Further construct validation of the CLEFT-Q: Ability to detect differences in outcome for four cleft-specific surgeries

Reliability and Validity of the CLEFT-Q in a Chinese Context

OBJECTIVE

To develop an appropriate Chinese version of the CLEFT-Q through translation and cultural adaptation and to evaluate its reliability and validity.

DESIGN

The English CLEFT-Q was translated into Chinese following the International Society for Pharmacoeconomics and Outcomes Research guidelines, including cognitive debriefing interviews, and its reliability and validity were assessed.

PARTICIPANTS

Patients (N = 246) were mostly in active orthodontic treatment, had a mean age of 14.7 ± 4.4 years, 29% were female, and were born with isolated cleft lip ± alveolus (12%), cleft palate (1%), or cleft lip and palate (87%).

MAIN OUTCOME MEASURES

The Chinese CLEFT-Q, including 13 subscales covering Appearance, Health-Related Quality of Life (HRQOL), and Facial Function. Criterion validity instruments included the Negative Physical Self, Satisfaction with Life Scale, and Scale of Positive and Negative Experience.

RESULTS

The wording of 67 items was adapted in the final translation. The internal consistency of the Chinese version of the CLEFT-Q was high based on Cronbach's alphas of 0.85 to 0.98 and split-half reliability of 0.85 to 0.92. Exploratory and confirmatory factor analyses yielded three factors, which demonstrated construct validity by broadly matching the structure of the original CLEFT-Q. The Appearance and HRQOL dimensions had weak to moderate correlations (r = -0.35 to 0.67) with the corresponding instruments for criterion validity.

CONCLUSIONS

The Chinese version of the CLEFT-Q is a patient-reported outcome measure that can reflect the quality of life of Chinese patients with cleft lip and/or palate with good reliability and validity.

The Dutch Version of the Orthognathic Quality of Life Questionnaire (OQLQ-NL): Validation for Cleft Patients

OBJECTIVE

The aim of this study is to validate the Dutch version of the Orthognathic Quality of Life Questionnaire (OQLQ-NL) for cleft patients who received orthognathic surgery.

METHODS

To compare the OQLQ-NL with the CLEFT-Q, we used a convenience sample of thirty-two cleft patients. Using the Cronbach's alpha coefficient for multiple item scales, internal reliabilities of the OQLQ-NL were evaluated. The OQLQ-NL was repeated at a two-week interval and the intraclass correlation coefficient was calculated, to establish of the test-retest reliability. The construct validity of the OQLQ-NL was evaluated by using Spearman's correlation to test its correlation with the CLEFT-Q.

RESULTS

Thirty-two patients filled in the OQLQ-NL and CLEFT-Q. The OQLQ-NL had excellent results in internal reliability and test-retest reliability. The vast majority of the correlations between the domains and scales of the questionnaires were as expected. Data from this study and previous studies confirm the construct validity of the OQLQ-NL.

CONCLUSION

Our results suggest the OQLQ-NL is a valid and reliable instrument for measuring quality of life in cleft patients who have received orthognathic surgery in the Netherlands.

Quality of Life After Orthognathic Surgery in Patients with Cleft: An Overview of Available Patient-Reported Outcome Measures

Measuring the impact of orthognathic surgery on quality of life is of significant importance in patients with cleft deformities. Standardized tools such as patient-reported outcome measures (PROMs) are needed to fully comprehend patients' needs and perceptions. Therefore, the availability of reliable, valid, and comprehensive questionnaires for patients is essential. The aim of this study is to identify PROMs measuring the impact of orthognathic surgery on quality of life in patients with cleft deformities and to evaluate the identified PROMs.

A systematic search of the literature was performed according to the preferred reporting items for systematic reviews and meta-analysis guidelines. All validated PROMs, regarding the impact of orthognathic surgery on quality of life in patients with cleft deformities, were identified and assessed according to the quality criteria proposed for measurement properties of health status questionnaires.

