Inpatient Versus Outpatient Cleft Lip Repair and Alveolar Bone Grafting: A Cost Analysis

Postoperative Daycare as a Safe and Cost-Effective Option for Secondary Alveolar Bone Graft (SABG) Surgery: A Retrospective Comparative Cohort Study

OBJECTIVE

To evaluate the outcomes of Secondary Alveolar Bone Grafting (SABG) in patients treated either in daycare or with multiple day hospitalization (MDH) in relation to costs and complication rates.

DESIGN

Retrospective comparative cohort study.

SETTING

The data was collected from two settings: Postoperative daycare or MDH after oral cleft surgery in an Academic Medical Center in The Netherlands.

PATIENTS

Data of 137 patients with unilateral Cleft lip, alveolus, and palate (CLAP) treated between 2006-2018 were evaluated. Registered clinical variables: age, gender, cleft subtype, bone donor site, type of hospitalization, length of stay, additional surgery, complications, surgeons, and costs.

INTERVENTIONS

Closure of the alveolar cleft with/without closure of the anterior palate.

MAIN OUTCOME MEASURES

Univariate analyses.

RESULTS

Of the 137 patients, 46.7% were treated in MDH, and 53.3% in daycare. Total costs for daycare were significantly lower (P < .001). All patients treated in daycare received mandibular symphysis bone, whereas in MDH, 46.9% received iliac crest bone instead. Bone donor site was associated with postoperative care type. Complication rates were slightly but not significantly higher in daycare (26%) vs. MDH (14.1%) (P = .09). Most were Grade I (minor) according to Clavien Dindo classification.

CONCLUSIONS

Daycare after alveolar cleft surgery is about as safe as MDH, but significantly cheaper.

Implementation of an Ambulatory Cleft Lip Repair Protocol: Surgical Outcomes

OBJECTIVES

Cleft lip repair has traditionally been performed as an inpatient procedure. There has been an interest toward outpatient cleft lip repair to reduce healthcare costs and avoid unnecessary hospital stay. We report surgical outcomes following implementation of an ambulatory cleft lip repair protocol and hypothesize that an ambulatory repair results in comparable safety outcomes to inpatient repair.

DESIGN/SETTING

This is a single-institution, retrospective study.

PATIENTS/PARTICIPANTS

Patients undergoing primary unilateral (UCL) and bilateral (BCL) cleft lip repair from 2012 to 2021 with a minimum 30-day follow-up. A total of 226 patients with UCL and 58 patients with BCL were included.

INTERVENTION

Ambulatory surgery protocol in 2016.

OUTCOME MEASURES

Variables include demographics and surgical data including 30-day readmission, 30-day reoperation, and postoperative complications.

RESULTS

There were no differences in rates of 30-day readmission, reoperation, wound complications, or postoperative complications between the pre- and post-protocol groups. Following ambulatory protocol implementation, 80% of the UCL group and 56% of the BCL group received ambulatory surgery. Average length of stay dropped from 24 h pre-protocol to 8 h post-protocol. The 20% of the UCL group and 44% of the BCL group chosen for overnight stay had a significantly higher proportion of congenital abnormalities and higher American Society of Anesthesiology (ASA) class. Reasons for overnight stay included cardiac/airway monitoring, prematurity, and monitoring of comorbidities. There were no differences in surgical outcomes between the ambulatory and overnight stay groups.

CONCLUSIONS

An ambulatory cleft lip repair protocol can significantly reduce average length of stay without adversely affecting surgical outcomes.

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.

Cost Analysis of Treating Pediatric Supracondylar Humerus Fractures in Community Hospitals Compared With a Tertiary Care Hospital

OBJECTIVE

In the current healthcare environment, providing cost-efficient care is of paramount importance. One emerging strategy is to use community hospitals (CHs) rather than tertiary care hospitals (TCHs) for some procedures. This study assesses the costs of performing closed reduction percutaneous pinning (CRPP) of pediatric supracondylar humerus fractures (SCHFs) at a CH compared with a TCH.

METHODS

A retrospective review of 133 consecutive SCHFs treated with CRPP at a CH versus a TCH over a 6-year period was performed. Total encounter and subcategorized costs were compared between the procedures done at a CH versus those done at a TCH.

RESULTS

Performing CRPP for a SCHF at a CH compared with a TCH saved 44% in costs (P < 0.001). Cost reduction of 51% was attributable to operating room costs, 19% to anesthesia-related costs, 16% to imaging-related costs, and 7% to supplies.

DISCUSSION

Performing CRPP for a SCHF at a CH compared with a TCH results in a 44% decrease in direct cost, driven largely by surgical, anesthesia, and radiology-related savings.

