10.1177/0272989X04271039NOV–DECMEDICAL DECISION MAKING/NOV–DEC 2004VAN HOWECLI APPLICATIONSST-UTILITY AN LYSI OF NE NATAL CIRCUMCISION
A Cost-Utility Analysis
of Neonatal Circumcision
Robert S. Van Howe, MD, MS, FAAP
A cost-utility analysis, based on published data from multi-
ple observational studies, comparing boys circumcised at
birth and those not circumcised was undertaken using the
Quality of Well-being Scale, a Markov analysis, the standard
reference case, and a societal perspective. Neonatal circum-
cision increased incremental costs by $828.42 per patient
and resulted in an incremental 15.30 well-years lost per 1000
males. If neonatal circumcision was cost-free, pain-free, and
had no immediate complications, it was still more costly than
not circumcising. Using sensitivity analysis, it was impossi-
ble to arrange a scenario that made neonatal circumcision
cost-effective. Neonatal circumcision is not good health pol-
icy, and support for it as a medical procedure cannot be justi-
fied financially or medically. Key words: circumcision;
phimosis; cost-utility analysis; circumcision complications;
penile cancer. (Med Decis Making 2004;24:584-601)
Neonatal male circumcision is the most commonlyperformed procedure on children in the United
States. Although the topic has been the subject of
heated debate during the past 3 decades, past studies1–4
have failed to demonstrate the cost-effectiveness of the
procedure. Despite these findings, most private insur-
ance and state Medicaid programs in the United States
continue to reimburse physicians who perform the
procedure. In an era of limited health care funding,
close scrutiny of the cost-effectiveness of medical prac-
tices has become increasingly important.
Advocates of the surgery claim that the benefits of
neonatal circumcision justify its universal implemen-
tation5; however, currently not a single national medi-
cal organization endorses neonatal circumcision.6–11
The American Academy of Pediatrics’ most recent task
force on circumcision concluded that “existing scien-
tific evidence demonstrates potential medical benefits
of newborn male circumcision; however, these data are
not sufficient to recommend routine neonatal circum-
cision.”11 The recommendation of the task force and
the near ubiquity of the practice in the United States
appear to be in conflict. In an effort to sort out these dif-
ferences, the best available tool to determine the finan-
cial and health impact of the benefits of neonatal
circumcision is a cost-utility analysis.
Since publication of the previous cost-utility and
cost-effectiveness studies,1–4 3 studies have documented
circumcised men to be at greater risk for sexually trans-
mitted diseases,12–14 and males circumcised at birth
have been shown to be at risk for penile cancer,15 con-
trary to the popular belief that circumcision eliminated
the possibility of this malignancy.16 Meatal stenosis
(italicized medical terms are defined in the appendix),
which was not included in previously published cal-
culations, has been discovered to frequently affect cir-
cumcised males.17–23 With the publication of these
studies, the Canadian Paediatric Society has recom-
mended that a new cost-utility analysis of neonatal cir-
cumcision be performed.7 Using the data currently
available in the medical literature, a cost-utility analy-
sis of neonatal circumcision was undertaken.
METHOD
A cost-utility analysis, using the reference case stan-
dard developed by the Panel on Cost-Effectiveness in
Health and Medicine convened by the US Public
Health Service in 1993,24 was performed. The analysis
adopted a societal perspective and included the 72-
year life span of an average male because circumcision
status is believed to impact health throughout life. Util-
584 • MEDICAL DECISION MAKING/NOV–DEC 2004
Received 25 February 2004 from the Department of Pediatrics, Michi-
gan State University College of Human Medicine, Marquette, Michi-
gan. Presented as a poster at the 20th annual meeting of the Society
for Medical Decision Making, Cambridge, Massachusetts, 27 October
1998. Revision accepted for publication 2 August 2004.
Address correspondence and reprint requests to Robert S. Van Howe,
MD, MS, 2083 W. Fair Avenue, Marquette, MI 49855-2340; phone:
906-228-7454; e-mail: vanhowe@lushen.com.
DOI: 10.1177/0272989X04271039

ity was estimated using the Quality of Well-being Scale
and values as previously described.2,25–27
The Quality of Well-being Scale assigns values in 4
categories: symptom/problem complexes, mobility
scale, physical activity scale, and social activity scale.