An electronic search yielded 577 articles. After a full-text review of 87 articles, 4 articles met the inclusion criteria, comprising 58 PROMs. Of these 58 PROMs, 1 PROM (the CLEFT-Q) has been validated to measure the impact of orthognathic surgery on patients with a facial cleft. Evaluation of methodological quality of the included articles and assessment of the measurement properties of the CLEFT-Q show that the CLEFT-Q scores relatively good for all available measurement properties, making it suitable for immediate use.

The CLEFT-Q was found to be the only valid instrument so far to measure the impact of orthognathic surgery on the quality of life in patients with cleft deformities.

Psychometric Validation of the CLEFT-Q Patient Reported Outcome Measure: A Prospective Study to Examine Cross-Sectional Construct Validity

OBJECTIVE

CLEFT-Q is a condition-specific patient-reported outcome measure (PROM) for patients with cleft lip and/or palate (CL/P). The aim of this study was to examine the cross-sectional construct validity of the CLEFT-Q scales.

DESIGN

Construct validity was assessed through a prospective study that tested hypotheses regarding correlations of scores with other PROMs that measure related constructs.

SETTING

Seven cleft centres in Canada, the USA, and UK were involved.

PATIENTS/PARTICIPANTS

Patients were aged eight to 29 years with CL/P.

INTERVENTIONS

Before undergoing rhinoplasty, orthognathic, cleft lip scar revision, and alveolar bone graft, participants were asked to complete the following PROMs: CLEFT-Q (9 scales), Child Oral Health Impact Profile (socio-emotional subscale) and Cleft Hearing Appearance and Speech Questionnaire (features 1 subscale).

MAIN OUTCOME MEASURE(S)

The correlation coefficients examining the relationship between the scales were the main outcome measures. Correlations (Spearman) were calculated and interpreted as follows: <0.3 weak, 0.30 to 0.50 moderate, ≥0.50 strong.

RESULTS

Participants (n = 177) were mostly male (61%) and aged between eight and 11 years (42%). Overall, 38 of 52 (73%) hypotheses tested were supported. More specifically, 20 of 26 (77%) hypotheses about correlations between the appearance scales were supported, two of three (67%) hypotheses about correlations between the health-related quality of life scales were supported, and 16 of 23 (70%) hypotheses about correlations between the appearance and health-related quality of life scales were supported.

CONCLUSIONS

Cross-sectional construct validity of the CLEFT-Q scales adds further evidence of the psychometric properties of this instrument.

Optimizing the Psychosocial Function Measures in the International Consortium for Health Outcomes Measurement Standard Set for Cleft

BACKGROUND

To ensure the feasibility of implementing PROMs in clinical practice, they must be continually appraised for undue burden placed on patients and clinicians and their usefulness for decision-making. This study assesses correlations between the CLEFT-Q psychosocial scales in the International Consortium for Health Outcomes Measurement Standard Set for cleft and explores their associations with patient characteristics and psychosocial care referral.

METHODS

Spearman correlation coefficients were calculated for CLEFT-Q psychological function, social function, school function, face, speech function, and speech-related distress scales. Logistic regressions were used to assess the association of cleft phenotype, syndrome, sex, and adoption status on scale scores and clinical referral to psychosocial care for further evaluation and management.

RESULTS

Data were obtained from 3067 patients with cleft lip and/or palate at three centers. Strong correlations were observed between social function and psychological function (r > 0.69) and school function (r > 0.78) scales. Correlation between school function and psychological function scales was lower (r = 0.59 to 0.68). Genetic syndrome (OR, 2.37; 95% CI, 1.04 to 5.41), psychological function (OR, 0.92; 95% CI, 0.88 to 0.97), school function (OR, 0.94; 95% CI, 0.90 to 0.98), and face (OR, 0.96; 95% CI, 0.94 to 0.98) were significant predictors for referral to psychosocial care.

