 (18.8%) 63 (19.9%) 6 (12.0%) Uncertain 14 (3.8%) 14 (4.4%) 0 (0.0%) Other 4 (1.1%) 4 (1.3%) 0 (0.0%) No response 1 (0.3%) 1 (0.3%) 0 (0.0%) Metropolitan Status 0.002* Suburban/Rural 124 (33.8%) 118 (37.2%) 6 (12.0%) Urban 241 (65.7%) 197 (62.1%) 44 (88.0%) Other 2 (0.5%) 2 (0.6%) 0 (0.0%) Teaching Status 0.885 Non-Teaching 59 (16.1%) 50 (15.8%) 9 (18.0%) Teaching 301 (82.0%) 261 (82.3%) 40 (80.0%) Don’t Know/Uncertain 5 (1.4%) 4 (1.3%) 1 (2.0%) No response 2 (0.5%) 2 (0.6%) 0 (0.0%) Respondent Specialty < 0.001* Pediatric Urology 165 (45.0%) 129 (40.7%) 36 (72.0%) Pediatric Hospitalist 202 (55.0%) 188 (59.3%) 14 (28.0%) * indicates statistical significance Comparison of Institutions by Circumcision Availability Table 1 compares characteristics of respondents and hospitals offering vs not offering neonatal circumcisions. More pediatric hospitalists than pediatric urologists were from institutions that offered circumcisions (59% vs 41%), whereas 72% of respondents from institutions that did not offer circumcisions were pediatric urologists (vs. 28% pediatric hospitalists; p < 0.001). A difference by geographic region was also observed: hospitals in the South were most frequently represented among hospitals that offered circumcisions whereas hospitals in the Western region were most represented among hospitals that did not offer circumcisions (p < 0.001). Urban institutions were more highly represented among hospitals that did not offer circumcisions compared to those that do (88% vs 62%, respectively, p = 0.002). On multivariate analysis, the 50 hospitals that did not offer neonatal circumcision were more likely to be located in the Western region (odds ratio [OR] = 8.33; 95% confidence interval [CI] = 3.1–25 vs Midwest), and in an urban area (OR = 4.2; 95% CI = 1.6–10 vs suburban/rural), compared with hospitals that offered the procedure (Fig. 1 ). Institutional Factors Table 2 displays characteristics of hospitals that offer neonatal circumcision. A standardized protocol/checklist was available at less than half of hospitals. Many specialties performed circumcisions including Pediatrics (74%), Obstetrics and Gynecology (57%), Pediatric Urology (54%), Family Medicine (31%) and Pediatric Surgery (31%), with variability depending on setting and type of anesthesia (Fig. 2 ). Pediatric Urology most frequently performed outpatient procedures without or under general anesthesia (56% and 80%, respectively), while Pediatrics most commonly performed circumcisions at the birth encounter without general anesthesia (70%). Hospitals offering neonatal circumcision had more availability on weekdays vs. weekends, and only 21% offered the procedure 24 hours per day. Most hospitals reported accepting private insurance (79%) and slightly fewer accepted Medicaid (64%) for neonatal circumcision. Over half (56%) reported that at least some patients paid cash for the procedure. Table 2 Characteristics at Institutions that Perform Circumcisions (N = 317) Characteristics N (%) Standard protocol, checklist, or similar that is used during the birth encounter that includes offering or performing circumcision Yes 139 (43.4%) No 133 (41.6%) Don’t Know/Unsure 44 (13.8%) No response 1 (0.3%) Who must initiate conversations about circumcision? Either hospital team or family 250 (78.9%) Family 20 (6.3%) Hospital Team 10 (3.2%) Don’t Know/Uncertain 6 (1.9%) Other 31 (9.8%) Entity that developed this protocol, checklist, or similar Institution 59 (18.4%) Department 34 (10.6%) Group Practice 21 (6.6%) Self 6 (1.9%) Government 1 (0.3%) Don’t Know/Unsure 106 (33.1%) Other 1 6 (1.9%) No response 84 (26.3%) Exclusion criteria at birth encounter for neonatal circumcision Penile Anatomic Abnormality (e.g., Hypospadias, Curvature, Buried Penis) 312 (97.5%) Family History of Bleeding Disorder 233 (72.8%) Prematurity 47 (14.7%) Weight Limit 38 (11.9%) Older Age at Discharge 35 (10.9%) Neonatal Intensive Care Unit 25 (7.8%) Other Exclusion 2 48 (15.0%) Days that neonatal circumcision is available Monday 262 (82.6%) Tuesday 261 (82.3%) Wednesday 262 (82.6%) Thursday 261 (82.3%) Friday 261 (82.3%) Saturday 246 (77.6%) Sunday 242 (76.3%) Don’t Know/Unsure 55 (17.4%) Times neonatal circumcision is available during birth encounter Regular Business Hours (Approximately 08:00 AM – 05:00 PM) 165 (51.6%) 24 Hours per Day 67 (20.9%) Don’t Know/Unsure 56 (17.5%) Other 3 25 (7.8%) No response 4 (1.3%) Specialty that performs neonatal circumcisions at institution Pediatrics 233 (73.5%) Obstetrics & Gynecology 181 (57.1%) Pediatric Urology 170 (53.6%) Family Medicine 98 (30.9%) Pediatric Surgery 97 (30.6%) Adult Urology 9 (2.8%) Other 4 7 (2.2%) Don’t Know/Unsure 3 (0.9%) Payment for Neonatal Circumcision Private Insurance 251 (79.4%) Medicaid 205 (64.9%) Self-Pay/Cash 177 (56.0%) Don’t Know/Unsure 53 (16.8%) Other 8 6 (1.9%) 1 Other entities: labor and delivery department, individual hospital unit, and pediatric urology 2 Other exclusions: refusal of Vitamin K, heart murmurs, hyperbilirubinemia, oxygen monitoring and poor feeding 3 Other time ranges: 8am – 9am, 8am – 10pm, every day at noon, only in the mornings and based on the availability of providers performing circumcisions, 4 Other specialties: general surgery, hospitalist (adult, pediatric), midwife, neonatology, nurse practitioner 5 Other specialties: hospitalist (adult, pediatric), neonatology 6 Other specialties: hospitalist, pediatrics, adult urology, and no one 7 Other specialties: general surgery, no one at their institution, or referred to another facility 8 Other payments: covered benefit through plan, hospital writes off the cost or covers if Medicaid, military, and Tricare For the 50 respondents from hospitals that did not offer neonatal circumcision, the most common reasons cited for lack of availability included: not a birth hospital (N = 22, 47%), lack of insurance coverage (N = 8, 17%), and low insurance reimbursement (N = 7, 15%), (Fig. 3 ). Qualitative Comments There were 105 free-text comments left by respondents (Table 3 ) when they were asked, “Do you have any other comments about availability of circumcision at your institution or in your region?”. Institutional, regional, or provider availability (N = 71, 68%), insurance and payment (N = 13, 12.4%), and ethics (N = 13, 12.4%) were the most common themes. Within the availability and payment themes, there were varied responses that highlighted either the ease or barriers to neonatal circumcision availability. Regarding ethics, several respondents indicated that they had ethical concerns with performing circumcisions as a routine/elective procedure. Table 3 Themes of Respondents’ Free-Text Comments (N = 105) Theme Frequency Representative Quotation Circumcision availability at institution or region 41 (39.0%) “If a family wants to have it done it is easy to get it performed” “There are no in-hospital postpartum circumcisions in the state of Nevada” Provider availability 30 (28.6%) “Providers can opt out of requested circumcision. This is increasing and parents are left to find circumcision services” “I get a lot of outpatient referrals because the rounding OB wasn't ‘comfortable’ performing circs or logistically there wasn't time to have it done before the family was discharged.” Insurance and payment 13 (12.4%) “The major limitation is financial - may families can not afford to self-pay, and Medicaid and most private insurances do not cover neonatal circumcisions in our state.” “…we accept Medicaid reimbursement so patients then don't have to pay anything. We really [don’t] let it [be] known too much that we do [them] in the office and don't charge Medicaid because it would be too many coming.” Ethics and personal opinions 13 (12.4%) “If this is being performed for cosmetic reasons only, it should not be permitted” “Just laying out my own bias that we should not do these (routine elective) procedures anymore. Sure there are indications and personal/cultural reasons but they could be outpatient.” Circumcision eligibility 11 (10.5%) “Excluded if family refuses Vitamin K at birth” “Some OBs will not do the circumcision, for prematurity (arbitrary cutoff), if the penis is too small, or if they are NICU.” Uncertainty about circumcision practices 6 (5.7%) “Unfortunately, not sure of exact weight limit at my institution” “Unsure what the practice is for premature infants at my institution” Discussion This survey of U.S. pediatric urologists and hospitalists indicates that neonatal circumcision availability and