For each condition, a value is assigned for each of the
scales. The total of the scale values is the quality of
well-being lost by having the condition. This total is
multiplied by the duration of the condition to estimate
the impact of the condition in quality-adjusted life
years. Odds ratios, used as an estimate of relative risk,
are expressed as the odds among noncircumcised
males divided by the odds among circumcised males.
Meta-analyses were performed using a random-effects
model (DerSimonian and Laird method) by the Mantel-
Haenszel method.28
The incidence values, financial costs, utility
weights, and durations used in this analysis are listed
in Table 1. The values used to calculate costs for uri-
nary tract infection and the costs and well-years lost for
immediate complications from neonatal circumcision
are listed in Table 2 and Table 3, respectively. All costs
have been adjusted to 1999 US dollars using the Con-
sumer Price Index.29 Incidence values listed in Table 1
are the lifetime, cumulative incidence values. In the
analysis, if a condition could occur over a number of
years, the yearly incidence was divided over these
years, and age-related yearly incidence rates were
applied where available.
Costs and utility were discounted at rates of 0%, 3%,
and 5%.30 Previously published age distributions of the
onset of penile cancer,31 HIV,32 phimosis, balano-
posthitis,33 and sexually transmitted diseases34 were
employed in this analysis.
Time lost from work for treatment and physician
visits were valued using the May 1999 average
earning in the private sector of the United States
(hourly = $13.19).35 Duration of time lost from work is
used as described in the reference case standard24 and,
with the exception of the hospitalization of normal
newborns for which no time lost from work costs were
assessed, equaled the length of hospitalization and/or
the length of illness of severity enough to prevent re-
turn to day care. The time lost from work cost for a phy-
sician visit was assumed to be 4 h or a half-day of work.
A Markov analysis model was chosen to accommo-
date varying ages of onset, chronic disease states, recur-
rences, and discounting. Calculations were performed
using DATA 3.5 for Healthcare for Windows (TreeAge
Software, Inc., Williamstown, MA). Cycle length was 1
year with 72 cycles performed. Transition probabilities
were determined by disease incidence, the odds ratios
as an estimate of relative risk between the 2 groups, and
the age-incidence data where available. Sensitivity
analysis as well as calculations of the most favorable
scenario (MFS; the least costly for circumcision and the
most costly for noncircumcision) and the least favor-
able scenario (LFS; the most costly for circumcision
and the least costly for noncircumcision) for neonatal
circumcision were performed. A Monte Carlo simula-
tion taking 1000 samples was performed employing
the distributions of 24 of the most influential variables.
Articles addressing the impact of neonatal circumci-
sion on health were collected by searching MEDLINE
using circumcision as a search word, reviewing the ci-
tations in pertinent articles, and querying experts in
the field. Articles published since 1900 were consid-
ered. Preference was given to the most current
information.
Sensitivity analysis was performed on 47 variables.
The greatest obstacle in performing the analysis was
the large number of variables in the decision tree and
the wide variation in the medical literature for nearly
all of these variables. This necessitated the establish-
ment of the MFS and LFS. The MFS would reflect the
opinions of circumcision advocates, who emphasize
circumcision’s benefits and downplay its risks while
emphasizing the prepuce’s propensity for disease. The
LFS would alternatively place neonatal circumcision
in the worst possible light. By establishing these sce-
narios, the most extreme views are accommodated in
the analysis. The 95% confidence interval for the anal-
ysis would likely be within these extremes.24 In the ab-
sence of a professional consensus, a baseline analysis
was developed based on review of the medical
literature, taking study design and methods into
account.
Cost of Neonatal Circumcision
A median physician reimbursement of $107, de-
rived from a national survey of physicians, was used in
the calculations and adjusted for 1999 US dollars.36
The cost of performing a neonatal circumcision con-
sists of more than the reimbursement to the physician.
The time of hospital personnel, use of hospital space,
and sterilization and handling of hospital equipment
have also to be considered and has been estimated pre-
viously to be 82% of the physician costs.4 The combina-
tion of the physician-related costs and hospital-related
costs brings the total cost of an inpatient neonatal cir-
cumcision to $195. The duration of symptoms follow-
ing neonatal circumcision was assumed to be 7 days.37
CLINICAL APPLICATIONS 585
COST-UTILITY ANALYSIS OF NEONATAL CIRCUMCISION