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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 factors and surgeon factors that are associated with use of secondary surgery.
Design Retrospective cohort study.
Setting Forty-three paediatric hospitals across the USA.
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 4939 children who underwent primary cleft palate repair. At 10 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 9 months of age was associated with an increased hazard of secondary palate surgery (initial HR 6.74, 95% CI 5.30 to 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 9 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.
- health services research
- outcomes research
- plastic surgery
- procedures
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Footnotes
Contributors TJS conceptualised and designed the study, carried out the initial analyses and interpretation of data, drafted the initial manuscript and approved the final manuscript as submitted. MH, ACC, HN and MTB designed the study, interpreted results of the analyses, reviewed and revised the manuscript and approved the final manuscript as submitted.
Funding TJS received support from the National Institute of Dental and Craniofacial Research of the National Institutes of Health (K23 DE025023). The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health. No other external funding was provided for this manuscript.
Competing interests MTB reports personal fees and from the 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.
Provenance and peer review Not commissioned; externally peer reviewed.