practices vary by hospital, region, and specialty. Approximately 1 in 6 respondents were from hospitals that do not offer neonatal circumcision. Multiple specialties performed neonatal circumcisions; pediatric urologists most frequently performed outpatient procedures with or without general anesthesia, and pediatrics most frequently performed circumcisions at the birth encounter without general anesthesia. At institutions that did offer circumcision, availability was most common during the week and during regular business hours. Almost 1 in 3 respondents added free-text comments, indicating general interest in the topic of neonatal circumcision availability. The comments provided additional insight about circumcision availability in their institution or region, provider availability or payment. Information from the current survey study confirms findings of existing large database investigations about circumcision practice patterns and trends. Regarding circumcision practitioner specialty, the present study findings are similar to a recent study using Pediatric Health Information Systems data by Many et al., which showed that pediatrics, obstetrics-gynecology, and perinatal medicine most commonly performed neonatal circumcisions. Beyond the neonatal period, pediatric urologists most commonly performed circumcisions in the study by Many,[ 15 ] a finding also echoed in our survey. The regional and insurance coverage trends indicated by the present survey are also aligned with prior studies using national databases. While American Academy of Pediatrics recommends coverage for all desired neonatal circumcisions,[ 2 ] a recent study by Navia et. al shows that male infants with private insurance had higher rates of neonatal circumcision.[ 13 ] Our study respondents indicate that private insurance is more frequently accepted as payment for neonatal circumcision, and that some families pay cash; thus financial barriers to desired circumcisions appear to exist for families with fewer financial resources. The present study also adds the clinician perspective to data from prior parent surveys about newborn circumcision access and reasons for delay. In the present physician survey, the most common reasons neonatal circumcision was not offered included the institution was not a birth hospital, the procedure was not covered by insurance, and low insurance reimbursement. Similarly, Jacobson et. al found that among patients seeking elective circumcision, one of the most common reasons for delay in desired neonatal circumcision in the Chicago area was that the hospital or physician did not perform neonatal circumcision; additional factors included prematurity, penile abnormality and low birth weight.[ 16 ] A 2016 survey of parents in San Antonio seeking delayed circumcision for boys less than 2 years old reported reasons for delay of circumcision beyond the newborn period included impaired proceduralist availability and lack of circumcision availability at the birth hospital.[ 17 ] Our study results reinforce findings in the larger body of literature that specialty/institutional availability and payment coverage are crucial factors in determining access to neonatal circumcision. To gain a more comprehensive understanding about why certain institutions experience limited circumcision availability, we are currently conducting a qualitative interview-based study of clinicians who perform circumcisions about this topic. Future studies will also focus on the development of efficient neonatal circumcision workflows for different hospital types and determine the most optimal recommendations for public and private insurance coverage of neonatal circumcision. While the current study provides an important physician perspective on the topic of access to neonatal circumcision, there are study limitations. The survey response was relatively low, particularly amongst pediatric hospitalists. However, findings largely align with previous studies about both circumcision trends and reasons for difficulty with access, suggesting the validity of the findings. Respondents only included pediatric urologists and pediatricians, and therefore does not represent all specialties that perform circumcisions. For some survey questions, around 15–25% of respondents were uncertain or did not respond. As such, insight about certain subtopics was suboptimal, including questions about a standardized protocol, exclusion criteria for neonatal circumcision, days of the week that circumcision were available, and reasons that institutions did not offer neonatal circumcision. Limited demographic information was ascertained for the sake of brevity and to maintain the anonymity of respondents. Therefore, some respondents could represent the same institutions, thus creating redundancy in responses. Conclusions The availability of neonatal circumcision varies based on hospital characteristics, including geographic location. Specialties that perform neonatal circumcision depend on setting and type of anesthesia used. Follow up research is currently focused on the institutional level to better understand potential local barriers to neonatal circumcision availability. The eventual goal is the creation of hospital-based and financial incentive structural strategies to ensure equitable access for neonatal circumcisions. Abbreviations AAP: American Academy of Pediatrics CI: confidence interval OR: odds ratio NC: neonatal circumcision SPU: Societies for Pediatric Urology Declarations Ethics approval and consent to participate: The study was approved by the Ann & Robert H. Lurie Children’s Hospital of Chicago Institutional Review Board and the need for obtaining informed consent from subjects was waived (IRB 2020-3505). All methods were performed in accordance with the relevant guidelines and this study was granted exemption by a Lurie Children’s IRB for reasons of it consisting of only surveys (that do not include children). Lurie Children’s IRB approved of waived consent due to participants only completing surveys, thus the research involves no more than minimal risk to subjects. Consent for publication: Not applicable. Availability of data and materials: The datasets generated and/or analyzed during the current study are available from the corresponding author on request. Competing interests: The authors declare that they have no competing interests Funding: None. Authors' contributions: EKJ, IR and HA conceived of the research project, with contribution from LS. EKJ supervised UN to analyze and interpret this data, and UN drafted the initial the manuscript. RFW built the survey, distributed the survey to participants via REDCap and assisted with manuscript drafting. All authors contributed to results interpretation, reviewed and edited the manuscript and approved of the final version. Acknowledgements: None. References Pfuntner A, Wier LM, Stocks C. 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Many BT, Rizeq YK, Vacek J, Cheon EC, Johnson E, Hu YY, et al. A contemporary snapshot of circumcision in US children’s hospitals. J Pediatr Surg 2020;55:1134–8. https://doi.org/10.1016/j.jpedsurg.2020.02.031. Jacobson DL, D’Oro A, Abdullah F, Barsness KA, Liu DB, Maizels M, et al. Caregiver Reported Reasons for Delay of Neonatal Circumcision. Urology 2020;140:143–9. https://doi.org/10.1016/j.urology.2020.01.043. Otto R, Evans G, Boniquit C, Peppas D, Leslie J. Why Desired Newborn Circumcisions Are Not Performed: A Survey. Urology 2016;97:188–93. https://doi.org/10.1016/j.urology.2016.06.054. Supplemental File Supplemental File is not available with this version. