Current National Incidence, Trends, and Health Care Resource Utilization of Cleft Lip–Cleft Palate:

National Trends in Microtia Repair Cost and Hospital Length of Stay

Microtia can have deleterious impacts on the functional, psychological, and aesthetic outcomes of affected young children. Reconstructive procedures can alleviate these negative outcomes and significantly improve the quality of life for patients; however, the cost and length of hospital stay (LOS) for such procedures and the factors that impact them have not been well-characterized. This study seeks to understand the hospital-level (institution type, size, and geographic region) and patient-level factors (race, age, and insurance status) that impact cost and LOS in patients who undergo microtia reconstructive surgery. A retrospective data analysis was conducted utilizing the National Inpatient Sample (NIS) database for the years 2008 to 2015. Inclusion criteria included patients who had an International Classification of Diseases, Ninth Revision (ICD-9) diagnostic code for microtia (744.23) as well as a procedure for microtia correction (186×/187×). A total of 714 microtia repair cases met the inclusion criteria and were sampled from the NIS database. Microtia repair cost was significantly increased on the West Coast compared with the Northeast ($34,947 versus $29,222, P =0.020), increased with patient age ($614/y, P =0.012), and gradually increased from 2008 to 2015 ($25,897-$48,985, P <0.001). Microtia LOS was significantly increased with government-controlled hospitals compared with private hospitals (1.93 versus 1.39 d, P =0.005), increased with patients on Medicaid compared with private insurance (2.33 versus 2.00 d, P =0.036), and overall decreased with patient age (-0.07 d/y, P =0.001). The results not only identify the multifactorial impacts that drive cost and LOS in microtia repair but provide insights into the financial and medical considerations patients and their families must navigate.

The Reality of Commercial Payer-Negotiated Rates in Cleft Lip and Palate Repair

BACKGROUND

Commercial payer-negotiated rates for cleft lip and palate surgery have not been evaluated on a national scale. The aim of this study was to characterize commercial rates for cleft care, both in terms of nationwide variation and in relation to Medicaid rates.

METHODS

A cross-sectional analysis was performed of 2021 hospital pricing data from Turquoise Health, a data service platform that aggregates hospital price disclosures. The data were queried by CPT code to identify 20 cleft surgical services. Within- and across-hospital ratios were calculated per CPT code to quantify commercial rate variation. Generalized linear models were used to assess the relationship between median commercial rate and facility-level variables and between commercial and Medicaid rates.

RESULTS

There were 80,710 unique commercial rates from 792 hospitals. Within-hospital ratios for commercial rates ranged from 2.0 to 2.9 and across-hospital ratios ranged from 5.4 to 13.7. Median commercial rates per facility were higher than Medicaid rates for primary cleft lip and palate repair ($5492.20 versus $1739.00), secondary cleft lip and palate repair ($5429.10 versus $1917.00), and cleft rhinoplasty ($6001.00 versus $1917.00; P < 0.001). Lower commercial rates were associated with hospitals that were smaller ( P < 0.001), safety-net ( P < 0.001), and nonprofit ( P < 0.001). Medicaid rate was positively associated with commercial rate ( P < 0.001).

CONCLUSIONS

Commercial rates for cleft surgical care demonstrated marked variation within and across hospitals, and were lower for small, safety-net, or nonprofit hospitals. Lower Medicaid rates were not associated with higher commercial rates, suggesting that hospitals did not use cost-shifting to compensate for budget shortfalls resulting from poor Medicaid reimbursement.

Sociodemographic Disparities in Access to Cleft Rhinoplasty

Various sociodemographic factors affect patient access to care. This study aims to assess how factors such as government-funded insurance and socioeconomic status impact the ability of adolescents with cleft lip-associated nasal deformities to access secondary rhinoplasty procedures. Patients older than 13 years old with a history of cleft lip/palate were identified in the National Inpatient Sample database from 2010 to 2012. Those who received a secondary rhinoplasty were identified using the International Classification of Diseases, Ninth Revision (ICD-9) procedural codes. A multivariate logistic regression model with post hoc analyses was performed to analyze if insurance status, socioeconomic status, and hospital-level variables impacted the likelihood of undergoing rhinoplasty. Of the 874 patients with a cleft lip/palate history, 154 (17.6%) underwent a secondary rhinoplasty. After controlling for various patient-level and hospital-level variables, living in a higher income quartile (based on zip code of residence) was an independent predictor of receiving a secondary cleft rhinoplasty (odds ratio=1.946, P =0.024). Patients had lower odds of receiving a cleft rhinoplasty if care occurred in a private, nonprofit hospital compared with a government-owned hospital (odds ratio=0.506, P =0.030). Income status plays a significant role in cleft rhinoplasty access, with patients from lower income households less likely to receive a secondary cleft rhinoplasty. Hospital-specific factors such as geographic region, bed size, urbanization, and teaching status may also create barriers for patients and their families in accessing surgical care for cleft lip nasal deformities.

Demographics and trends of cleft lip and palate patients born in Tennessee from 2000 to 2017

OBJECTIVE

The goal of this study was to evaluate the prevalence of orofacial clefts (OFCs) in Tennessee over the span of 2000-2017, and evaluate the effects of race/ethnicity, sex, maternal/paternal age and socioeconomic status on the prevalence.

METHODS

Records of all live births and demographics of newborns in Tennessee from 2000 to 2017 were requested from the Tennessee Department of Health to calculate the prevalence of OFCs. Data from United States Census was also obtained. Data provided were deidentified.

RESULTS

Tennessee showed a significant decrease in prevalence rates of cleft lip, with and without cleft palate (CL ± P), when comparing the time periods of 2000-2007 to 2008-2017. A significant positive correlation was found with CL ± P prevalence rates in regions with higher Caucasian populations and a negative correlation in regions with higher African American populations. The CP prevalence rates showed a negative correlation with increased median household income.

