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Variation among cleft centres in the use of secondary surgery for children with cleft palate: a retrospective cohort
Thomas J Sitzman1,2, Monir Hossain3, Adam C Carle2
1Division of Plastic Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA.
Insights
Significant variation exists in secondary palate surgery rates among US children with cleft palate. Early primary repair before nine months increases the need for revision surgery, highlighting the importance of surgical timing.
Area of Science:
- Craniofacial Surgery
- Pediatric Surgery
- Health Services Research
Background:
- Secondary palate surgery, or revision palate surgery, is a common follow-up procedure for children with cleft palate.
- The utilization of secondary palate surgery varies significantly across healthcare facilities.
Purpose of the Study:
- To determine if cleft palate centers differ in their use of secondary palate surgery.
- To identify modifiable hospital and surgeon factors associated with secondary surgery rates.
Main Methods:
- Retrospective cohort study of 4,939 children undergoing primary cleft palate repair from 1999-2013 in 43 US pediatric hospitals.
- Analysis of time from primary repair to secondary palate surgery.
- Assessment of hospital and surgeon-level variations in secondary surgery rates.
Main Results:
- By 10 years post-primary repair, 44% of children had secondary palate surgery, with rates ranging from 9% to 77% across hospitals.
- Primary palate repair before nine months of age significantly increased the hazard of secondary surgery (HR 6.74).
- Hospital and surgeon factors explained 59% and 41% of the variation in secondary surgery, respectively; procedure volume and antibiotics were not associated.
Conclusions:
- Substantial variation in secondary palate surgery rates exists, influenced by age at primary repair, hospital, and surgeon.
- Performing primary palate repair before nine months of age is linked to a higher likelihood of requiring secondary surgery.
- Further research is needed to pinpoint specific factors contributing to outcome disparities among centers and surgeons.
Objectives:
To test whether cleft centres vary in their use of secondary cleft palate surgery, also known as revision palate surgery, and if so to identify modifiable hospital- and surgeon-factors that are associated with use of secondary surgery.
Design:
Retrospective cohort study.
Setting:
Forty-three paediatric hospitals across the United States.
Patients:
Children with cleft lip and palate who underwent primary cleft palate repair from 1999 to 2013.
Main Outcome Measures:
Time from primary cleft palate repair to secondary palate surgery.
Results:
We identified 4,939 children who underwent primary cleft palate repair. At ten years after primary palate repair, 44% of children had undergone secondary palate surgery. Significant variation existed among hospitals (p<0.001); the proportion of children undergoing secondary surgery by 10 years ranged from 9% to 77% across hospitals. After adjusting for patient demographics, primary palate repair before nine months of age was associated with an increased hazard of secondary palate surgery (initial hazard ratio 6.74, 95% CI 5.30-8.73). Postoperative antibiotics, surgeon procedure volume, and hospital procedure volume were not associated with time to secondary surgery (p>0.05). Of the outcome variation attributable to hospitals and surgeons, between-hospital differences accounted for 59% (p<0.001), while between-surgeon differences accounted for 41% (p<0.001).
Conclusions:
Substantial variation in the hazard of secondary palate surgery exists depending on a child's age at primary palate repair and the hospital and surgeon performing their repair. Performing primary palate repair before nine months of age substantially increases the hazard of secondary surgery. Further research is needed to identify other factors contributing to variation in palate surgery outcomes among hospitals and surgeons.
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