Medicaid for the Plastic and Reconstructive Surgeon

Medicaid is a complex federally and state funded health insurance program in the United States that insures an estimated 76 million individuals, approximately 20 percent of the U.S. population. Many physicians may not receive formal training or education to help understand the complexities of Medicaid. Plastic surgeons, residents, and advanced practice practitioners benefit from a basic understanding of Medicaid, eligibility requirements, reimbursement methods, and upcoming healthcare trends. Medicaid is implemented by states with certain federal guidelines. Eligibility varies from state to state (in many states it's linked to the federal poverty level), and is based on financial and nonfinancial criteria. The passage of the Affordable Care Act in 2010 permitted states to increase the federal poverty level eligibility cutoff to expand coverage for low-income adults. The aim of this review is to provide a brief history of Medicaid, explain the basics of eligibility and changes invoked by the Affordable Care Act, and describe how federal insurance programs relate to plastic surgery, both at academic institutions and in community practice environments.

Surgical Approaches and 30-Day Complications of Velopharyngeal Insufficiency Repair Using American College of Surgeons National Surgical Quality Improvement Program-Pediatric

BACKGROUND

This study aims to outline the 30-d complications of different velopharyngeal insufficiency (VPI) correction techniques using the American College of Surgeons National Surgical Quality Improvement Program-Pediatric.

METHODS

Using the American College of Surgeons National Surgical Quality Improvement Program-Pediatric, VPI cases from 2012 to 2015 were identified. Patients were subdivided into two cohorts: (1) palatal procedures and (2) pharyngeal procedures, with the latter being subdivided into (1) pharyngeal flap and (2) sphincter pharyngoplasty. Patient characteristics and postoperative outcomes were compared using Pearson's chi-squared or Fischer's exact test for categorical variables and independent t-tests, Wilcoxon-Mann-Whitney, or analysis of variance for continuous variables.

RESULTS

A total of 767 VPI cases were identified: 191 (24.9%) treated with palatal procedures and 576 (75.1%) with pharyngeal procedures, of which 444 were pharyngeal flap and 132 were sphincter pharyngoplasty. Patients who underwent palatal procedure had longer anesthesia (152.41 min) and operating time (105.72 min), whereas patients who underwent pharyngeal procedure had longer length of stay (1.66 d). There were no significant differences in outcomes between the two groups, nor were there significant differences in outcomes between pharyngeal flap and sphincter pharyngoplasty subgroups. Patients who experienced complications were younger, shorter, inpatient, and having a shorter operation time, longer anesthesia time, or longer length of stay. Plastic surgeons performed the majority of palatal procedures (62.3%), whereas pharyngeal procedures were most often performed by otolaryngologists (48.8%).

CONCLUSIONS

As per national data, both palatal and pharyngeal procedures for repair can be performed with comparable 30-d complications. The chosen technique may be based on patient presentation and on the surgeon comfort level.

Perioperative Outcome Differences Between Pain Management Protocols in Cleft Alveolar Bone Grafting

PURPOSE

Postoperative hip pain is commonly reported after anterior iliac crest harvest for alveolar bone grafting. The goal of this study is to describe our institution's experience and examine the efficacy of our pain management protocols.

METHODS

A retrospective review was performed by abstracting demographic, operative, and pain management data from January 2011 to April 2013. Paired t-tests and Fisher exact tests were used to examine differences when comparing 2 groups, while ANOVA was used to examine difference between the 3 protocols for harvest and pain management: trapdoor technique and local anesthetic injection (TD+LAI), TD and pain catheter (TD+PC), and split crest and LAI.

RESULTS

Eighty-four patients, 52 males (61.9%), averaging 8.8 years old (±2.9) were included. Postoperatively, 17 (71%) patients in the PC group received IV narcotics compared to 27 (45%) in those without a PC (P = .03). When comparing all 3 protocols, no significant difference was found in IV morphine usage or duration of IV morphine treatment. In subgroup analysis, when patients in the groups TD+PC versus TD+LAI were examined, those in the TD+PC group had significantly shorter hospital stays and were more likely to go home postoperative day 1 (P = .03; P = .04).

CONCLUSIONS

Overall, patients tolerated alveolar bone grafting well regardless of harvest technique or pain management approach. While indwelling PCs did not significantly decrease IV morphine usage, these patients had significantly shorter lengths of stays.

Caregiver-Reported Outcomes and Barriers to Care among Patients with Cleft Lip and Palate

BACKGROUND

For children with cleft lip and/or palate, access to care is vital for optimizing speech, appearance, and psychosocial outcomes. The authors posited that inadequate access to care negatively impacts outcomes in this population.

METHODS

Sixty caregivers of children with cleft lip and palate were surveyed to assess perceived barriers using the validated Barriers to Care questionnaire. The questionnaire includes 39 items divided into five subscales, with higher scores indicating fewer barriers. Caregiver-reported outcomes were assessed using the Cleft Evaluation Profile, which captures cleft-specific appearance- and speech-related outcomes. Higher scores correspond to less satisfactory outcomes. Desire for revision surgery was assessed as a binary outcome among caregivers. Multivariable regression was used to evaluate the relationship of barriers to care, caregiver-reported outcomes, and desire for revision, adjusting for clinical and demographic covariates.