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Under Review Version 1 posted Editorial decision: Major revision 16 Sep, 2021 Reviews received at journal 07 Sep, 2021 Reviewers agreed at journal 02 Sep, 2021 Reviewers invited by journal 02 Sep, 2021 Editor assigned by journal 02 Sep, 2021 Editor invited by journal 02 Sep, 2021 Submission checks completed at journal 02 Sep, 2021 First submitted to journal 13 Aug, 2021 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-812059","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":49653548,"identity":"1d1be8cc-19d0-4bce-9cb2-10262289efc5","order_by":0,"name":"Ushasi Naha","email":"","orcid":"","institution":"University of Illinois College of Medicine","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Ushasi","middleName":"","lastName":"Naha","suffix":""},{"id":49653549,"identity":"6dff678b-7efc-402a-84cf-37414c91216f","order_by":1,"name":"Hans Arora","email":"","orcid":"","institution":"Division of Urology, Ann \u0026 Robert H. Lurie Children’s Hospital of Chicago","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Hans","middleName":"","lastName":"Arora","suffix":""},{"id":49653550,"identity":"561f708f-0d99-479a-b337-675b49a9a5db","order_by":2,"name":"Ryan Walton","email":"","orcid":"","institution":"Division of Urology, Ann \u0026 Robert H. Lurie Children’s Hospital of Chicago","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Ryan","middleName":"","lastName":"Walton","suffix":""},{"id":49653551,"identity":"d9e155ba-8aa9-46e3-aeea-f29d07ceb7d9","order_by":3,"name":"Ilina Rosoklija","email":"","orcid":"","institution":"Division of Urology, Ann \u0026 Robert H. Lurie Children’s Hospital of Chicago","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Ilina","middleName":"","lastName":"Rosoklija","suffix":""},{"id":49653553,"identity":"7903abb9-95de-4c24-8314-ae394e843468","order_by":4,"name":"Lindsay Skibley","email":"","orcid":"","institution":"Department of Pediatrics, Northwestern University Feinberg School of Medicine","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Lindsay","middleName":"","lastName":"Skibley","suffix":""},{"id":49653555,"identity":"feda3f62-467c-4b62-8371-f7755f3b564f","order_by":5,"name":"Emilie Johnson","email":"data:image/png;base64,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","orcid":"","institution":"Division of Urology, Ann \u0026 Robert H. Lurie Children’s Hospital of Chicago","correspondingAuthor":true,"submittingAuthor":false,"prefix":"","firstName":"Emilie","middleName":"","lastName":"Johnson","suffix":""}],"badges":[],"createdAt":"2021-08-13 22:44:02","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-812059/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-812059/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":13058102,"identity":"50ef125e-7569-4cd5-96c3-6a9466e87376","added_by":"auto","created_at":"2021-09-03 16:33:25","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":140476,"visible":true,"origin":"","legend":"Factors Associated with Institutions that Offer Circumcisions","description":"","filename":"Figure1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-812059/v1/cbb5af1f647ea097b24a11fd.jpg"},{"id":13058196,"identity":"d37f4dfb-ee8f-4b71-a3c3-587221b16f32","added_by":"auto","created_at":"2021-09-03 16:36:25","extension":"jpg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":51117,"visible":true,"origin":"","legend":"Specialties that Perform Circumcisions (N = 317) ","description":"","filename":"Figure2.jpg","url":"https://assets-eu.researchsquare.com/files/rs-812059/v1/50c189fbb7208d730664bebb.jpg"},{"id":13058233,"identity":"4dfcab58-64be-4c2f-96a9-c801dfd4b24e","added_by":"auto","created_at":"2021-09-03 16:39:25","extension":"jpg","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":65946,"visible":true,"origin":"","legend":"Reasons Institutions Do Not Offer Neonatal Circumcisions * Other reasons included high inpatient volume (1), high facility charges (1) and because providers/specialties stopped offering (2). ","description":"","filename":"Figure3.jpg","url":"https://assets-eu.researchsquare.com/files/rs-812059/v1/8bfe0e4a9a6a09844fdd0baf.jpg"},{"id":13713399,"identity":"8a74c63a-a3de-4e2c-85d4-b4b7a0ad2dbf","added_by":"auto","created_at":"2021-09-17 14:32:49","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":505448,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-812059/v1/bd057085-1903-41c6-b8e9-e2cb93cd08ce.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Neonatal Circumcision Availability in the United States: A Physician Survey","fulltext":[{"header":"Introduction","content":"\u003cp\u003eCircumcisions are the most commonly performed pediatric surgical procedure.[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e] For families who seek circumcision for their sons, health benefits include the decreased risk of urinary tract infections, sexually transmitted infections and penile cancer. These benefits are greatest for boys when the circumcision is performed in the neonatal period.[\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e] When circumcisions are done beyond the neonatal period, there are higher complication rates,[\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e] and general anesthesia is required, leading to increased risks[\u003cspan additionalcitationids=\"CR5 CR6 CR7\" citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e] and costs.[\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]\u003c/p\u003e \u003cp\u003eOver time, neonatal circumcision rates in the United States have modestly declined overall. However, boys with public insurance have had lower rates of circumcision compared to those with private insurance, even when controlling for demographics, geographic region, hospital and year of birth. Additionally, boys from lower-income families have lower rates of circumcision in comparison to boys from families with higher income.[\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e] This suggests that there are barriers in access underlying the differing rates of neonatal circumcision. Indeed, a study of free-standing children\u0026rsquo;s hospitals found that 28% of boys undergoing delayed surgical circumcisions were Black/African-American, and 68% of boys had public insurance.[\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e] After the defunding of Medicaid coverage for circumcision, state-specific rates of neonatal circumcision decreased by around 20%. In states and years without Medicaid coverage, Black infants had lower odds of undergoing neonatal circumcision.[\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]\u003c/p\u003e \u003cp\u003eThough prior data indicate differences in neonatal circumcision access by demographic factors including income, insurance type, and race, the precise reasons for these differences have not been identified. Differences in availability and efficiency of neonatal circumcision at birth hospitals may be one factor contributing to the apparent disparity in access to neonatal circumcision. The present study aims to assess physician perspectives on access to neonatal circumcision at hospitals throughout the United States, and identify potential underlying reasons contributing to disparities in access to the procedure. Our hypothesis is that neonatal circumcision availability will differ based on the geographic location and by hospital characteristics.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eSurvey Development\u003c/h2\u003e \u003cp\u003eA 21-question survey was developed to ascertain hospital characteristics and circumcision practices of institutions that care for newborns across the United States (Supplement 1). Hospital characteristics assessed included the teaching and metropolitan status, geographic region and whether the institution was public or private. We also assessed whether hospitals had a standard circumcision protocol used during the birth encounter. Availability of circumcision, including details of time, dates, payment options and specialties that perform circumcisions, as well as circumcision exclusion criteria, were collected. The last question was a free-text question where respondents could add any further comments about the availability of neonatal circumcisions at their institution or in their region. The study was approved by the Ann \u0026amp; Robert H. Lurie Children\u0026rsquo;s Hospital of Chicago Institutional Review Board and the need for obtaining informed consent from subjects was waived (IRB 2020\u0026ndash;3505).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003eSurvey Distribution\u003c/h2\u003e \u003cp\u003eA cross-sectional, anonymous survey was electronically distributed to physician members of the Societies for Pediatric Urology (SPU) and the American Academy of Pediatrics (AAP) Section on Hospital Medicine through organizational email lists. Responses were collected starting on March 31 until May 12, 2020. One reminder email was sent to AAP members and two reminder emails were sent to the SPU email lists. Survey responses were recorded and stored without participant identifiers using REDcap.