Exploring Barriers to the Inclusion of Underrepresented Minorities in Urology: The Temporal and Financial Costs of Residency Interviews.

OBJECTIVE: To investigate whether interview travel cost and time differed for urology residency applicants from medical schools with higher vs lower proportions of students from groups underrepresented in medicine (URiMs). METHODS: We identified 22 medical schools, 11 with <15% and 11 with >20% URiM students, and 17 "highly ranked" urology residency programs. We contacted the residency programs and requested interview dates, preferred lodging options, and institution-based cost-savings. We constructed interview itineraries for 22 hypothetical students (one from each school), and compared the total cost and time for travel to all 17 interviews. Total travel time and interview costs for the students at schools with <15% and >20% URiM were compared, with findings considered statistically significant at P <.05. RESULTS: Each student was able to attend all 17 interviews. The median total cost was similar for applicants from schools >20% URiM ($8074.80; range: $7027.60-$13702.59) and <15% URiM ($8764.60; range: $6698.48-$11966.83; P = .89). The median aggregate travel time for applicants from schools >20% URiM was 176.4 (range: 93.7-246.2) hours and for applicants from schools <15% URiM was 160.5 (range: 128.2-203.9) hours (P = .62). CONCLUSION: Financial and temporal costs were similar for applicants from medical schools with <15% or >20% URiM students. Thus, absolute cost considerations are unlikely to account for differences in URiM representation in urology. However, the relative impact of interview costs may be different for URiM students. Effective and durable engagement of URiM students in urology requires an introspective assessment of objective vs anecdotal barriers to recruiting and retaining URiM medical students.

Geographic Variations in Pharmacy Services and Availability of Commonly Prescribed Pediatric Urology Medications: An Opportunity to Improve Health Equity in Washington State.

OBJECTIVE: To describe geographic and sociodemographic variations in operating hours and availability of medications commonly prescribed by pediatric urologists at Washington State retail pharmacies. METHODS: We identified all retail pharmacies in the state. We stratified counties by population density and household income (HI) and compared differences in pharmacy operating hours and availability of 10 commonly prescribed medications. RESULTS: 1057/1058 pharmacies were contacted. All pharmacies had liquid formulations of oxycodone, hydrocodone, ibuprofen, acetaminophen, amoxicillin, and trimethoprim-sulfamethoxazole in stock. Liquid formulations of ciprofloxacin (10%) and oxybutynin (14.3%) were uncommonly stocked, while 92.5% of pharmacies stocked nitrofurantoin suspension, and 80.9% nitrofurantoin capsules. Statewide, 108 (10.2%) of pharmacies were closed on Saturdays and 297 (28.1%) closed on Sunday. More high (HPDC) than low population density (LPDC) (62.5% vs 0%, P < .001) and high-HI than low-HI counties (62.5% vs 0%, P = .30) had 24-hour pharmacies. A larger proportion of pharmacies were open 7-days in HPDC than LPDC (75.6% vs 56.2%, P < .0001) and in high-HI than low-HI counties (100% vs 62.5%, P = .30). The likelihood of a pharmacy being open 7 days/week was significantly higher in HPDC (vs LPDC; OR = 13.2, 95% CI: 4.39-39.7) and high-HI (vs low-HI; OR = 4.98, 95% CI: 2.58-9.60) counties. CONCLUSION: Most pharmacies in Washington State carry medications commonly prescribed by pediatric urologists. However, retail pharmacy operating hours are widely variable and create geographic and temporal barriers in rural and poor areas that may limit the timely administration of prescription medication. Providers should consider a patient's practical ability to fill a prescription when starting a time-sensitive medication.

Gender Differences in Authorship in Urology: a Five-year Review of Publications in Five High-impact Journals.

OBJECTIVE: To describe the proportions of peer-reviewed manuscripts authored by women in 5 high-impact, widely available urology journals, and to compare these to the proportion of women in urology. About 9% of attending urologists and 25% of urology residents are women. We hypothesized that women comprised fewer than 25% of first authors and fewer than 10% of last/senior authors. METHODS: We searched peer-reviewed original manuscripts in the Journal of Urology, Journal of Pediatric Urology, Neurourology and Urodynamics, Urology, and Urologic Oncology from January 2014 to June 2019. First and last author gender identity was recorded. Observed and expected proportions and temporal trends were compared, with findings considered statistically significant at P < .05. RESULTS: Of 8653 multiple-author papers, 2275 (26.3%) had women as first authors, paralleling the current proportion of women in training (P = .98). Women were senior/last authors in 1255 (14.5%) papers; this was higher than the current proportion of female urologists in practice (P < .0001) for all journals but NAU (P = .59). Only 527 (6.1%) of multiple-author papers had both female first and last authors whereas 5640 (65.3%) of papers had both male first and last authors. The first author was more likely female when the senior author was female (OR = 2.34, 95% CI: 2.06-2.65); most female-first and -last authored manuscripts were published in subspecialty journals and those utilizing double-blind peer review. CONCLUSION: The proportion of female first- and senior-authored manuscripts is significantly higher than the proportion of women in urology, and may reflect differential subspecialty choices and mentorship opportunities for women.

Accuracy and comprehensiveness of publicly-available online data about bedwetting: An actionable opportunity to improve parent and caregiver self-education.