RESULTS

Sixty percent of caregivers perceived barriers to care, and caregivers who reported poorer access to care described poorer cleft-related outcomes (r = 0.19, p = 0.024). Caregivers with poorer skills (r = 0.17, p = 0.037), expectations (r = 0.17, p = 0.045), and pragmatics (r = 0.18, p = 0.026) subscale scores were associated with worse Cleft Evaluation Profile scores. Barriers were also negatively associated with aesthetic item scores (r = 0.11, p = 0.025). Finally, caregivers reporting fewer barriers were 21.2 percent less likely to express interest in revision surgery.

CONCLUSIONS

Barriers to care were associated with poorer appearance-related outcomes and increased interest in revision among caregivers of cleft patients. Enhancing access to care is critical in order to effectively meet goals of care for these families.

Predicting the Ideal Patient for Ambulatory Cleft Lip Repair

BACKGROUND

The utilization of ambulatory surgical centers (ASCs) for cleft lip repair is increasing to reduce costs. This study better defines the patient population appropriate for ambulatory cleft repair with uplift modeling, a predictive analytics technique.

METHODS

Pediatric patients who underwent cleft lip repair were identified in the 2007 to 2011 California Healthcare Cost and Utilization Project State Inpatient Database and State Ambulatory Surgery and Services Database. The 2-model uplift approach was utilized using multivariate logistic regressions fit to assess the effect of ASCs, age, comorbidities, and procedure type on mortality or 30-day readmission.

RESULTS

Of the pediatric cleft lip repairs in California between 2007 and 2011, 2383 (83%) were conducted in inpatient facilities and 498 (17%) in ASCs. The 30-day readmission rates were 2.01% and 1.93% for ASC repairs and inpatient repairs, respectively ( P = .909). Uplift modeling predicts that of the 2881 patients, approximately 40% of patients would have benefit from an ASC repair and an ASC repair would have had no effect on the remaining 60%. Patients likely to benefit from an ASC repair were more likely younger than 1 year old, nonsyndromic, not to have a respiratory or neurologic diagnosis, have less number of procedures, and to have undergone an isolated cleft lip repair.

CONCLUSION

Uplift modeling predicts that approximately 40% of patients would benefit from an ASC cleft lip repair. Targeting patients younger than 1 year old, nonsyndromic, with no respiratory or neurologic diagnosis for ASC cleft lip repair, may be a safe and cost-saving endeavor.

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.

Cost Savings From Utilization of an Ambulatory Surgery Center for Orthopaedic Day Surgery

INTRODUCTION

Healthcare providers are increasingly searching for ways to provide cost-efficient, high-quality care. Previous studies on evaluating cost used estimated cost-to-charge ratios, which are inherently inaccurate. The purpose of this study was to quantify actual direct cost savings from performing pediatric orthopaedic sports day surgery at an ambulatory surgery center (ASC) compared with a university-based children's hospital (UH).

METHODS

Custom-scripted accounting software was queried for line-item costs for a period of 3 fiscal years (fiscal year 2012 to fiscal year 2014) for eight day surgery procedures at both a UH and a hospital-owned ASC. Hospital-experienced direct costs were compared while controlling for surgeon, concomitant procedures, age, sex, and body mass index.

RESULTS

One thousand twenty-one procedures were analyzed. Using multiple linear regression analysis, direct cost savings at the ASC ranged from 17% to 43% for seven of eight procedures. Eighty percent of the cost savings was attributed to time (mean, 64 minutes/case; P < 0.001) and 20% was attributed to supply utilization (P < 0.001). Of the time savings in the operating room, 73% (mean, 47 minutes; P < 0.001) was attributed to the surgical factors whereas 27% (17 minutes; P < 0.001) was attributed to anesthesia factors.

CONCLUSIONS

Performing day surgery at an ASC, compared with a UH, saves 17% to 43% from the hospital's perspective, which was largely driven by surgical and anesthesia-related time expenditures in the operating room.

LEVEL OF EVIDENCE

Level II.

The Americleft Project: Burden of Care from Secondary Surgery

Background:

The burden of care for children with cleft lip and palate extends beyond primary repair. Children may undergo multiple secondary surgeries to improve appearance or speech. The purpose of this study was to compare the use of secondary surgery between cleft centers.

Methods:

This retrospective cohort study included 130 children with complete unilateral cleft lip and palate treated consecutively at 4 cleft centers in North America. Data were collected on all lip, palate, and nasal surgeries. Nasolabial appearance was rated by a panel of judges using the Asher-McDade scale. Risk of secondary surgery was compared between centers using the log-rank test, and hazard ratios estimated with a Cox proportional hazards model.

Results:

Median follow-up was 18 years (interquartile range, 15–19). There were significant differences among centers in the risks of secondary lip surgery (P < 0.001) and secondary rhinoplasty (P < 0.001). The cumulative risk of secondary lip surgery by 10 years of age ranged from 5% to 60% among centers. The cumulative risk of secondary rhinoplasty by 20 years of age ranged from 47% to 79% among centers. No significant differences in nasolabial appearance were found between children who underwent secondary lip or nasal surgery and children who underwent only primary surgery (P > 0.10).

Conclusions:

Although some cleft centers were significantly more likely to perform secondary surgery, the use of secondary surgery did not achieve significantly better nasolabial appearance than what was achieved by children who underwent only primary surgery.