bs_bs_banner
doi:10.1111/jpc.12911
ORIGINAL ARTICLE
Undescended testis: Level of knowledge among potential referring health-care providers Li Yan Lim,1* Shireen A Nah,2* Narasimhan K Lakshmi,2 Te-Lu Yap,2 Anette S Jacobsen,2 Yee Low2 and Caroline CP Ong2 1
Yong Loo Lin School of Medicine, National University of Singapore, 2Department of Paediatric Surgery, KK Women’s & Children’s Hospital, Singapore
Aim: Studies report that most boys with undescended testis(UDT) are referred and operated beyond the recommended age of 1 year, possibly due to lack of awareness of treatment guidelines. We investigate the level of knowledge of UDT among potential referring health-care providers. Method: We devised a survey on the clinical features and appropriate management of UDT. Using convenience sampling, we approached health-care professionals with regular contact with paediatric patients and final year medical students. Respondents were allowed to remain anonymous. They were categorised according to specialty and level of experience/training. Results: Of 1179 approached, 203 responded. Thirty-six (24%) of 149 qualified doctors had never seen a case of UDT. Median score was 6 (range 1–9). There was no significant difference in scores when comparing specialty. Mean scores decreased significantly in trend according to level of experience. When questioned regarding timings of referral and orchidopexy, 24% of qualified doctors would not refer until 9 months of age, and 66% thought orchidopexy should be done after 1 year old. Half would stop examining for UDT after 2 years old. Conclusions: Inexperience with UDT and outdated knowledge may contribute to delays in referral for UDT. Many would stop examining for UDT at 2 years old, placing undue reliance on accurate physical examination in early childhood and indicating lack of awareness of the ascending testis. Community health initiatives must emphasise recent changes in guidelines for management of UDT. Key words:
cryptorchidism; general practice; orchidopexy; questionnaire; referral pattern.
What is already known on this topic
What this paper adds
1 Current guidelines indicate that orchidopexy should be done between the age of 6 and12 months. 2 Studies report that most boys with undescended testis (UDT) are referred and operated beyond the recommended age of 1 year.
1 Inexperience with UDT and outdated knowledge regarding recommended timings of referral and orchidopexy may contribute to delays in referral for UDT. 2 More than half would not continue to examine for UDT beyond 2 years old, placing undue burden on accurate physical examination in early childhood. 3 There is lack of awareness of the ascending testis among potential referring health-care providers.
Undescended testis (UDT) occurs in up to 6% of all male infants.1 Although spontaneous descent may occur, orchidopexy is recommended to prevent complications, preserve fertility and reduce the risk of malignancy. Current guidelines indicate that orchidopexy should be done between the age of 6 to 12 months, compared with older guidelines that recommended surgery before 2 years of age.2,3 However, many studies, including one from our institution, Correspondence: Dr Caroline CP Ong, Department of Paediatric Surgery, KK Women’s & Children’s Hospital, 100 Bukit Timah Road, 229899, Singapore. Fax: (65) 6291 0161; email: [email protected] Competing interest: None declared. *These authors contributed equally to the work Some data in this paper were presented at the Annual Congress of the British Association of Paediatric Surgeons 2014 Accepted for publication 21 March 2015.
report that most boys with UDT are referred and operated beyond the recommended age of 1 year.4,5 Appropriate and timely referrals for further management of UDT depend heavily on general practitioners (GPs) and community paediatricians who may be unaware of the latest treatment guidelines for UDT.6,7 In this study, we evaluate the level of knowledge of UDT among potential referring health-care providers.
Materials and Methods This prospective study took place over a 12-month period between January and December 2013. Institutional ethical approval was obtained. We devised a survey on the clinical features and appropriate management of UDT using a combination of seven multiplechoice questions (MCQ) and three free text questions.
Journal of Paediatrics and Child Health 51 (2015) 1109–1114 © 2015 The Authors Journal of Paediatrics and Child Health © 2015 Paediatrics and Child Health Division (Royal Australasian College of Physicians)
1109
Undescended testis: A survey of knowledge
LY Lim et al.