CONCLUSION

To our knowledge, this is the first study to show a significant negative correlation with median household income and CP prevalence rates. Our study showing an increase in prevalence rates of OFCs with decreased socioeconomic status indicates that the areas of Tennessee with the lowest median household income averages would likely benefit from understanding other possible modifiable factors that are driving this correlation.

Follow-Up Care Barriers for Patients with Orofacial Clefts

OBJECTIVE

The aim of this study was to evaluate whether a patient with a cleft's age, associated syndrome, cleft phenotype or travel distance affects their follow-up rate.

DESIGN

This study is a retrospective review of patients with CL/P treated by a craniofacial clinic.

SETTING

The setting was a craniofacial clinic at a tertiary care university hospital.

PATIENTS, PARTICIPANTS

Candidates were patients seen by the craniofacial clinic between January 2007 and December 2019. An initial pool of 589 patients was then reduced to 440 due to exclusion criteria.

INTERVENTIONS

None.

MAIN OUTCOME MEASURE(S)

The outcome measure was actual patient attendance to the craniofacial team compared to the team goal expectation of annual return visits.

RESULTS

The mean age of participants at the end of the study was 9.0 ±  5.4 years with a mean follow-up period (total possible follow-up period length based on patient age at presentation and study window) of 5.5 ±  3.6 years. There was no association between cleft phenotype, type of syndrome, or distance to the clinic with attendance. Children with syndromes had an 11% decrease in the odds of attending follow-up visits with each 1-year increase in age compared to a 4% decrease in children without syndromes.

CONCLUSIONS

The only significant factors determining patient attendance were the presence of a syndrome and increasing age.

The prevalence, risk of premature births, mortality and causes of death of cleft lip with or without palate in South Korea: a nationwide population-based cohort study

BACKGROUND

Very few recent nationwide studies have assessed the epidemiology of cleft lip with or without palate (CL/P). The purpose of this study was to identify the prevalence, risk of premature births, mortality and cause of death of CL/P.

METHODS

This nationwide population-based cohort study evaluated all 5 747 830 live births in South Korea, including CL/P infants, from 2006 to 2018. The prevalence with trend analysis, risk of premature births, mortality and cause of death of CL/P with or without associated syndromes (non-syndromic, syndromic CL/P) and subgroups (cleft lip only, cleft palate only, cleft lip with palate) were evaluated.

RESULTS

Among 5 747 830 live births, 11 284 children were identified as having CL/P during the study period. The annual prevalence was 1.96 per 1000 births. The prevalence ratio, which shows the trend during the period, was 1.021. Both non-syndromic and syndromic CL/P children had higher risk of premature births compared with children without CL/P (odds ratio: non-syndromic 1.43, syndromic 5.29). The mortality rates per 1000 person-years were 0.39 for children without CL/P, 0.98 for non-syndromic CL/P children and 12.20 for syndromic CL/P children. The causes of deaths were not different for children without CL/P in non-syndromic CL/P, but the most common cause of deaths was cardiovascular anomalies in syndromic CL/P.

CONCLUSION

The reported prevalence of 1.96 per 1000 births is one of the highest prevalences worldwide. CL/P children had high risks of premature births and risk of mortality. The most common cause of deaths was cardiovascular anomalies.

Socioeconomic Disparities in Cleft Lip Care

OBJECTIVE

The purpose of this study was to utilize a multicenter dataset to elucidate whether socioeconomic factors were associated with access to cleft lip surgery, treatment by higher-volume providers, and family choice for higher-volume centers.

DESIGN

Retrospective cohort study.

SETTING

Hospitals participating in the Pediatric Health Information System.

PATIENTS

Primary cleft lip repair performed in the United States between 2010 and 2020.

OUTCOMES

Travel distance, hospital volume, hospital choice.

RESULTS

During the study interval, 8954 patients underwent unilateral (78.4%, n  =  7021) or bilateral (21.6%, n  =  1933) primary cleft lip repair. Patients with unilateral cleft lip were repaired significantly earlier if they were White (P < .001) and significantly later if they lived in an urban community (P  =  .043). Similarly, patients with bilateral cleft lip were repaired significantly earlier if they were White (P < .001). Patients from above-median income households (P  =  .011) and living in urban communities (P < .001) were significantly more likely to be treated at high-volume hospitals, whereas those living in underserved communities (P < .001) were significantly less likely to be treated at high-volume hospitals. White patients were significantly more likely to be treated by high-volume surgeons (P < .001). Patients with White race were significantly more likely to choose a higher-volume hospital than the one most locally available (P < .001).

CONCLUSIONS

Patients with White race are more likely to travel farther and be treated by high-volume surgeons although at smaller hospitals. Patients from underserved areas travel significantly farther for cleft care and are treated at lower-volume hospitals. Patients in urban communities have shorter travel distances and are treated at higher-volume hospitals.

Sociodemographic Predictors of Patient Age at Time of Cleft Lip and Palate Repair

Objective:

To identify the impact of sociodemographic and health variables on the age at which patients undergo cleft lip repair, cleft palate repair, and primary speech evaluation.

Design:

A retrospective, noninterventional quality assessment, and quality improvement study was designed.

Setting:

This institutional study was performed at Michigan Medicine in Ann Arbor, MI.

Patients:

All patients born between 2011 and 2014 who received surgical cleft repair, excluded those who were adopted (n = 165).

Main Outcome Measure:

The age at which patients undergo cleft lip repair, cleft palate repair, and primary speech evaluation.