[\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003eAnalysis\u003c/h2\u003e \u003cp\u003eDescriptive statistics were used to summarize survey respondents and characteristics at institutions that perform circumcisions. Univariate comparisons of hospital characteristics and circumcision practices between institutions that do and do not perform circumcisions were performed using Pearson chi-square tests. Multivariable logistic regression was performed to assess adjusted associations between institutional characteristics and circumcision availability. Covariates were initially determined a priori, taking into account the statistical significance of covariates in the univariate analysis. Covariates in the regression model included geographic region, private versus public institution, metropolitan status and teaching status. Regression analyses were displayed using forest plots. All statistical analyses were performed using R 4.0.0 (R Foundation for Statistical Computing, Vienna, Austria) using 95% confidence intervals with two-sided p-values\u0026thinsp;\u0026lt;\u0026thinsp;0.05 considered significant. An inductive, qualitative analysis of free-text comments about neonatal circumcision availability was performed, and key themes were summarized.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cdiv class=\"Section2\" id=\"Sec7\"\u003e\n \u003ch2\u003eCohort Characteristics\u003c/h2\u003e\n \u003cp\u003eA total of 367 physicians (165 pediatric urologists [45%], 202 pediatric hospitalists [55%]; Table \u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e) responded to the survey, with an estimated response rate of 9.5% (pediatric hospitalists: 6%; pediatric urologists: 23%). Response rates were estimated based on the number of clinicians on the organizational email lists. Most respondents (317/367 [86%]) reported neonatal circumcision availability at their institution. The geographic distribution by US region was relatively even (South: 31%, Midwest: 28%, West: 23%, Northeast: 17%). Most respondents worked at private, non-profit institutions (66%) in urban settings (66%) that were teaching hospitals (82%).\u003c/p\u003e\n \u003cdiv class=\"gridtable\"\u003e\n \u003ctable border=\"1\" id=\"Tab1\"\u003e\n \u003ccaption\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003eUnivariate Analysis of Respondents and Hospital Characteristics\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eTotal\u003c/p\u003e\n \u003cp\u003e(N\u0026thinsp;=\u0026thinsp;367)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eCircumcisions offered\u003c/p\u003e\n \u003cp\u003e(N\u0026thinsp;=\u0026thinsp;317)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eCircumcisions not offered\u003c/p\u003e\n \u003cp\u003e(N\u0026thinsp;=\u0026thinsp;50)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003ep-value\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eRegion\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"3\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026lt;\u0026thinsp;0.001*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMidwest\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e101 (27.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e95 (30.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e6 (12.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNortheast\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e62 (16.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e61 (19.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1 (2.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eSouth\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e114 (31.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e102 (32.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e12 (24.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eWest\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e85 (23.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e58 (18.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e27 (54.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eOther\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4 (1.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1 (0.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3 (6.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNo response\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1 (0.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0 (0.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1 (2.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eType of Institution\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"3\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.307\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePrivate for Profit\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e36 (9.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e29 (9.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e7 (14.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePrivate Non-profit\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e243 (66.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e206 (65.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e37 (74.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePublic\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e69 (18.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e63 (19.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e6 (12.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eUncertain\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e14 (3.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e14 (4.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0 (0.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eOther\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4 (1.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4 (1.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0 (0.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNo response\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1 (0.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1 (0.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0 (0.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMetropolitan Status\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"3\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.002*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eSuburban/Rural\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e124 (33.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e118 (37.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e6 (12.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eUrban\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e241 (65.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e197 (62.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e44 (88.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eOther\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2 (0.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2 (0.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0 (0.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eTeaching Status\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"3\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.885\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNon-Teaching\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e59 (16.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e50 (15.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e9 (18.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eTeaching\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e301 (82.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e261 (82.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e40 (80.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eDon\u0026rsquo;t Know/Uncertain\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e5 (1.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4 (1.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1 (2.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNo response\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2 (0.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2 (0.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0 (0.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eRespondent Specialty\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"3\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026lt;\u0026thinsp;0.001*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePediatric Urology\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e165 (45.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e129 (40.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e36 (72.