To identify child-, surgeon- and hospital-specific factors at the time of primary cleft palate repair that are associated with the use of secondary palate surgery.
Design:
Retrospective cohort study.
Setting:
Forty-nine pediatric hospitals.
Participants:
Children who underwent cleft palate repair between 1998 and 2015.
Main Outcome Measure:
Time from primary cleft palate repair to secondary palate surgery.
Results:
By 5 years after the primary palate repair, 27.5% of children had undergone secondary palate surgery. In multivariable analysis, cleft type and age at primary palate repair were both associated with secondary surgery (P < .01). Children with unilateral cleft lip and palate had a 1.69-fold increased hazard of secondary surgery (95% confidence interval [CI]: 1.54-1.85) compared to children with cleft palate alone. Primary palate repair before 9 months had a 3.99-fold increased hazard of secondary surgery (95% CI: 3.39-4.07) compared to repair at 16 to 24 months of age. After adjusting for cleft type, age at repair, and procedure volume, there remained substantial variation in secondary surgery use among surgeons and hospitals (P < .01). For children with isolated cleft palate, the predicted proportion of children undergoing secondary surgery within 5 years of primary repair ranged from 8.5% to 46.0% across surgeons and 9.1% to 49.4% across hospitals.
Conclusions:
There are substantial differences among surgeons and hospitals in the rates of secondary palate surgery. Further work is needed to identify causes for this variation among providers and develop interventions to reduce the need for secondary surgery.
AhlRHarding-BellA. Comparing methodologies in a series of speech outcome studies: challenges and lessons learned. Cleft Palate Craniofac J. 2018;55(1):35–44.
2.
AndersonJBBeekmanRHIIIKuglerJDRosenthalGLJenkinsKJKlitznerTSMartinGRNeishSRDarbieLKingE; National Pediatric Cardiiology Quality Improvement Collabrative. Use of a learning network to improve variation in interstage weight gain after the norwood operation. Congenit Heart Dis. 2014;9(6):512–520.
3.
Asher-McDadeCBrattstromVDahlEMcWilliamJMolstedKPlintDAPrahl-AndersenBSembGShawWCTheRP. A six-center international study of treatment outcome in patients with clefts of the lip and palate: part 4. Assessment of nasolabial appearance. Cleft Palate Craniofac J. 1992;29(5):409–412.
4.
AznarMLSchonmeyrBEchanizGNebekerLWendbyLCampbellA. Role of postoperative antimicrobials in cleft palate surgery: prospective, double-blind, randomized, placebo-controlled clinical study in India. Plast Reconstr Surg. 2015;136(1):59e–66e.
5.
BastaMNSilvestreJStranskyCSolotCCohenMMcDonald-McGinnDZackaiEKirschnerRLowDWRandallP. A 35-year experience with syndromic cleft palate repair: operative outcomes and long-term speech function. Ann Plast Surg. 2014;73(suppl 2):S130–S135.
6.
BezuhlyMFischbachSKlaimanPFisherDM. Impact of 22q deletion syndrome on speech outcomes following primary surgery for submucous cleft palate. Plast Reconstr Surg. 2012;129(3):502e–510e.
7.
BrandaoGRde Souza FreitasJAGenaroKFYamashitaRPFukushiroAPLaurisJR. Speech outcomes and velopharyngeal function after surgical treatment of velopharyngeal insufficiency in individuals with signs of velocardiofacial syndrome. J Craniofac Surg. 2011;22(5):1736–1742.
8.
BrattstromVMolstedKPrahl-AndersenBSembGShawWC. The Eurocleft study: intercenter study of treatment outcome in patients with complete cleft lip and palate. Part 2: craniofacial form and nasolabial appearance. Cleft Palate Craniofac J. 2005;42(1):69–77.
9.
BrittoMTFullerSCKaplanHCKotagalULannonCMargolisPAMuethingSESchoettkerPJSeidM. Using a network organisational architecture to support the development of Learning Healthcare Systems. BMJ Qual Saf. 2018;27:937–946. doi: 10.1136/bmjqs-2017-007219.
10.
BrittonLAlberyLBowdenMHarding-BellAPhippenGSellD. A cross-sectional cohort study of speech in five-year-olds with cleft palate ± lip to support development of national audit standards: benchmarking speech standards in the United Kingdom. Cleft Palate Craniofac J. 2014;51(4):431–451.
11.
BykowskiMRNaranSWingerDGLoseeJE. The rate of oronasal fistula following primary cleft palate surgery: a meta-analysis. Cleft Palate Craniofac J. 2015;52(4):e81–e87.
12.
CassellCHDanielsJMeyerRE. Timeliness of primary cleft lip/palate surgery. Cleft Palate Craniofac J. 2009;46(6):588–597.
13.
CrandallWKappelmanMDCollettiRBLeibowitzIGrunowJEAliSBaronHIBermanJHBoyleBCohenS. ImproveCareNow: the development of a pediatric inflammatory bowel disease improvement network. Inflamm Bowel Dis. 2011;17(1):450–457.
14.
DaskalogiannakisJMercadoARussellKHathawayRDugasGLongREJrCohenMSembGShawW. The Americleft study: an inter-center study of treatment outcomes for patients with unilateral cleft lip and palate: part 3. Analysis of craniofacial form. Cleft Palate Craniofac J. 2011;48(3):252–258.