Results:

Cleft lip repair was performed significantly later for patients identifying as Asian (18 weeks, P = .01), patients with Child Protective Services contact (19 weeks, P = .01), patients with a significant comorbidity (14 weeks, P = .02), and patients who underwent preliminary lip adhesion surgery (19 weeks, P < .01). Cleft palate repair was performed significantly later for patients identifying racially as Asian (19 weeks, P = .03) and other (22 weeks, P = .03). Preliminary speech and language evaluation were performed significantly later for patients identifying as black (55 weeks, P = .03) and patients diagnosed with an isolated cleft lip (71 weeks, P < .01).

Conclusions:

Timing of cleft lip, cleft palate repair, and primary speech and language evaluation are subject to variation which may be predicted by clinically accessible factors. By identifying race, Child Protective Services contact, and care variables as significant predictors of increased patient age at time of intervention, multidisciplinary cleft care teams can proactively allocate patient support resources.

Delay in Cleft Lip and Palate Surgical Repair: An Institutional Review on Cleft Health Disparities in an Urban Population

Access to specialized medical care is critical to decrease complications and minimize long-term morbidity, yet racial disparities in cleft surgery persist as time to initial reconstruction remains delayed among minority patients. Research has demonstrated an average 3-week delay in surgery for minority patients nationally. A retrospective chart review of patient demographics, visit timing, and surgical history was performed for patients who underwent primary cleft lip with or without palate (CL + P) reconstruction between 2002 and 2016 at an urban craniofacial center. Of the 89 children who underwent surgery, 87% were ethnic minorities (58% Hispanic, 25% African-American, 4% Asian/Other). Caucasian children were the earliest to receive CL (3.5 months) and CP (13-months) repair. Minority children trended toward a delay in CL repair, with surgery for African-Americans at 5-months (P = 0.06) and Hispanics at 4.8-months (P = 0.07). Time from first visit to CL surgery showed significant delays for minority, non-English speaking, and public insurance patients; however, for CP repair, male children were delayed from first visit to surgery compared to females (P = 0.03). While there was no statistical difference in age at CL or CP surgical repair among our racial/ethnic cohorts, there were significant racial/ethnic differences in timing spent in the preoperative period for CL. However, racial/ethnic differences decreased as the patients spent more time within the healthcare system. Thus, established, interdisciplinary cleft/craniofacial centers well versed in minority patients can minimize the complex social and cultural factors that contribute to delays in cleft care.

Psychological Well-being and Medical Guidance of Parents of Children With Cleft in Belgium During Feeding Problems of the Child: A Mixed Method Study

PURPOSE

Cleft is one of the most common anomalies affecting 1 in every 500-750 newborns. Depending on the type of cleft and its size, these children may experience feeding problems immediately after birth. Cleft has consequences for the child, as well as for the parents. The aim of this study was to gain a better understanding on the factors influencing the psychological well-being of the parents. Also, the experiences of parents of children with feeding problems and the received medical guidance were studied.

DESIGN AND METHODS

A mixed method convergent parallel design was used. In the quantitative study, a cross-sectional design was applied, in which parents completed 3 validated questionnaires about their psychological well-being. For the qualitative research a phenomenological design was used to conduct semi-structured interviews. Ninety parents agreed to join the quantitative study, of which 15 participated in the qualitative study as well.

RESULTS

The timing of the diagnosis revealed a significant difference in the depression and stress scores, while the number of children was significant for depression, anxiety, and stress. Other parental- and child-related factors did not cause a significant difference in psychological well-being. Different opinions about medical guidance and feeding problems came up during the interviews.

CONCLUSION

With these results, a recommendation toward future medical guidance can be given. The number of children and the timing of diagnosis were found to be significant variables determining the psychological well-being of the parents. All parents agreed on the need for a point of contact and an umbrella framework for a clearer guidance. Moreover, caregivers should have more knowledge about cleft and associated feeding problems.

Decision-Making in Cleft-Related Surgery: A Qualitative Analysis of Patients and Caregivers

OBJECTIVE

Preference-sensitive surgical decisions merit shared decision-making, as decision engagement can reduce decisional conflict and regret. Elective cleft-related procedures are often preference sensitive, and therefore, we sought to better understand decision-making in this population.

DESIGN

Semistructured interviews were conducted to elicit qualitative data. A hierarchical codebook was developed through an iterative process in preparation for thematic analysis. Thematic analysis was performed to examine differences between patients and caregivers.

SETTING

Multidisciplinary cleft clinic at a tertiary care center.

PARTICIPANTS

Patients with cleft lip aged 8 and older (n = 31) and their caregivers (n = 31) were purposively sampled. Inability to converse in English, intellectual disability, or syndromic diagnoses resulted in exclusion.

MAIN OUTCOME MEASURES

Preferences surrounding surgical decision-making identified during thematic analysis.

RESULTS

Mean patient age was 12.7 (standard deviation: 3.1). Most had unilateral cleft lip and palate (43.8%). Three themes emerged: Insufficient Understanding of Facial Difference and Treatment, Diversity of Surgical Indications, and Barriers to Patient Autonomy. Almost half of caregivers believed their children understood their clefts, but most of these children failed to provide information about their cleft. Although many patients and caregivers acknowledged that surgery addressed function and/or appearance, patients and caregivers exhibited differences regarding the necessity of surgery. Furthermore, a large proportion of patients believed their opinions mattered in decisions, but less than half of caregivers agreed.

CONCLUSIONS

Patients with clefts desire to participate in surgical decisions but have limited understanding of their facial difference and surgical indications. Cleft surgeons must educate patients and facilitate shared decision-making.

Non-syndromic cleft lip with or without palate-susceptible SNPs is associated with hyperdontia

BACKGROUND

Non-syndromic supernumerary teeth (NSST) or hyperdontia may share common genetic determinants with non-syndromic cleft lip with or without palate (NSCL/P). The aim of this study was to test the associations between five genome-wide-associated NSCL/P-susceptible single nucleotide polymorphisms (SNPs) (rs2235371, rs7078160, rs8049367, rs4791774, and rs13041247) and the occurrence of NSST.