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePediatric Hospitalist\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e202 (55.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e188 (59.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e14 (28.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"5\"\u003e\n \u003cp\u003e* indicates statistical significance\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n \u003c/div\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv class=\"Section2\" id=\"Sec8\"\u003e\n \u003ch2\u003eComparison of Institutions by Circumcision Availability\u003c/h2\u003e\n \u003cp\u003eTable\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e compares characteristics of respondents and hospitals offering vs not offering neonatal circumcisions. More pediatric hospitalists than pediatric urologists were from institutions that offered circumcisions (59% vs 41%), whereas 72% of respondents from institutions that did not offer circumcisions were pediatric urologists (vs. 28% pediatric hospitalists; p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). A difference by geographic region was also observed: hospitals in the South were most frequently represented among hospitals that offered circumcisions whereas hospitals in the Western region were most represented among hospitals that did not offer circumcisions (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Urban institutions were more highly represented among hospitals that did not offer circumcisions compared to those that do (88% vs 62%, respectively, p\u0026thinsp;=\u0026thinsp;0.002). On multivariate analysis, the 50 hospitals that did not offer neonatal circumcision were more likely to be located in the Western region (odds ratio [OR]\u0026thinsp;=\u0026thinsp;8.33; 95% confidence interval [CI]\u0026thinsp;=\u0026thinsp;3.1\u0026ndash;25 vs Midwest), and in an urban area (OR\u0026thinsp;=\u0026thinsp;4.2; 95% CI\u0026thinsp;=\u0026thinsp;1.6\u0026ndash;10 vs suburban/rural), compared with hospitals that offered the procedure (Fig.\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv class=\"Section2\" id=\"Sec9\"\u003e\n \u003ch2\u003eInstitutional Factors\u003c/h2\u003e\n \u003cp\u003eTable \u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003e displays characteristics of hospitals that offer neonatal circumcision. A standardized protocol/checklist was available at less than half of hospitals. Many specialties performed circumcisions including Pediatrics (74%), Obstetrics and Gynecology (57%), Pediatric Urology (54%), Family Medicine (31%) and Pediatric Surgery (31%), with variability depending on setting and type of anesthesia (Fig. \u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003e). Pediatric Urology most frequently performed outpatient procedures without or under general anesthesia (56% and 80%, respectively), while Pediatrics most commonly performed circumcisions at the birth encounter without general anesthesia (70%). Hospitals offering neonatal circumcision had more availability on weekdays vs. weekends, and only 21% offered the procedure 24 hours per day. Most hospitals reported accepting private insurance (79%) and slightly fewer accepted Medicaid (64%) for neonatal circumcision. Over half (56%) reported that at least some patients paid cash for the procedure.\u003c/p\u003e\n \u003cdiv class=\"gridtable\"\u003e\n \u003ctable border=\"1\" id=\"Tab2\"\u003e\n \u003ccaption\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003eCharacteristics at Institutions that Perform Circumcisions (N\u0026thinsp;=\u0026thinsp;317)\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eCharacteristics\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eN (%)\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003eStandard protocol, checklist, or similar that is used during the birth encounter that includes offering or performing circumcision\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e139 (43.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e133 (41.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eDon\u0026rsquo;t Know/Unsure\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e44 (13.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNo response\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1 (0.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003eWho must initiate conversations about circumcision?\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eEither hospital team or family\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e250 (78.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eFamily\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e20 (6.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eHospital Team\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e10 (3.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eDon\u0026rsquo;t Know/Uncertain\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e6 (1.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eOther\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e31 (9.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003eEntity that developed this protocol, checklist, or similar\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eInstitution\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e59 (18.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eDepartment\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e34 (10.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eGroup Practice\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e21 (6.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eSelf\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e6 (1.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eGovernment\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1 (0.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eDon\u0026rsquo;t Know/Unsure\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e106 (33.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eOther\u003csup\u003e1\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e6 (1.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNo response\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e84 (26.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003eExclusion criteria at birth encounter for neonatal circumcision\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePenile Anatomic Abnormality (e.g.,\u003c/p\u003e\n \u003cp\u003eHypospadias, Curvature, Buried Penis)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e312 (97.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eFamily History of Bleeding Disorder\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e233 (72.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePrematurity\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e47 (14.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eWeight Limit\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e38 (11.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eOlder Age at Discharge\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e35 (10.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNeonatal Intensive Care Unit\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e25 (7.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eOther Exclusion\u003csup\u003e2\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e48 (15.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003eDays that neonatal circumcision is available\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMonday\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e262 (82.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eTuesday\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e261 (82.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eWednesday\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e262 (82.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eThursday\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e261 (82.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eFriday\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e261 (82.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eSaturday\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e246 (77.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eSunday\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e242 (76.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eDon\u0026rsquo;t Know/Unsure\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e55 (17.