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. 2017 May;1(1):e000063.
doi: 10.1136/bmjpo-2017-000063. Epub 2017 Aug 31.

Variation among cleft centres in the use of secondary surgery for children with cleft palate: a retrospective cohort study

Thomas J Sitzman  1   2 , Monir Hossain  3 , Adam C Carle  2 , Pamela C Heaton  4 , Maria T Britto  2   5
Affiliations

Variation among cleft centres in the use of secondary surgery for children with cleft palate: a retrospective cohort study

Thomas J Sitzman et al. BMJ Paediatr Open. 2017 May.

Abstract

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.

Keywords: Health Services Research; Outcomes Research; Plastic Surgery; Procedures.

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Conflict of interest statement

COMPETING INTERESTS All authors have completed the ICMJE uniform disclosure form at www.icmje.org/coi_disclosure.pdf and declare: no support from any organisation for the submitted work; no financial relationships with any organisations that might have an interest in the submitted work in the previous three years; Dr. Britto reports personal fees and other from American Board of Pediatrics Research Advisory Committee, outside the submitted work; all other authors report no other relationships or activities that could appear to have influenced the submitted work.

Figures

Figure 1
Figure 1
Kaplan-Meier curves for time until secondary palate surgery. (A) Time to secondary surgery for all patients in the study. (B) Time to secondary surgery by hospital for hospitals with >175 patients undergoing palate repair during the observation period. At-risk table and censoring times for each hospital are shown in figure 3 online supplementary file 3. Log-rank test is stratified by patient gender, race and median household income for ZIP code of residence.
Figure 2
Figure 2
Kaplan-Meier curve for time until secondary surgery based on age at primary palate repair. This figure demonstrates the time-dependent hazard of secondary surgery. For children who underwent primary palate repair before 9 months of age, the hazard of secondary surgery lies principally in the first 2 years after primary repair.
See this image and copyright information in PMC

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