MATERIALS AND METHODS

A total of 163 cases and 326 controls were recruited and their genomic DNA was extracted from blood samples. Five NSCL/P-susceptible SNPs (rs2235371, rs7078160, rs8049367, rs4791774, and rs13041247) were genotyped by TaqMan method. Odds ratio (OR) and 95% confidence interval (CI) were used to estimate the associations between the SNPs and the risk of NSST by PLINK software.

RESULTS

Rs4791774 (A > G) and rs13041247 (T > C) were associated with risk of NSST (rs4791774: P_add  = 0.011, OR, 95% CI = 0.62, 0.43-0.90; rs13041247: P_homo  = 0.031, OR, 95% CI = 1.79, 1.05-3.05) and one supernumerary tooth (rs4791774: P_dom  = 0.009, OR, 95% CI = 0.56, 0.36-0.87; rs13041247: P_homo  = 0.034, OR, 95% CI = 1.82, 1.05-3.15). Rs4791774 (A > G) was also showed association with risk of upper arch supernumerary teeth only (P_add  = 0.010, OR, 95% CI = 0.60, 0.41-0.89).

CONCLUSION

Non-syndromic cleft lip with or without palate-susceptible loci rs4791774 (A > G) and rs13041247 (T > C) were associated with the risk of supernumerary teeth.

Epidemiology and clinical profile of individuals with cleft lip and palate utilising specialised academic treatment centres in South Africa

OBJECTIVE

The study was conducted to determine the epidemiology and clinical profile of individuals with cleft lip and/or palate (CLP) utilizing specialized academic treatment centres in South Africa's public health sector.

MATERIALS AND METHODS

The Human Research Ethics Committee of the University of the Witwatersrand in Johannesburg provided ethical approval for the study. We conducted a retrospective record review of all cases of CLP treated at the specialised academic centres for the two-year period from 1 January 2013 until 31 December 2014. We used a structured, pre-tested record review form to obtain demographic, clinical and treatment information on each CLP case. We used Stata 13 to analyse the data and conducted statistical tests at 5% significance level.

RESULTS

We analysed 699 records of individuals with CLP. The estimated prevalence of CLP in the South African public health sector was 0.3 per 1000 live births, with provincial variation of 0.1/1000 to 1.2/1000. The distribution of clefts was: 35.3% cleft palate; 34.6% cleft lip and palate; 19.0% cleft lip and other cleft anomalies at 2%. Of the total number of CLP, 47.5% were male and 52.5% female, and this difference was statistically significant (p<0.001). The majority of clefts occurred on the left for males (35.5%) and palate for females (43.4%), with a male predominance of unilateral cleft lip and palate (53.3%).

CONCLUSION

The study findings should inform the implementation of South Africa's planned birth defect surveillance system and health service planning for individuals with CLP.

Outcomes of Primary Palatoplasty: An Analysis Using the Pediatric Health Information System Database

BACKGROUND

Previous attempts at reporting oronasal fistula development and secondary speech surgery following cleft palate surgery have been limited to single-center case series. This limitation can be overcome by querying large databases created by health care governing bodies or health care alliances. The authors examined the effect of cleft type and demographic variables on the clinical outcomes.

METHODS

Data from the Pediatric Health Information System database were queried for patients, aged 6 to 18 months, who had undergone primary palatoplasty between 2004 and 2009. Subsequent repair of an oronasal fistula and/or secondary speech surgery between 2004 and 2015 was identified by procedure codes. Logistic regression models were used to assess the associations between cleft type with oronasal fistula and with secondary speech surgery.

RESULTS

Seven thousand three hundred twenty-five patients were identified, and 6.4 percent (n = 468) had a subsequent repair of an oronasal fistula and 18.5 percent (n = 1355) had a secondary speech operation. Adjusted for age, sex, and race, patients with cleft lip and palate have increased odds of oronasal fistula (OR, 5.60; 95 percent CI, 4.44 to 7.07) and secondary speech surgery (OR, 2.32; 95 percent CI, 2.05 to 2.63).

CONCLUSIONS

Using a large, multi-institution billing database, the authors were able to estimate the prevalence of oronasal fistula and surgically treated velopharyngeal insufficiency following primary palatoplasty in the United States. In addition, the authors demonstrated that patients with isolated cleft palate develop fewer oronasal fistulas and require less secondary speech surgery than patients with cleft lip and palate.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Risk, III.

Trends in sociodemographic disparities of pediatric cochlear implantation over a 15-year period

OBJECTIVE

Sociodemographic disparities of cochlear implantation in children have been reported. This study sought to determine if disparities in children receiving cochlear implants have narrowed, widened or remained constant.

METHODS

Children 18 years or younger who underwent cochlear implantation from 1997 to 2012 were selected using the Kids' Inpatient Database. Demographic data included primary insurance payer, income quartile and race. The Cochran-Armitage test was used to determine if trends were significant. Prevalence rates of cochlear implantation by race were generated. A Poisson regression model was used to evaluate the rates of cochlear implantation within each racial group.

RESULTS

The proportion of children receiving cochlear implants with private insurance decreased from 79.3% to 42.6% (p < .0001), whereas children with Medicaid increased from 17.4% to 35.2% (p < .0001). Proportion of implanted children from the lowest two income quartiles increased from 15.5% to 24.4% (p < .0001) and 10.3%-21.8% (p < .0035), respectively. Rates of implantation among children from income quartile four decreased from 50.9% to 35.3% (p < .0001). White children were implanted twice as often as Black or Hispanic children (p = .007 and p = .0012 respectively). Asian children were implanted more than twice as often as Black or Hispanic Children (p = .0154 and p = .0098 respectively).