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003eTimes neonatal circumcision is available during birth encounter\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eRegular Business Hours (Approximately\u003c/p\u003e\n \u003cp\u003e08:00 AM \u0026ndash; 05:00 PM)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e165 (51.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e24 Hours per Day\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e67 (20.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eDon\u0026rsquo;t Know/Unsure\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e56 (17.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eOther\u003csup\u003e3\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e25 (7.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNo response\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4 (1.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003eSpecialty that performs neonatal circumcisions at institution\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePediatrics\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e233 (73.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eObstetrics \u0026amp; Gynecology\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e181 (57.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePediatric Urology\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e170 (53.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eFamily Medicine\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e98 (30.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePediatric Surgery\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e97 (30.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAdult Urology\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e9 (2.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eOther\u003csup\u003e4\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e7 (2.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eDon\u0026rsquo;t Know/Unsure\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3 (0.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003ePayment for Neonatal Circumcision\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePrivate Insurance\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e251 (79.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMedicaid\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e205 (64.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eSelf-Pay/Cash\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e177 (56.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eDon\u0026rsquo;t Know/Unsure\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e53 (16.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eOther\u003csup\u003e8\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e6 (1.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e\u003csup\u003e1\u003c/sup\u003e Other entities: labor and delivery department, individual hospital unit, and pediatric urology\u003c/p\u003e\n \u003cp\u003e\u003csup\u003e2\u003c/sup\u003e Other exclusions: refusal of Vitamin K, heart murmurs, hyperbilirubinemia, oxygen monitoring and poor feeding\u003c/p\u003e\n \u003cp\u003e\u003csup\u003e3\u003c/sup\u003e Other time ranges: 8am \u0026ndash; 9am, 8am \u0026ndash; 10pm, every day at noon, only in the mornings and based on the availability of providers performing circumcisions,\u003c/p\u003e\n \u003cp\u003e\u003csup\u003e4\u003c/sup\u003e Other specialties: general surgery, hospitalist (adult, pediatric), midwife, neonatology, nurse practitioner\u003c/p\u003e\n \u003cp\u003e\u003csup\u003e5\u003c/sup\u003e Other specialties: hospitalist (adult, pediatric), neonatology\u003c/p\u003e\n \u003cp\u003e\u003csup\u003e6\u003c/sup\u003e Other specialties: hospitalist, pediatrics, adult urology, and no one\u003c/p\u003e\n \u003cp\u003e\u003csup\u003e7\u003c/sup\u003e Other specialties: general surgery, no one at their institution, or referred to another facility\u003c/p\u003e\n \u003cp\u003e\u003csup\u003e8\u003c/sup\u003eOther payments: covered benefit through plan, hospital writes off the cost or covers if Medicaid, military, and Tricare\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n \u003c/div\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eFor the 50 respondents from hospitals that did not offer neonatal circumcision, the most common reasons cited for lack of availability included: not a birth hospital (N\u0026thinsp;=\u0026thinsp;22, 47%), lack of insurance coverage (N\u0026thinsp;=\u0026thinsp;8, 17%), and low insurance reimbursement (N\u0026thinsp;=\u0026thinsp;7, 15%), (Fig.\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv class=\"Section2\" id=\"Sec10\"\u003e\n \u003ch2\u003eQualitative Comments\u003c/h2\u003e\n \u003cp\u003eThere were 105 free-text comments left by respondents (Table \u003cspan class=\"InternalRef\"\u003e3\u003c/span\u003e) when they were asked, \u0026ldquo;Do you have any other comments about availability of circumcision at your institution or in your region?\u0026rdquo;. Institutional, regional, or provider availability (N\u0026thinsp;=\u0026thinsp;71, 68%), insurance and payment (N\u0026thinsp;=\u0026thinsp;13, 12.4%), and ethics (N\u0026thinsp;=\u0026thinsp;13, 12.4%) were the most common themes. Within the availability and payment themes, there were varied responses that highlighted either the ease or barriers to neonatal circumcision availability. Regarding ethics, several respondents indicated that they had ethical concerns with performing circumcisions as a routine/elective procedure.\u003c/p\u003e\n \u003cdiv class=\"gridtable\"\u003e\n \u003ctable border=\"1\" id=\"Tab3\"\u003e\n \u003ccaption\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003eThemes of Respondents\u0026rsquo; Free-Text Comments (N\u0026thinsp;=\u0026thinsp;105)\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eTheme\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eFrequency\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eRepresentative Quotation\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eCircumcision availability at institution or region\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e41 (39.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;If a family wants to have it done it is easy to get it performed\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;There are no in-hospital postpartum circumcisions in the state of Nevada\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eProvider availability\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e30 (28.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;Providers can opt out of requested circumcision. This is increasing and parents are left to find circumcision services\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;I get a lot of outpatient referrals because the rounding OB wasn\u0026apos;t \u0026lsquo;comfortable\u0026rsquo; performing circs or logistically there wasn\u0026apos;t time to have it done before the family was discharged.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eInsurance and payment\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e13 (12.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;The major limitation is financial - may families can not afford to self-pay, and Medicaid and most private insurances do not cover neonatal circumcisions in our state.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;\u0026hellip;we accept Medicaid reimbursement so patients then don\u0026apos;t have to pay anything. We really [don\u0026rsquo;t] let it [be] known too much that we do [them] in the office and don\u0026apos;t charge Medicaid because it would be too many coming.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eEthics and personal opinions\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e13 (12.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;If this is being performed for cosmetic reasons only, it should not be permitted\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;Just laying out my own bias that we should not do these (routine elective) procedures anymore. Sure there are indications and personal/cultural reasons but they could be outpatient.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eCircumcision eligibility\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e11 (10.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;Excluded if family refuses Vitamin K at birth\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;Some OBs will not do the circumcision, for prematurity (arbitrary cutoff), if the penis is too small, or if they are NICU.