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Marked Variation Exists Among Surgeons and Hospitals in the Use of Secondary Cleft Lip Surgery
Thomas J Sitzman1,2, Adam C Carle3,4, Jaclyn N Lundberg5
1Division of Plastic Surgery, Phoenix Children's Hospital, Phoenix, AZ, USA.
Insights
Timing of primary cleft lip repair and patient factors influence secondary surgeries. Significant variations in secondary cleft lip surgery rates exist among surgeons and hospitals, warranting further investigation.
Area of Science:
- Pediatric surgery
- Craniofacial anomalies
- Health services research
Background:
- Secondary cleft lip surgery is common, but factors influencing its use are not fully understood.
- Variations in surgical practice and outcomes exist across healthcare providers.
Purpose of the Study:
- To identify child, surgeon, and hospital factors associated with secondary cleft lip surgery after primary repair.
- To investigate variations in secondary surgery rates among different providers.
Main Methods:
- Retrospective cohort study of children undergoing primary cleft lip repair (1999-2015).
- Analysis of factors influencing time to secondary lip surgery.
- Assessment of surgeon and hospital-level variations in secondary surgery rates.
Main Results:
- 24.0% of children had secondary cleft lip surgery within 5 years of primary repair.
- Early primary repair (before 3 months) increased secondary surgery risk; multiple congenital anomalies decreased it.
- Substantial variation in secondary surgery use persisted among surgeons and hospitals after adjustment.
Conclusions:
- Significant differences exist in secondary cleft lip surgery rates among surgeons and hospitals.
- Further research is needed to understand the drivers of this provider variation.
Objective:
To identify child-, surgeon-, and hospital-specific factors at the time of primary cleft lip repair that are associated with the use of secondary cleft lip surgery.
Design:
Retrospective cohort study.
Setting:
Forty-nine pediatric hospitals.
Participants:
Children who underwent cleft lip repair between 1999 and 2015.
Main Outcome Measure:
Time from primary cleft lip repair to secondary lip surgery.
Results:
By 5 years after primary lip repair, 24.0% of children had undergone a secondary lip surgery. In multivariable analysis, primary lip repair before 3 months had a 1.22-fold increased hazard of secondary surgery (95% confidence interval [CI]: 1.02-1.46) compared to repair at 7 to 12 months of age, and children with multiple congenital anomalies had a 0.77-fold decreased hazard of secondary surgery (95% CI: 0.68-0.87). After adjusting for cleft type, age at repair, presence of multiple congenital anomalies, and procedure volume, there remained substantial variation in secondary surgery use among surgeons and hospitals (P < .01). For children with unilateral cleft lip repaired at 3 to 6 months of age, the predicted proportion of children undergoing secondary surgery within 5 years of primary repair ranged from 4.9% to 21.8% across surgeons and from 4.5% to 24.7% across hospitals.
Conclusions:
There are substantial differences among surgeons and hospitals in the rates of secondary lip surgery. Further work is needed to identify causes for this variation among providers.