CONCLUSIONS

Income and insurance disparities have narrowed within the inpatient pediatric cochlear implantation cohort. Racial disparities still exist. White and Asian children are implanted at higher rates than Black or Hispanic children.

Sociodemographic Predictors of Missed Appointments Among Patients With Cleft Lip and Palate

Objective:

To identify disparities in compliance of and care for patients with cleft lip and/or palate (CL/P) by determining the impact of sociodemographic variables on the rate of missed appointments and Child Protective Services (CPS) involvement.

Design:

A retrospective, noninterventional quality assessment and quality improvement study were designed.

Setting:

This institutional study was performed at the University of Michigan in Ann Arbor, Michigan.

Patients:

All patients born between January 1, 2011, and December 31, 2014, who underwent surgical CL/P repair, excluding those with fewer than 5 appointments (n = 178).

Main Outcome Measure:

The rate of missed appointments, calculated as the total number of no-show appointments divided by the total number of scheduled appointments. All appointments from CL/P diagnosis to data collection were considered, including those outside of plastic surgery.

Results:

The average patient was 4.5 years of age and had 49 total scheduled appointments. The overall rate of missed appointments was 9.6%, with 66.8% of patients missing at least 1 scheduled visit. Patients who were black ( P = .04), not affiliated with a religion ( P = .01), Medicaid users ( P = .01), from an unstable social background ( P = .01), or received need-based financial assistance ( P = .00) were significantly more likely to miss appointments. Child Protective Services was involved with 3.9% of patients.

Conclusions:

Disparities exist in attendance rates among patients with CL/P, and at-risk patient populations have been identified. The allocation of cleft care resources must be efficiently planned in order to enhance the quality of care for at-risk individuals.

Perfil da fala de pacientes submetidos à palatoplastia primária

RESUMO Objetivo caracterizar o perfil e a fala de pacientes submetidos à palatoplastia primária em um hospital escola de São Paulo, levando-se em consideração a idade do paciente no momento da cirurgia (precoce até os 2 anos de idade e tardio após 2 anos). Método 97 indivíduos, de ambos os gêneros, com diagnóstico de fissura de palato associada ou não à de lábio, divididos em dois grupos: 1) grupo precoce (GP), composto por 43 indivíduos operados até o segundo ano de vida; 2) grupo tardio (GT), composto por 54 indivíduos operados após o segundo ano. Os participantes foram submetidos à avaliação clínica fonoaudiológica. Os parâmetros avaliados e considerados para o estudo foram: classificação da ressonância, presença de ronco nasal audível, ocorrência de fraca pressão intraoral, ocorrência de emissão nasal, classificação da inteligibilidade de fala e presença de distúrbios articulatórios compensatórios (DACs). Uma porcentagem randomicamente selecionada de participantes (30%) foi reavaliada por mais duas fonoaudiólogas e a comparação entre os juízes indicou alta concordância. Resultados (nível de significância de 5%): os grupos não se diferenciaram em relação à classificação da ressonância (p=0,067), grau de hipernasalidade (p=0,113), presença de ronco nasal (p=0,179), ocorrência de fraca pressão intraoral (p=0,152), ocorrência de emissão nasal (p=0,369) e classificação da inteligibilidade de fala (p=0,113). Em relação à presença de DACs, os grupos se diferenciaram (p=0,020), com maior ocorrência de fonemas alterados no GT. Conclusão foi possível caracterizar o perfil geral e de fala dos pacientes submetidos à palatoplastia primária do referido hospital escola. Concluiu-se que a realização da cirurgia precocemente traz melhores resultados em relação à fala.

Cryogel scaffolds from patient-specific 3D-printed molds for personalized tissue-engineered bone regeneration in pediatric cleft-craniofacial defects

Bone defects are extremely common in children with cleft-craniofacial conditions, especially those with alveolar cleft defects and cranial defects. This study used patient-specific 3D-printed molds derived from computed tomography and cryogel scaffold fabrication as a proof of concept for the creation of site-specific implants for bone reconstruction. Cryogel scaffolds are unique tissue-engineered constructs formed at sub-zero temperatures. When thawed, the resulting structure is macroporous, sponge-like, and mechanically durable. Due to these unique properties, cryogels have excellent potential for the treatment of patient-specific bone defects; however, there is little literature on their use in cleft-craniofacial defects. While 3D-printing technology currently lacks the spatial resolution to print the microstructure necessary for bone regeneration, it can be used to create site-specific molds. Thus, it is ideal to integrate these techniques for the fabrication of scaffolds with patient-specific geometry. Overall, all cryogels possessed appropriate geometry to allow for cell infiltration after 28 days. Additionally, suitable mechanical durability was demonstrated where, despite mold geometry, all cryogels could be compressed without exhibiting crack propagation. Such a patient-specific scaffold would be ideal in pediatric cleft-craniofacial defects, as these are complex 3D defects and children have less donor bone availability.

Health-Related Quality of Life and the Desire for Revision Surgery Among Children With Cleft Lip and Palate

PURPOSE

Children with cleft lip with or without palate (CLCP) require multiple reconstructive procedures, however, little is known about their desire for surgical revision. The purpose of this study was to examine the relationship between health-related quality of life (HRQOL) and the desire for revision.

METHODS

The authors surveyed children with CLCP (n = 71) and their caregivers regarding general and cleft-specific HRQOL and the desire for revision surgery. The authors used logistic regression models to evaluate the relationship between HRQOL and the desire for revision stratified by age, and determined the level of agreement between caregivers and children.

RESULTS

In this cohort, 54.9% of children desired revision, primarily of the nose (n = 23), lip (n = 20), and dentoalveolar structures (n = 19). Children 11 years or older were more likely to desire revision than younger children (OR 3.39, 95% CI [1.19, 9.67], P <0.05). Children who reported poorer HRQOL with respect to appearance (OR 2.31, 95% CI [1.25-4.29], P = 0.008), social development (OR 0.91, 95% CI [0.84-0.99], P = 0.02), and communication (OR 0.94, 95% CI [0.89-0.99], P = 0.02) were significantly more likely to desire revision than children who reported more positive HRQOL. Caregivers' and children's desires for revision were only modestly correlated (r = 0.41).

