Centralization of Services: Standard Setting and Outcomes

Centralization of cleft care in the UK. Part 6: a tale of two studies

Objectives

We summarize and critique the methodology and outcomes from a substantial study which has investigated the impact of reconfigured cleft care in the United Kingdom (UK) 15 years after the UK government started to implement the centralization of cleft care in response to an earlier survey in 1998, the Clinical Standards Advisory Group (CSAG).

Setting and Sample Population

A UK multicentre cross-sectional study of 5-year-olds born with non-syndromic unilateral cleft lip and palate. Data were collected from children born in the UK with a unilateral cleft lip and palate between 1 April 2005 and 31 March 2007.

Materials and Methods

We discuss and contextualize the outcomes from speech recordings, hearing, photographs, models, oral health and psychosocial factors in the current study. We refer to the earlier survey and other relevant studies.

Results

We present arguments for centralization of cleft care in healthcare systems, and we evidence this with improvements seen over a period of 15 years in the UK. We also make recommendations on how future audit and research may configure.

Conclusions

Outcomes for children with a unilateral cleft lip and palate have improved after the introduction of a centralized multidisciplinary service, and other countries may benefit from this model. Predictors of early outcomes are still needed, and repeated cross-sectional studies, larger longitudinal studies and adequately powered trials are required to create a research-led evidence-based (centralized) service.

A cross-sectional survey of 5-year-old children with non-syndromic unilateral cleft lip and palate: the Cleft Care UK study. Part 1: background and methodology

Objectives

We describe the methodology for a major study investigating the impact of reconfigured cleft care in the United Kingdom (UK) 15 years after an initial survey, detailed in the Clinical Standards Advisory Group (CSAG) report in 1998, had informed government recommendations on centralization.

Setting and Sample Population

This is a UK multicentre cross-sectional study of 5-year-olds born with non-syndromic unilateral cleft lip and palate. Children born between 1 April 2005 and 31 March 2007 were seen in cleft centre audit clinics.

Materials and Methods

Consent was obtained for the collection of routine clinical measures (speech recordings, hearing, photographs, models, oral health, psychosocial factors) and anthropometric measures (height, weight, head circumference). The methodology for each clinical measure followed those of the earlier survey as closely as possible.

Results

We identified 359 eligible children and recruited 268 (74.7%) to the study. Eleven separate records for each child were collected at the audit clinics. In total, 2666 (90.4%) were collected from a potential 2948 records. The response rates for the self-reported questionnaires, completed at home, were 52.6% for the Health and Lifestyle Questionnaire and 52.2% for the Satisfaction with Service Questionnaire.

Conclusions

Response rates and measures were similar to those achieved in the previous survey. There are practical, administrative and methodological challenges in repeating cross-sectional surveys 15 years apart and producing comparable data.

Centralization of Services for Children Born with Orofacial Clefts in the United Kingdom: A Cross-Sectional Survey

Objective

To examine current provision of cleft lip and/or palate services in the U.K. and compliance with recommendations made by the Clinical Standards Advisory Group (CSAG) in 1998.

Design

Cross-sectional questionnaire survey.

Setting

All 11 services within the U.K. providing care for children born with a cleft lip and palate.

Participants

Members from each healthcare specialty in each U.K. cleft team.

Interventions

Self-administered postal questionnaires enquired about the provision of cleft services. Data were collected about the overall cleft service, team coordination, hearing, orthodontics, pediatric dentistry, primary cleft surgery, psychology, restorative dentistry, secondary surgery, specialist cleft nursing, and speech and language therapy.

Results

Questionnaires were returned from members of 130/150 cleft teams (87%) and these showed that U.K. cleft services have been restructured to 11 centralized services with 17 primary operative sites and 61 peripheral sites. All services provide care through a multidisciplinary (MDT) model, but the composition of each team varies. Primary cleft surgery and orthodontics were the only specialties that were represented in all cleft teams. Specialties may be represented in a team but their attendance at MDT clinics is variable. Only one team met all of the CSAG recommendations.

Conclusions

Our survey shows that cleft services have centralized over the last 10 years, and an MDT model of care has been adopted. Further research is needed to show how this has influenced outcomes and to see whether some models of centralized care are associated with better outcomes.

Occlusal disorders among patients with total clefts of lip, alveolar bone, and palate

Clefts are common birth defects. They are accompanied by various malformations, including disturbances in facial look as well as skeletal disorders that include malocclusions, most frequently crossbites and class III anomalies. The aim of the study was to present the commonest malocclusions in patients with total cleft of the lip, alveolar bone and palate (n = 154) and compare the results to the healthy on-cleft patients (n = 151). Normal occlusion, characteristic for I angle class, was observed in 50% of the control group and 30% of the examined. In the examined patients with clefts, most frequently crossbite and open bite on the cleft side was observed. In patients with clefts, only 2 out of 154 patients presented isolated dental anomalies. In healthy individuals the commonest occlusal disorder was distal occlusion and dental anomalies. The commonest malocclusions among patients with clefts are crossbites and class III malocclusions.

Surgical outcomes auditing systems in humanitarian organizations

BACKGROUND

Operation Smile is a humanitarian volunteer-based organization that provides cleft care around the world. Successful primary surgery is the key to improving the quality of life of patients with oral clefts. A cleft surgery outcomes database and evaluation system has been developed and implemented.

METHODS

During Operation Smile's "World Journey of Smiles" in November 2007, a total of 4100 patients were operated on during a 10-day period at 40 simultaneous missions in 25 countries. Photographs taken before surgery, right after surgery, and at the follow-up consultations were entered in a database and used as media to evaluate surgical outcomes objectively by independent unbiased evaluators. Data about complications collected during the postoperative consultations were also entered.

RESULTS

A postoperative consultation, 6 months to 1 year after surgery was conducted at 24 sites, 19 of which sent back postoperative images; and most returned postoperative examination forms. At those 19 sites, 703 of 1917 patients returned for a 6- to 9-month postoperative visit, for a 36.67% return rate. After matching before and after pictures, 562 patients were able to be entered into the database, allowing 580 procedures to be evaluated. Feedback reports have been sent to 134 volunteer surgeons around the world. Results were compared among sites and locations; and the places where future actions were needed to improve the quality of surgery were identified.

CONCLUSIONS

The current outcomes evaluation system has proven beneficial in tracking patient outcomes, auditing surgical performance, and providing feedback to surgeons and other team members. Challenges are discussed.

What are the occlusal outcomes for unilateral cleft lip and palate patients? A national project in the UK

AIM

This national project assessed the orthodontic outcome for unilateral cleft lip and palate (UCLP) patients in the UK.

METHOD

Six consecutively treated fixed appliance cases where orthognathic surgery was not undertaken were assessed using the peer assessment rating (PAR) index on orthodontic study models. These cases were submitted by NHS consultant orthodontists undertaking treatment on patients with cleft lip and/or palate.

SETTING

UK NHS consultant-led hospital service.

RESULTS

The mean reduction in PAR score was 69% + or - 22. The mean start PAR score was 41 + or - 11. The mean end of treatment PAR was 12 + or - 9. The proportion of cases where the score was worse or no different was 7.5%.

CONCLUSION

The mean percentage PAR reduction compares well with other national projects looking at outcome from patients treated in the hospital service. The mean PAR reduction could be used as a benchmark for outcome in UCLP orthodontic treatments in future audit projects and the annual consultant appraisal process.