INTRODUCTION: Monosymptomatic nocturnal enuresis (MNE) is one of the most common reasons for referral to pediatric urologists. Prior to subspecialist visits, many parents seek electronically available information online to gather information about this condition and potential treatment options. Previous publications suggest that electronically available information on medical conditions do not always align with evidence-based or expert recommendations. We wondered if the same was true for MNE. OBJECTIVE: To describe the content and accessibility of electronically available information on MNE, and its alignment with recommendations from the International Children's Continence Society (ICCS-MNE). STUDY DESIGN: We simulated a layperson's electronic search using 10 pertinent search terms associated with bedwetting. We evaluated the first five pages (50 results) for each search. We evaluated all publicly-available (non-paywalled) sites for concordance with ICCS-MNE in eight domains (increasing fluid intake, limiting bladder irritants, optimizing bowel habits, utilizing timed voiding, pelvic floor relaxation, endorsing alarm use, avoiding medications as standard first-line therapies, and pediatrician referral), as well as statements discouraging blaming or punishing the child. Sites were classified as layperson-derived (blogs, communities/forums) or commercially-derived (medical institutions, commercial medical sites, corporations, government). Reading level was assessed by readable.io (compound scoring algorithms). RESULTS: Of 500 pages, 410 (82%) met inclusion criteria. Of these, 49.3% were layperson-derived and 47.8% were commercially-derived. Publication year ranged from 1999 to 2017. A median three (range 0-8) therapeutic domains were mentioned per site. Only one site discussed all eight therapeutic domains. Commercial sites discussed more ICCS-MNE domains than blogs and communities/forums (median 4.1 vs. 2.4, p < 0.0001; Figure). Blogs and forums were less likely to recommend subspecialist evaluation (53.0% vs. 81.1%, p < 0.0001), but more likely to recommend alternative medicine therapies (57.9% vs. 28.6%, p < 0.0001). The overall median readability grade level was lower for blogs/communities than for commercial sites (7.9 vs. 8.6, p < 0.0001). DISCUSSION: Our findings show that the vast majority of electronically available information on MNE is not congruent with or does not include all ICCS-MNE recommendations. About half of websites are blogs and forums; these not only are more likely to recommend alternative medicine therapies and less likely to recommend subspecialist evaluation, but have lower reading levels and thus may be accessible to more laypersons. CONCLUSION: Neither commercially-derived nor layperson-derived websites are comprehensive with regard to ICCS-MNE recommendations. Our findings underscore the need to ensure that electronically published data are accurate, and to understand what data patients may have acquired before visiting with clinicians.

Availability of Common Pediatric Radiology Studies: Are Rural Patients at a Disadvantage?

BACKGROUND: Many families wish to have radiologic tests performed locally, especially when obtaining these tests in specialized pediatric centers would require long-distance travel with associated costs and inconveniences. The differential availability of specialized and common pediatric uroradiographic tests in rural and urban areas has not been described. We undertook this study to describe the availability of common radiographic tests ordered by pediatric urologists, and to identify disparities in the availability of radiographic tests between urban and rural locations. MATERIALS AND METHODS: We surveyed all freestanding hospitals in Washington State on the availability of flat-plate abdominal radiograph (AXR), renal-bladder ultrasounds (RBUS), voiding cystourethrograms (VCUG), MAG-3 renal scans, and nuclear cystograms (NC) for children, as well as testing restrictions, availability of sedation for urology tests, and presence of onsite radiologists. Rural and urban hospitals were compared on these characteristics. RESULTS: The survey was completed by 74 of 88 institutions (84.1%); 17 (23.0%) were rural (population <2500), 32 (43.2%) were in urban clusters (population 2500-50,000), and 25 (33.8%) were in urban areas (population >50,000). Seventy-three (98.6%) institutions offered AXR, 68 (91.9%) offered RBUS, 44 (59.5%) offered VCUG, 26 (35.1%) offered MAG-3, and 15 (20.3%) offered NC to children. All urban and most (16/17; 94.1%) rural institutions had shareable digital imaging capability. AXR (100% versus 96%, P = 0.88) and RBUS (70.6% versus 96%, P = 0.15) availability was similar in rural and urban settings, whereas VCUG (11.8% versus 72%, P = 0.001), MAG-3 (5.9% versus 60%, P = 0.006), and NC (0% versus 44%, P = 0.017) were more commonly available in urban settings. Fewer rural hospitals employed full-time, in-house radiologists (35.3% versus 96%, P < 0.0001) or offered sedation (6.3% versus 36%, P = 0.01) for testing, but an equal proportion had age restrictions on the tests offered (40% versus 17.6%, P = 0.50). Fellowship-trained pediatric radiologists (0% versus 16%, P = 0.39) and child life specialists (0% versus 20%, P = 0.28) worked exclusively in urban settings. Most hospitals offering specialized radiographic tests (VCUG: 90.9%; P < 0.0001 and MAG-3: 92.3%; P = 0.002) had onsite radiologists. CONCLUSIONS: The geographically widespread availability of AXR and RBUS may represent an opportunity to offer families care closer to home, realizing cost and time savings. Anxious children and those requiring more specialized studies may benefit from referral to urban centers. The lack of rural radiologists may be an actionable barrier to availability of specialized radiology testing.