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eUncertainty about circumcision practices\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e6 (5.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;Unfortunately, not sure of exact weight limit at my institution\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;Unsure what the practice is for premature infants at my institution\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n \u003c/div\u003e\n\u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis survey of U.S. pediatric urologists and hospitalists indicates that neonatal circumcision availability and practices vary by hospital, region, and specialty. Approximately 1 in 6 respondents were from hospitals that do not offer neonatal circumcision. Multiple specialties performed neonatal circumcisions; pediatric urologists most frequently performed outpatient procedures with or without general anesthesia, and pediatrics most frequently performed circumcisions at the birth encounter without general anesthesia. At institutions that did offer circumcision, availability was most common during the week and during regular business hours. Almost 1 in 3 respondents added free-text comments, indicating general interest in the topic of neonatal circumcision availability. The comments provided additional insight about circumcision availability in their institution or region, provider availability or payment.\u003c/p\u003e \u003cp\u003eInformation from the current survey study confirms findings of existing large database investigations about circumcision practice patterns and trends. Regarding circumcision practitioner specialty, the present study findings are similar to a recent study using Pediatric Health Information Systems data by Many et al., which showed that pediatrics, obstetrics-gynecology, and perinatal medicine most commonly performed neonatal circumcisions. Beyond the neonatal period, pediatric urologists most commonly performed circumcisions in the study by Many,[\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e] a finding also echoed in our survey. The regional and insurance coverage trends indicated by the present survey are also aligned with prior studies using national databases. While American Academy of Pediatrics recommends coverage for all desired neonatal circumcisions,[\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e] a recent study by Navia et. al shows that male infants with private insurance had higher rates of neonatal circumcision.[\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e] Our study respondents indicate that private insurance is more frequently accepted as payment for neonatal circumcision, and that some families pay cash; thus financial barriers to desired circumcisions appear to exist for families with fewer financial resources.\u003c/p\u003e \u003cp\u003eThe present study also adds the clinician perspective to data from prior parent surveys about newborn circumcision access and reasons for delay. In the present physician survey, the most common reasons neonatal circumcision was not offered included the institution was not a birth hospital, the procedure was not covered by insurance, and low insurance reimbursement. Similarly, Jacobson et. al found that among patients seeking elective circumcision, one of the most common reasons for delay in desired neonatal circumcision in the Chicago area was that the hospital or physician did not perform neonatal circumcision; additional factors included prematurity, penile abnormality and low birth weight.[\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e] A 2016 survey of parents in San Antonio seeking delayed circumcision for boys less than 2 years old reported reasons for delay of circumcision beyond the newborn period included impaired proceduralist availability and lack of circumcision availability at the birth hospital.[\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]\u003c/p\u003e \u003cp\u003eOur study results reinforce findings in the larger body of literature that specialty/institutional availability and payment coverage are crucial factors in determining access to neonatal circumcision. To gain a more comprehensive understanding about why certain institutions experience limited circumcision availability, we are currently conducting a qualitative interview-based study of clinicians who perform circumcisions about this topic. Future studies will also focus on the development of efficient neonatal circumcision workflows for different hospital types and determine the most optimal recommendations for public and private insurance coverage of neonatal circumcision.\u003c/p\u003e \u003cp\u003eWhile the current study provides an important physician perspective on the topic of access to neonatal circumcision, there are study limitations. The survey response was relatively low, particularly amongst pediatric hospitalists. However, findings largely align with previous studies about both circumcision trends and reasons for difficulty with access, suggesting the validity of the findings. Respondents only included pediatric urologists and pediatricians, and therefore does not represent all specialties that perform circumcisions. For some survey questions, around 15\u0026ndash;25% of respondents were uncertain or did not respond. As such, insight about certain subtopics was suboptimal, including questions about a standardized protocol, exclusion criteria for neonatal circumcision, days of the week that circumcision were available, and reasons that institutions did not offer neonatal circumcision. Limited demographic information was ascertained for the sake of brevity and to maintain the anonymity of respondents. Therefore, some respondents could represent the same institutions, thus creating redundancy in responses.\u003c/p\u003e"},{"header":"Conclusions","content":"\u003cp\u003eThe availability of neonatal circumcision varies based on hospital characteristics, including geographic location. Specialties that perform neonatal circumcision depend on setting and type of anesthesia used. Follow up research is currently focused on the institutional level to better understand potential local barriers to neonatal circumcision availability. The eventual goal is the creation of hospital-based and financial incentive structural strategies to ensure equitable access for neonatal circumcisions.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eAAP: American Academy of Pediatrics\u003c/p\u003e\n\u003cp\u003eCI: confidence interval\u003c/p\u003e\n\u003cp\u003eOR: odds ratio\u003c/p\u003e\n\u003cp\u003eNC: neonatal circumcision\u003c/p\u003e\n\u003cp\u003eSPU: Societies for Pediatric Urology\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study was approved by the Ann \u0026amp; Robert H. Lurie Children\u0026rsquo;s Hospital of Chicago Institutional Review Board and the need for obtaining informed consent from subjects was waived (IRB 2020-3505). All methods were performed in accordance with the relevant guidelines and this study was granted exemption by a Lurie Children\u0026rsquo;s IRB for reasons of it consisting of only surveys (that do not include children). Lurie Children\u0026rsquo;s IRB approved of waived consent due to participants only completing surveys, thus the research involves no more than minimal risk to subjects.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets generated and/or analyzed during the current study are available from the corresponding author on request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNone.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026apos; contributions:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eEKJ, IR and HA conceived of the research project, with contribution from LS. EKJ supervised UN to analyze and interpret this data, and UN drafted the initial the manuscript. RFW built the survey, distributed the survey to participants via REDCap and assisted with manuscript drafting. All authors contributed to results interpretation, reviewed and edited the manuscript and approved of the final version.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNone.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n \u003cli\u003ePfuntner A, Wier LM, Stocks C. Most Frequent Conditions in U.S. Hospitals, 2010: Statistical Brief #148. 2006.\u003c/li\u003e\n \u003cli\u003eBlank S, Brady M, Buerk E, Carlo W, Diekema D, Freedman A, et al. Male circumcision. Pediatrics 2012;130. https://doi.org/10.1542/peds.2012-1990.