CONCLUSIONS

Children with CLCP who report poorer HRQOL are more likely to desire revision than children with higher HRQOL; these differences are further magnified among older children. Given the modest correlation between patient and caregiver goals for revision, it is important to evaluate both perspectives when considering revision surgery.

National Estimates of and Risk Factors for Inpatient Revision Surgeries for Orofacial Clefts

Objective

To provide national estimates of the number and cost of primary and revision cleft lip and palate surgeries in the U.S. and to determine patient and hospital characteristics associated with disproportionate use of revision surgery.

Design

Retrospective cross-sectional study using data obtained from the 2003, 2006, and 2009 Kids’ Inpatient Database.

Setting

Inpatient.

Patients

Children with CL, CP, or CLP undergoing inpatient cleft lip and/or palate surgery.

Interventions

Inpatient cleft lip and/or palate surgery.

Main Outcome Measures

Orofacial cleft surgery estimates, estimates of primary versus revision surgeries, and estimated inflation-adjusted hospitalization costs.

Results

In 2009, there were a total of 2824 and 5431 hospitalizations for cleft lip and palate surgeries, respectively. Revision surgery accounted for 24.2% of cleft lip surgeries and 36.8% of cleft palate surgeries. Children with CLP (OR 1.87, 95% CI 1.48-2.38), a syndromic diagnosis (OR 1.47, 95% CI: 1.16-1.87), or private insurance (OR 1.71, 95% CI: 1.41-2.09) were more likely to undergo cleft lip revision surgery. Similar risk factors were found for children undergoing cleft palate revision. Mean cost per hospitalization ranged from $7564 to $8393 in 2009, depending on surgery type, and did not change significantly (in 2009 U.S. $) between 2003 and 2009.

Conclusions

Interventions to reduce revision surgery by improving results of primary surgery should be targeted in the population of identified high-risk (e.g., syndromic) patients. In addition, the association of health insurance status with revision surgery highlights the need to understand and address the impact of economic disparities on cleft care delivery.

Trends in epidemiology and hospitalization utilization for myelomeningocele repair from 2000 to 2009

PURPOSE

Although the incidence of myelomeningocele (MMC) has declined over the past decades with folic acid supplementation and prenatal screening, neural tube defects remain the most common birth defect in the USA. A majority of affected neonates require surgical repair. To characterize US trends in the epidemiology and hospital utilization of MMC repair over the past decade, we analyzed a nationally representative database.

METHODS

We queried the Healthcare Cost and Utilization Project (HCUP) Kid's Inpatient Database (KID) for all discharges with procedure code for MMC repair for the years 2000, 2003, 2006, and 2009. The cohorts from these time points were compared for their demographic and in-hospital variables. Results are reported as estimated frequencies and means with 95 % confidence intervals (CI).

RESULTS

Sex, race, insurance status, family income level, and mortality of affected infants have not changed significantly over the decade. A majority of neonatal MMC repairs occur in larger hospital bed size and more specialized children's hospital centers. Of patients, 52.3 to 60 % receive VPS placement during the same admission as the primary MMC repair. Total hospital costs for the MMC hospitalizations have remained relatively stable from 42,843 dollars in 2003 to 46,749 dollars in 2009 (adjusted to 2009 dollars).

CONCLUSION

Demographics of children having MMC repair have not changed significantly over the past decade, while these surgeries have become more concentrated in pediatric-specialized centers. There appears to be a plateau in public health and access advances with relatively stable cost of MMC hospital care.

A Comparative Cost Analysis of Cleft Lip Adhesion and Nasoalveolar Molding before Formal Cleft Lip Repair

BACKGROUND

Patients with complete cleft lip and palate may benefit from cleft lip adhesion or nasoalveolar molding before formal cleft lip repair. The authors compared the relative costs to insurers of these two treatment modalities and the burden of care to families.

METHODS

A retrospective analysis was performed of cleft lip and palate patients treated with nasoalveolar molding or cleft lip adhesion at The Children's Hospital of Philadelphia between January of 2007 and June of 2012. Demographic, appointment, and surgical data were reviewed; surgical, inpatient hospital, and orthodontic charges and costs were obtained. Multivariate linear regression and two-sample, two-tailed independent t tests were performed to compare cost and appointment data between groups.

RESULTS

Forty-two cleft adhesion and 35 nasoalveolar molding patients met inclusion criteria. Mean costs for nasoalveolar molding were $3550.24 ± $667.27. Cleft adhesion costs, consisting of both hospital and surgical costs, were $9370.55 ± $1691.79. Analysis of log costs demonstrated a significant difference between the groups, with the mean total cost for nasoalveolar molding significantly lower than that for adhesion (p < 0.0001). Nasoalveolar molding patients had significantly more made, cancelled, no-show, and missed visits and a higher missed percentage than adhesion patients (p < 0.0001) for all except no-show appointments, (p = 0.0199), indicating a higher burden of care to families.

CONCLUSIONS

Nasoalveolar molding may cost less before formal cleft lip repair treatment than cleft lip adhesion. Third-party payers who cover adhesion and not nasoalveolar molding may not be acting in their own best interest. Nasoalveolar molding places a higher burden of care on families, and this fact should be considered in planning treatment.

Factors associated with high hospital resource use in a population-based study of children with orofacial clefts

BACKGROUND

Little is known about population-based maternal, child, and system characteristics associated with high hospital resource use for children with orofacial clefts (OFC) in the US.