Using convenience sampling, the survey was administered to medical professionals who had regular contact with paediatric patients. They included the following: 1 Attendees at paediatric-focused educational forums for continuing professional development 2 Members of the neonatology and paediatric departments at the 2 largest national tertiary centres with specialist paediatric care 3 Doctors at government community health clinics 4 Private care community paediatricians, including GPs 5 Final year medical students were also invited, as we wanted to compare those with and without practical workplace experience. Each participant was approached either in person or via email, up to a maximum of two times. Data collected included specialty, level of experience and associated institution, and on whether they had ever seen a case of UDT. It was optional for participants to provide their contact information. Specialty: Although the majority of those approached were either paediatricians or GPs, we also considered non-paediatric specialists for participation, as long as their practice included management of children, for example, paediatric neurosurgeons and emergency physicians with paediatric patients. Level of experience: In our setting, consultants are those recognised as specialists in their field. Registrars are those in advanced specialty training. Residents (junior medical officers in formal specialty training programmes) were categorised with medical officers otherwise not in specialty training, as both these groups have similar years of workplace experience.
Survey design Both physical and online versions of the survey were provided. We used ‘Google Forms’ for the online version, an Internetbased survey format that can be completed in real time. We limited our questionnaire to essential questions we thought might affect achievement of diagnosis and urgency of referral. Time for completion of the survey was estimated to be between 5 and 10 min. The survey covered the following aspects of UDT: 1 The epidemiology and clinical presentation of UDT a. Incidence of UDT (MCQ) b. Age at which to check for position of gonads (MCQ) c. Physical findings indicating the presence of UDT (free text) 2. Management of UDT a. Type of recommended treatment (MCQ and free text) b. Timing of treatment (MCQ) 3. Known sequelae of the pathology (free text) 4. Referral for expert management a. Timing (MCQ) A maximum score of 9 was possible. Where answers were free text, we allowed for some variability, for example ‘malignancy’ and ‘cancer’ were considered similar.
GP educational update with pretest and posttest As part of a 2-h educational update organised by our institution, GPs were given a 15-min talk on the clinical presentation and 1110
management of UDT. The same survey was administered before and after the talk. For the purpose of this study, results from the pretest were analysed for comparison with other respondents.
Statistical analysis For statistical analysis, we used χ2 tests for categorical variables and Kruskal–Wallis tests for non-parametric continuous variables (IBM SPSS Statistics version 19 IBM, Armonk, NY, USA). Data are stated as median and range or mean and standard deviation (SD). A P-value of
doi:10.1111/jpc.12911
ORIGINAL ARTICLE
Undescended testis: Level of knowledge among potential referring health-care providers Li Yan Lim,1* Shireen A Nah,2* Narasimhan K Lakshmi,2 Te-Lu Yap,2 Anette S Jacobsen,2 Yee Low2 and Caroline CP Ong2 1
Yong Loo Lin School of Medicine, National University of Singapore, 2Department of Paediatric Surgery, KK Women’s & Children’s Hospital, Singapore
Aim: Studies report that most boys with undescended testis(UDT) are referred and operated beyond the recommended age of 1 year, possibly due to lack of awareness of treatment guidelines. We investigate the level of knowledge of UDT among potential referring health-care providers. Method: We devised a survey on the clinical features and appropriate management of UDT. Using convenience sampling, we approached health-care professionals with regular contact with paediatric patients and final year medical students. Respondents were allowed to remain anonymous. They were categorised according to specialty and level of experience/training. Results: Of 1179 approached, 203 responded. Thirty-six (24%) of 149 qualified doctors had never seen a case of UDT. Median score was 6 (range 1–9). There was no significant difference in scores when comparing specialty. Mean scores decreased significantly in trend according to level of experience. When questioned regarding timings of referral and orchidopexy, 24% of qualified doctors would not refer until 9 months of age, and 66% thought orchidopexy should be done after 1 year old. Half would stop examining for UDT after 2 years old. Conclusions: Inexperience with UDT and outdated knowledge may contribute to delays in referral for UDT. Many would stop examining for UDT at 2 years old, placing undue reliance on accurate physical examination in early childhood and indicating lack of awareness of the ascending testis. Community health initiatives must emphasise recent changes in guidelines for management of UDT. Key words:
cryptorchidism; general practice; orchidopexy; questionnaire; referral pattern.
What is already known on this topic
What this paper adds
1 Current guidelines indicate that orchidopexy should be done between the age of 6 and12 months. 2 Studies report that most boys with undescended testis (UDT) are referred and operated beyond the recommended age of 1 year.