15.
de Agostino Biella PassosVde Carvalho CarraraCFda Silva DalbenGCostaBGomideMR. Prevalence, cause, and location of palatal fistula in operated complete unilateral cleft lip and palate: retrospective study. Cleft Palate Craniofac J. 2014;51(2):158–164.
16.
DorfDSCurtinJW. Early cleft palate repair and speech outcome. Plast Reconstr Surg. 1982;70(1):74–81.
17.
FeudtnerCHaysRMHaynesGGeyerJRNeffJMKoepsellTD. Deaths attributed to pediatric complex chronic conditions: national trends and implications for supportive care services. Pediatrics. 2001;107(6):E99.
18.
FieldstonESShahSSHallMHainPDAlpernERDel BeccaroMAHardingJMacyML. Resource utilization for observation-status stays at children’s hospitals. Pediatrics. 2013;131(6):1050–1058.
19.
GoodmanEKReillyAFFisherBTFitzgeraldJLiYSeifAEHuangYSBagatellRAplencR. Association of weekend admission with hospital length of stay, time to chemotherapy, and risk for respiratory failure in pediatric patients with newly diagnosed leukemia at freestanding US children’s hospitals. JAMA Pediatr. 2014;168(10):925–931.
20.
HaapanenMLRantalaSL. Correlation between the age at repair and speech outcome in patients with isolated cleft palate. Scand J Plast Reconstr Surg Hand Surg. 1992;26(1):71–78.
21.
HardwickeJTLandiniGRichardBM. Fistula incidence after primary cleft palate repair: a systematic review of the literature. Plast Reconstr Surg. 2014;134(4):618e–627e.
22.
LithoviusRHYlikontiolaLPSandorGK. Frequency of pharyngoplasty after primary repair of cleft palate in northern Finland. Oral Surg Oral Med Oral Pathol Oral Radiol. 2014;117(4):430–434.
23.
MackayDMazahariMGrahamWPJeffordsKLeberDGormanPLieserJDWryeSKutzRSaggersG. Incidence of operative procedures on cleft lip and palate patients. Ann Plast Surg. 1999;42(4):445–448.
24.
MahoneyMHSwanMCFisherDM. Prospective analysis of presurgical risk factors for outcomes in primary palatoplasty. Plast Reconstr Surg. 2013;132(1):165–171.
25.
MarsMAsher-McDadeCBrattstromVDahlEMcWilliamJMolstedKPlintDAPrahl-AndersenBSembGShawWC. A six-center international study of treatment outcome in patients with clefts of the lip and palate: part 3. Dental arch relationships. Cleft Palate Craniofac J. 1992;29(5):405–408.
26.
McAteerJPLaRiviereCADrugasGTAbdullahFOldhamKTGoldinAB. Influence of surgeon experience, hospital volume, and specialty designation on outcomes in pediatric surgery: a systematic review. JAMA Pediatr. 2013;167(5):468–475.
27.
PatelKBSullivanSRMurthyASMarrinanEMullikenJB. Speech outcome after palatal repair in nonsyndromic versus syndromic Robin sequence. Plast Reconstr Surg. 2012;130(4):577e–584e.
28.
RautioJAndersenMBolundSHukkiJVindenesHDavenportPArctanderKLarsonOBerggrenAAbyholmF. Scandcleft randomised trials of primary surgery for unilateral cleft lip and palate: 2. Surgical results. J Plast Surg Hand Surg. 2017;51(1):14–20.
29.
SembGBrattstromVMolstedKPrahl-AndersenBZuurbierPRumseyNShawWC. The Eurocleft study: intercenter study of treatment outcome in patients with complete cleft lip and palate. Part 4: relationship among treatment outcome, patient/parent satisfaction, and the burden of care. Cleft Palate Craniofac J. 2005;42(1):83–92.
30.
SitzmanTJHossainMCarleACHeatonPCBrittoMT. Variation among cleft centres in the use of secondary surgery for children with cleft palate: a retrospective cohort study. BMJ Paediatrics Open. 2017;1(1):e000063.
31.
SommerladBC. A technique for cleft palate repair. Plast Reconstr Surg. 2003;112(6):1542–1548.
32.
SpiegelhalterDJ. Funnel plots for comparing institutional performance. Stat Med. 2005;24(8):1185–1202.
33.
ThompsonJAHeatonPCKeltonCMSitzmanTJ. National estimates of and risk factors for inpatient revision surgeries for orofacial clefts. Cleft Palate Craniofac J. 2017;54(1):60–69.
34.
TukeyJW. Exploratory Data Analysis. Reading, MA: Addison-Wesley; 1977.
35.
WilliamsACSandyJRThomasSSellDSterneJA. Influence of surgeon’s experience on speech outcome in cleft lip and palate. Lancet. 1999;354(9191):1697–1698.
36.
WilliamsWNSeagleMBPegoraro-KrookMISouzaTVGarlaLSilvaMLMachado NetoJSDutkaJCNackashiJBoggsS. Prospective clinical trial comparing outcome measures between Furlow and von Langenbeck Palatoplasties for UCLP. Ann Plast Surg. 2011;66(2):154–163.
37.
YangMEldridgeSMerloJ. Multilevel survival analysis of health inequalities in life expectancy. Int J Equity Health. 2009;8:31.
38.
YsunzaAPamplonaMCMendozaMGarcia-VelascoMAguilarMPGuerreroME. Speech outcome and maxillary growth in patients with unilateral complete cleft lip/palate operated on at 6 versus 12 months of age. Plast Reconstr Surg. 1998;102(3):675–679.