METHODS

This was a statewide, population-based, retrospective observational study of children with OFC born between 1998 and 2006, identified by the Florida Birth Defects Registry whose records were linked with longitudinal hospital discharge records. We stratified the descriptive results by cleft type [cleft lip with cleft palate, cleft lip, and cleft palate] and by isolated versus nonisolated OFC (accompanied by other coded major birth defects). We used Poisson regression to analyze associations between selected characteristics and high hospital resource use (≥90th percentile of estimated hospitalized days and inpatient costs) for birth, postbirth, and total hospitalizations initiated before age 2 years.

RESULTS

Our analysis included 2,129 children with OFC. Infants who were born low birth weight (<2500 grams) were significantly more likely to have high birth hospitalization costs for CLP (adjusted prevalence ratio: 1.6 [95% confidence interval: 1.0-2.7]), CL (adjusted prevalence ratio: 3.0 [95% confidence interval: 1.1-8.1]), and CP (adjusted prevalence ratio: 2.3 [95% confidence interval: 1.3-4.0]). Presence of multiple birth defects was significantly associated with a three- to eleven-fold and a three- to nine-fold increase in the prevalence of high costs and number of hospitalized days, respectively; at birth, postbirth before age 2 years and overall hospitalizations.

CONCLUSION

Children with cleft palate had the greatest hospital resources use. Additionally, the presence of multiple birth defects contributed to greater inpatient days and costs for children with OFC.

Toward an orofacial gene regulatory network

Orofacial clefting is a common birth defect with significant morbidity. A panoply of candidate genes have been discovered through synergy of animal models and human genetics. Among these, variants in interferon regulatory factor 6 (IRF6) cause syndromic orofacial clefting and contribute risk toward isolated cleft lip and palate (1/700 live births). Rare variants in IRF6 can lead to Van der Woude syndrome (1/35,000 live births) and popliteal pterygium syndrome (1/300,000 live births). Furthermore, IRF6 regulates GRHL3 and rare variants in this downstream target can also lead to Van der Woude syndrome. In addition, a common variant (rs642961) in the IRF6 locus is found in 30% of the world's population and contributes risk for isolated orofacial clefting. Biochemical studies revealed that rs642961 abrogates one of four AP-2alpha binding sites. Like IRF6 and GRHL3, rare variants in TFAP2A can also lead to syndromic orofacial clefting with lip pits (branchio-oculo-facial syndrome). The literature suggests that AP-2alpha, IRF6 and GRHL3 are part of a pathway that is essential for lip and palate development. In addition to updating the pathways, players and pursuits, this review will highlight some of the current questions in the study of orofacial clefting.

Prevalence, demographics, and complications of cleft palate surgery

INTRODUCTION

Current published data on the demographics of cleft lip and palate is sparse and differs intranationally in reported incidence, demographics, and complication rates, making accurate local data both valuable and useful. We investigate the prevalence, demographics, and complications of cleft palate correction surgery in the inpatient setting over a 15-year period.

METHODS

A retrospective review of The California Hospital Discharge Data sets of all pediatric patients who underwent cleft palate repair or cleft palate revision from 1997 to 2011. Children's hospitals (CHs) were analyzed as a separate group. For each record, age, gender, ethnicity, length of stay, total charges, principal payer, complications, and disposition were analyzed.

RESULTS

10,450 correction surgeries were performed during 1997-2011. This was an annual case-volume of 697 and annual population-adjusted rate of 2.0, neither of which changed over time (p=0.9 and 0.06, respectively). Of all surgeries, 21.5% were revisions, 48.3% were performed in CHs, 56.2% were performed on males, and 65.5% were performed on Caucasians. The median length of stay was 1 day, which did not change over time (p=1.0). The median total charges increased from $9.074 to $35,643 over the studied period (p<0.001). Admission to CHs was associated with shorter stay (1-3 days vs. 1-4 days) and higher total charges ($15,560 vs. $13,242; both p<0.001). Complications occurred in 393 (3.8%) of the surgeries. This percentage did not change over time (p=0.2). The most common complication was fistula/abscess/infection, which occurred in 159 cases (1.5%). Respiratory complications requiring ventilation occurred 66 cases (0.6%). Complications were more common in CHs (4.8% vs. 2.8%; p<0.001). Mortality rate was <0.1%.

CONCLUSIONS

Our study constitutes the entire surgical cohort within a state, allowing for an accurate representation of the true perioperative complication rate of these procedures. The prevalence, demographics, and outcomes of the cleft palate correction surgery have remained unchanged during 1997-2011. Collectively, our data suggest that primary and secondary palatoplasty present low perioperative risk.

Risk factors involved in orofacial cleft predisposition - review

Clefts that occur in children are a special topic. Avoiding risk factors, and also an early diagnosis of cleft possibility can result in minimizing or avoiding them. If on the other hand when clefts occur they require a long-term, multistage specialized treatment. Etiology of clefts seems to be related to many factors. Factors such as genetic, environmental, geographic and even race factors are important. Identification of risk factors can lead to prevention and prophylactic behaviors in order to minimize its occurrence. Exposure to environmental factors at home and work that lead to cleft predisposition should not be disregarded. It seems that before planning a family it would be wise to consult with doctors of different specializations, especially in high-risk families with cleft history in order to analyze previous lifestyle. Clefts are very common in hereditary facial malformations and are causing a lot of other irregularities in the head and neck region. In this paper after a brief papers review authors present socio-geographic, environmental and also work place related factors that are influencing pregnant women condition and should be taken under serious consideration.

Population-based study of birth prevalence and factors associated with cleft lip and/or palate in Taiwan 2002-2009

Background

Facial cleft deformities, including cleft lip with or without cleft palate (CL/P) and cleft palate (CP), are common congenital birth anomalies, especially in Asia. This study aimed to analyze the prevalence of CL/P and CP and to identify associated factors in Taiwan.