1 Inexperience with UDT and outdated knowledge regarding recommended timings of referral and orchidopexy may contribute to delays in referral for UDT. 2 More than half would not continue to examine for UDT beyond 2 years old, placing undue burden on accurate physical examination in early childhood. 3 There is lack of awareness of the ascending testis among potential referring health-care providers.
Undescended testis (UDT) occurs in up to 6% of all male infants.1 Although spontaneous descent may occur, orchidopexy is recommended to prevent complications, preserve fertility and reduce the risk of malignancy. Current guidelines indicate that orchidopexy should be done between the age of 6 to 12 months, compared with older guidelines that recommended surgery before 2 years of age.2,3 However, many studies, including one from our institution, Correspondence: Dr Caroline CP Ong, Department of Paediatric Surgery, KK Women’s & Children’s Hospital, 100 Bukit Timah Road, 229899, Singapore. Fax: (65) 6291 0161; email: [email protected] Competing interest: None declared. *These authors contributed equally to the work Some data in this paper were presented at the Annual Congress of the British Association of Paediatric Surgeons 2014 Accepted for publication 21 March 2015.
report that most boys with UDT are referred and operated beyond the recommended age of 1 year.4,5 Appropriate and timely referrals for further management of UDT depend heavily on general practitioners (GPs) and community paediatricians who may be unaware of the latest treatment guidelines for UDT.6,7 In this study, we evaluate the level of knowledge of UDT among potential referring health-care providers.
Materials and Methods This prospective study took place over a 12-month period between January and December 2013. Institutional ethical approval was obtained. We devised a survey on the clinical features and appropriate management of UDT using a combination of seven multiplechoice questions (MCQ) and three free text questions.
Journal of Paediatrics and Child Health 51 (2015) 1109–1114 © 2015 The Authors Journal of Paediatrics and Child Health © 2015 Paediatrics and Child Health Division (Royal Australasian College of Physicians)
1109
Undescended testis: A survey of knowledge
LY Lim et al.
Using convenience sampling, the survey was administered to medical professionals who had regular contact with paediatric patients. They included the following: 1 Attendees at paediatric-focused educational forums for continuing professional development 2 Members of the neonatology and paediatric departments at the 2 largest national tertiary centres with specialist paediatric care 3 Doctors at government community health clinics 4 Private care community paediatricians, including GPs 5 Final year medical students were also invited, as we wanted to compare those with and without practical workplace experience. Each participant was approached either in person or via email, up to a maximum of two times. Data collected included specialty, level of experience and associated institution, and on whether they had ever seen a case of UDT. It was optional for participants to provide their contact information. Specialty: Although the majority of those approached were either paediatricians or GPs, we also considered non-paediatric specialists for participation, as long as their practice included management of children, for example, paediatric neurosurgeons and emergency physicians with paediatric patients. Level of experience: In our setting, consultants are those recognised as specialists in their field. Registrars are those in advanced specialty training. Residents (junior medical officers in formal specialty training programmes) were categorised with medical officers otherwise not in specialty training, as both these groups have similar years of workplace experience.
Survey design Both physical and online versions of the survey were provided. We used ‘Google Forms’ for the online version, an Internetbased survey format that can be completed in real time. We limited our questionnaire to essential questions we thought might affect achievement of diagnosis and urgency of referral. Time for completion of the survey was estimated to be between 5 and 10 min. The survey covered the following aspects of UDT: 1 The epidemiology and clinical presentation of UDT a. Incidence of UDT (MCQ) b. Age at which to check for position of gonads (MCQ) c. Physical findings indicating the presence of UDT (free text) 2. Management of UDT a. Type of recommended treatment (MCQ and free text) b. Timing of treatment (MCQ) 3. Known sequelae of the pathology (free text) 4. Referral for expert management a. Timing (MCQ) A maximum score of 9 was possible. Where answers were free text, we allowed for some variability, for example ‘malignancy’ and ‘cancer’ were considered similar.
GP educational update with pretest and posttest As part of a 2-h educational update organised by our institution, GPs were given a 15-min talk on the clinical presentation and 1110
management of UDT. The same survey was administered before and after the talk. For the purpose of this study, results from the pretest were analysed for comparison with other respondents.
Statistical analysis For statistical analysis, we used χ2 tests for categorical variables and Kruskal–Wallis tests for non-parametric continuous variables (IBM SPSS Statistics version 19 IBM, Armonk, NY, USA). Data are stated as median and range or mean and standard deviation (SD). A P-value of