\u003c/li\u003e\n \u003cli\u003eEl Bcheraoui C, Zhang X, Cooper CS, Rose CE, Kilmarx PH, Chen RT. Rates of adverse events associated with male circumcision in US medical settings, 2001 to 2010. JAMA Pediatr 2014;168:625\u0026ndash;34. https://doi.org/10.1001/jamapediatrics.2013.5414.\u003c/li\u003e\n \u003cli\u003eRappaport BA, Suresh S, Hertz S, Evers AS, Orser BA. Anesthetic Neurotoxicity \u0026mdash; Clinical Implications of Animal Models. N Engl J Med 2015;372:796\u0026ndash;7. https://doi.org/10.1056/nejmp1414786.\u003c/li\u003e\n \u003cli\u003eMellon RD, Simone AF, Rappaport BA. Use of anesthetic agents in neonates and young children. Anesth Analg 2007;104:509\u0026ndash;20. https://doi.org/10.1213/01.ane.0000255729.96438.b0.\u003c/li\u003e\n \u003cli\u003eBhananker SM, Ramamoorthy C, Geiduschek JM, Posner KL, Domino KB, Haberkern CM, et al. Anesthesia-related cardiac arrest in children: Update from the pediatric perioperative cardiac arrest registry. Anesth Analg 2007;105:344\u0026ndash;50. https://doi.org/10.1213/01.ane.0000268712.00756.dd.\u003c/li\u003e\n \u003cli\u003eBordet F, Allaouchiche B, Lansiaux S, Combet S, Pouyau A, Taylor P, et al. Risk factors for airway complications during general anaesthesia in paediatric patients. Paediatr Anaesth 2002;12:762\u0026ndash;9. https://doi.org/10.1046/j.1460-9592.2002.00987.x.\u003c/li\u003e\n \u003cli\u003eCronj\u0026eacute; L. A review of paediatric anaesthetic-related mortality, serious adverse events and critical incidents. South African J Anaesth Analg 2015;21:147\u0026ndash;53. https://doi.org/10.1080/22201181.2015.1119503.\u003c/li\u003e\n \u003cli\u003eSchoen EJ, Colby CJ, To TT. Cost analysis of neonatal circumcision in a large health maintenance organization. J Urol 2006;175:1111\u0026ndash;5. https://doi.org/10.1016/S0022-5347(05)00399-X.\u003c/li\u003e\n \u003cli\u003eHart-Cooper GD, Tao G, Stock JA, Hoover KW. Circumcision of privately insured males aged 0 to 18 years in the United States. Pediatrics 2014;134:950\u0026ndash;6. https://doi.org/10.1542/peds.2014-1007.\u003c/li\u003e\n \u003cli\u003eJacobson DL, Balmert LC, Holl JL, Rosoklija I, Davis MM, Johnson EK. Nationwide Circumcision Trends: 2003 to 2016. J Urol 2021;205:257\u0026ndash;63. https://doi.org/10.1097/JU.0000000000001316.\u003c/li\u003e\n \u003cli\u003eRoth JD, Keenan AC, Carroll AE, Rink RC, Cain MP, Whittam BM, et al. Readmission characteristics of elective pediatric circumcisions using large-scale administrative data. J Pediatr Urol 2016;12:27.e1-27.e6. https://doi.org/10.1016/j.jpurol.2015.10.006.\u003c/li\u003e\n \u003cli\u003eNavia MZ, Jacobson DL, Balmert LC, Rosoklija I, Holl JL, Davis MM, et al. State-Level Public Insurance Coverage and Neonatal Circumcision Rates. Pediatrics 2020;146. https://doi.org/10.1542/peds.2020-1475.\u003c/li\u003e\n \u003cli\u003eHarris PA, Taylor R, Thielke R, Payne J, Gonzalez N, Conde JG. Research electronic data capture (REDCap)-A metadata-driven methodology and workflow process for providing translational research informatics support. J Biomed Inform 2009;42:377\u0026ndash;81. https://doi.org/10.1016/j.jbi.2008.08.010.\u003c/li\u003e\n \u003cli\u003eMany BT, Rizeq YK, Vacek J, Cheon EC, Johnson E, Hu YY, et al. A contemporary snapshot of circumcision in US children\u0026rsquo;s hospitals. J Pediatr Surg 2020;55:1134\u0026ndash;8. https://doi.org/10.1016/j.jpedsurg.2020.02.031.\u003c/li\u003e\n \u003cli\u003eJacobson DL, D\u0026rsquo;Oro A, Abdullah F, Barsness KA, Liu DB, Maizels M, et al. Caregiver Reported Reasons for Delay of Neonatal Circumcision. Urology 2020;140:143\u0026ndash;9. https://doi.org/10.1016/j.urology.2020.01.043.\u003c/li\u003e\n \u003cli\u003eOtto R, Evans G, Boniquit C, Peppas D, Leslie J. Why Desired Newborn Circumcisions Are Not Performed: A Survey. Urology 2016;97:188\u0026ndash;93. https://doi.org/10.1016/j.urology.2016.06.054.\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Supplemental File","content":"\u003cp\u003eSupplemental File is not available with this version.\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-urology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"buro","sideBox":"Learn more about [BMC Urology](http://bmcurol.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/buro/default.aspx","title":"BMC Urology","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"neonatal, circumcision, access, pediatrics, pediatric urology","lastPublishedDoi":"10.21203/rs.3.rs-812059/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-812059/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground\u003c/strong\u003e: A significant proportion of boys present to surgical specialists later in infancy/early childhood for elective operative circumcision despite the higher procedural risks. This study aims to assess physician perspectives on access to neonatal circumcision (NC) across the United States and identify potential reasons contributing to disparities in access. \u003c/p\u003e\u003cp\u003e\u003cstrong\u003eMethods\u003c/strong\u003e: A cross-sectional survey was electronically distributed to physician members of the Societies for Pediatric Urology and the American Academy of Pediatrics Section on Hospital Medicine. Hospital characteristics and circumcision practices were assessed. Associations between NC availability and institutional characteristics were evaluated using chi-squared testing and multivariable logistic regression. Qualitative analyses of free-text comments were performed. \u003c/p\u003e\u003cp\u003e\u003cstrong\u003eResults\u003c/strong\u003e: A total of 367 physicians responded (129 urologists [41%], 188 pediatric hospitalists [59%])). NC was available at 86% of hospitals represented. On univariate and multivariate analysis, the 50 hospitals who did not offer NC were more likely to be located in the Western region (odds ratio [OR]=8.33; 95% confidence interval [CI]=3.1-25 vs Midwest) and in an urban area (OR=4.2; 95% CI=1.6-10 vs suburban/rural) compared with hospitals that offered NC. Most common reasons for lack of availability included not a birth hospital (N=22, 47%), lack of insurance coverage (N=8, 17%), and low insurance reimbursement (N=7, 15%). Institutional, regional, or provider availability (68%), insurance/payment (12.4%), and ethics (12.4%) were common themes in the qualitative comments.\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eConclusions\u003c/strong\u003e: Overall availability of neonatal circumcision varied based on hospital characteristics, including geography. Information from this survey will inform development of interventions designed to offer NC equitably and comprehensively.\u0026nbsp;\u0026nbsp;\u003c/p\u003e","manuscriptTitle":"Neonatal Circumcision Availability in the United States: A Physician Survey","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2021-09-03 16:33:23","doi":"10.21203/rs.3.rs-812059/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Major revision","date":"2021-09-16T07:27:24+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2021-09-07T21:09:38+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"6ff132dd-b7ed-453c-a7e6-9902c4e6fbd0","date":"2021-09-02T12:27:10+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2021-09-02T07:27:47+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2021-09-02T07:08:08+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2021-09-02T07:02:24+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2021-09-02T06:56:25+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Urology","date":"2021-08-13T22:35:09+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-urology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"buro","sideBox":"Learn more about [BMC Urology](http://bmcurol.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/buro/default.aspx","title":"BMC Urology","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"152bd016-3bb1-4843-a3ee-f6733d87dd2f","owner":[],"postedDate":"September 3rd, 2021","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[{"id":6944854,"name":"Urology \u0026 Nephrology"}],"tags":[],"updatedAt":"2021-10-08T08:14:09+00:00","versionOfRecord":[],"versionCreatedAt":"2021-09-03 16:33:23","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-812059","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-812059","identity":"rs-812059","version":["v1"]},"buildId":"cBFmMYwuxLRRLfASyISRj","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}