Methods

This population-based epidemiological study retrospectively analyzed birth data obtained from the Department of Health in Taiwan for years 2002–2009. Frequency distribution, percentages and related predictors were investigated, and findings were presented by types of cleft deformities. Logistic regression analysis was performed to identify factors associated with cleft deformities.

Results

Overall prevalence of cleft deformities among 1,705,192 births was 0.1% for CL/P and 0.04% for CP over the 8-year study period. Higher prevalence of CL/P or CP was observed with multiple pregnancies, being male for CL/P, being female for CP, gestational age ≤37 weeks and lower birth weight (<1.5 kg). Both CL/P and CP were significantly associated with gestational age <37 weeks and birth weight<1.5 kg (all P <0.0001). CL/P was significantly associated with multiple parities (P = 0.0004–0.002). Male newborns and female newborns were significantly associated with CL/P and CP, respectively (both P<0.0001).

Conclusions

Overall prevalence for congenital cleft deformities in study subjects was 0.1%, in keeping with high rates in Asia. Results suggest the need for awareness and early identification of those at high risk for cleft deformities, including newborns with gestational age <37 weeks, weighing <1.5 kg at birth and women with multiple parities, as a potential strategy to counter long-term adverse effects on speech and language in this population.

Recovering the personal identity of an elderly patient with cleft lip: a case report

Instances of unoperated cleft lip and/or palate (CLP) in adult or elderly patients are still seen in developing countries. This paper presents the multidisciplinary management and the personal identity revival of a 72-year-old patient with unoperated unilateral complete cleft lip. The facial deformity was characterized by a protrusion of the excess of orbicularis oris muscle, irregularities of the upper lip, nose distortion, and septum deviation to the cleft side. The patient was edentulous with the maxillary alveolar ridge collapsed and an associated fistula. The cleft lip was repaired using the Tennison-Randall technique and complete dentures were delivered after the oroantral fistula had been closed. The patient was very pleased with the improvement in speech and eating and she approved of her facial esthetics. The existence of unoperated oral clefts in the elderly population highlights the need to improve policies in treating patients with CLP, mainly in developing countries.

Resource Utilization in Primary Repair of Cleft Lip

Objective

To determine national variations in resource utilization for primary repair of cleft lip, identify patient and institutional factors associated with high resource use, and estimate the current incidence of cleft lip in the United States.

Study Design

Retrospective analysis of a national, pediatric database (2009 Kids’ Inpatient Database [KID]).

Methods

Patients aged 1 year and younger were selected using international classification of disease codes for cleft lip and procedure codes for cleft lip repair. A number of demographic variables were analyzed, and hospital charges were considered as a measure of resource utilization.

Results

There were 1318 patients identified. The national incidence was 0.09%, with a male to female ratio of 1.8:1. Regional incidence varied from 0.07% (Northeast) to 0.10% (West). The mean age at surgery was 4.2 months. The average length of stay was 1.4 days. The national average hospital charge was $20,147, ranging from $14,635 (South) to $23,663 (West). Teaching hospitals charge an average of $9764 higher than nonteaching hospitals. The strongest predictor of charge was length of stay, increasing charge by $8102 for every additional hospital day ( P < .01).

Conclusion

Regional variations exist in resource utilization for primary cleft lip repair. Resource use is higher in the West and among teaching hospitals.

Profile evaluation of patients with cleft lip and palate undergoing surgery at a reference center in rio de janeiro, Brazil

In Brazil, the classic timeline for operating on cleft lip and palate is three months old for cheiloplasty and is 12 to 18 months old for palatoplasty. As from Brazilian treatment centers are usually located in major cities, patients living in more remote areas are often unable to receive treatment at the ideal ages. Data were analyzed retrospectively on 45 patients with cleft lip and/or palate, consecutively operated at the Reference Center, Rio de Janeiro Federal University, Brazil. Particularly noteworthy among these data are gender, clinical presentation, operations performed, age of surgery, and the distance between their homes and the hospital. The average age of patients undergoing primary cheiloplasty was 9.4 months, with primary palatoplasties performed at an average age of 7.2 years. As 67% of these patients lived in other towns, they encountered difficulties in seeking and continuing specialized care. Despite attempts to decentralize cleft palate care in Brazil, suitable conditions are not yet noted for following the treatment protocols in a full and adequate manner.

Team-Oriented Care for Orofacial Clefts: A Review of the Literature

Objective

To examine the process of team-oriented care for children with orofacial clefts.

Design

Systematic review of available studies reporting team-oriented management of children and adults with orofacial clefts. We identified studies from OVID, PsychINFO, REHABDATA, PubMed, and The Cleft Palate–Craniofacial Journal to complete this review.

Main Outcome Measures

Process of team-oriented treatment, which included use of team-oriented care, continuity of team-oriented care, and approaches to team-oriented care.

Results

We identified nine studies including 1398 participants. We found that studies examining team-oriented approaches to orofacial clefts were limited. Studies of orofacial teams suggest that use of team-oriented approaches to care are highly variable. It is unclear how these inconsistencies in approaches to care influence long-term outcomes.

Conclusions

Although the literature suggests that the process of team-oriented care results in better outcomes in individuals with orofacial clefts, process of care as a measurable outcome has yet to be adequately examined. Future studies are needed to investigate the impact on clinical outcomes and their relationship to cost effectiveness and efficiency of care.

Cone beam computed tomography use in orthodontics

Cone beam computed tomography (CBCT) is widely used by orthodontists to obtain three-dimensional (3-D) images of their patients. This is of value as malocclusion results from discrepancies in three planes of space. This review tracks the use of CBCT in orthodontics, from its validation as an accurate and reliable tool, to its use in diagnosing and treatment planning, and in assessing treatment outcomes in orthodontics.