CONCLUSIONS

Because social function as measured by the CLEFT-Q showed strong correlations with both school and psychological function, its additional value for measuring psychosocial function within the Standard Set is limited, and it is reasonable to consider removing this scale from the International Consortium for Health Outcomes Measurement Standard Set for cleft.

Adult Cleft Patients: An Exploration of Functional Needs and Treatment Barriers

BACKGROUND

Management of cleft lip and palate has been well characterized in pediatric patients, but limited data exist regarding the long-term functional outcomes of cleft patients once they reach adulthood.

MATERIALS AND METHODS

An institutional, cross-sectional survey of adult patients with a history of cleft lip and/or palate was performed. The survey recorded patient characteristics, concerns, and barriers to care. Patient-reported outcome measures were assessed using the Nasal Obstruction Symptom Evaluation Scale, Epworth Sleepiness Scale, Mandibular Function Impairment Questionnaire, and the CLEFT-Q Speech Modules.

RESULTS

A total of 63 patients (18.2%) participated in the survey. The mean patient age was 43.7 years (median: 41 y, range: 19-93 y), and the most common diagnosis was cleft lip and palate (51%) followed by isolated cleft palate (35%) and isolated cleft lip (14%). A subset of patients scored with moderate to severe dysfunction on each outcome measure including the Nasal Obstruction Symptom Evaluation Instrument (59%), Epworth Sleepiness Scale (7%), and Mandibular Function Impairment Questionnaire (13%). Respondent scores on the CLEFT-Q Speech modules demonstrated a bimodal distribution with lower scores in a significant subset of patients with cleft palate and cleft lip and palate. Many respondents (41%) were interested in clinical evaluation but cited barriers to seeking treatment including financial barriers (35%) or lack awareness of clinical options (27%).

CONCLUSIONS

Many cleft patients have persistent needs or concerns in adulthood, especially regarding speech and nasal breathing. Systemic barriers pose challenges to these patients undergoing clinical evaluation.

No statistically significant difference in long term scarring outcomes of pediatric burns patients treated surgically vs. those treated conservatively

Introduction

Paediatric burns are a common clinical presentation. The long-term scar outcomes in paediatric burns patients are relatively unknown as most are discharged after 6 weeks follow up, apart from the small number that are followed up by scar services depending on geographical availability. We aimed to determine whether the long-term scarring outcomes are significantly different in those who had surgical treatment with Versajet® debridement and Biobrane®, vs. those treated conservatively with non-adherent Mepitel® and Acticoat® dressings, in a cohort of paediatric burns patients.

Methods

The parents of all paediatric burns patients admitted to Stoke Mandeville Hospital from October 2014 to September 2017 were contacted by telephone to fill in the paediatric Brisbane Burn Scar Impact Profile (BBSIP), the only patient reported outcome measure (PROM) specifically aimed at children. The results from the questionnaires underwent statistical analysis to see if there was a significant difference in questionnaire scores between children treated surgically vs. those treated conservatively.

Results

A total of 107 children were admitted in the timeframe, responses were received from 34 patients with 13 having been treated surgically and 21 having been treated conservatively. In all 58 questions that make up the BBSIP, there was no statistically significant difference observed in the scores of those treated surgically vs. those treated conservatively. For 31 questions on the BBSIP, the lowest score indicating the best outcome was observed in all patients in both groups.

Discussion

Surgical management for burns is always the last resort. Our results could be interpreted to suggest clinicians need not fear the longer-term impact a scar may have when deciding whether to treat a paediatric burns patient surgically or conservatively. This study is the first to assess longer-term scar outcomes using the BBSIP. A larger data set and comparison with other burn units in the UK may help to provide more information on scar outcomes between different methods of surgical and conservative treatment. We found no statistically significant difference in the long-term scar outcomes as assessed by the BBSIP in paediatric burn patients treated with Versajet® debridement and Biobrane®, vs. those treated conservatively with non-adherent Mepitel® and Acticoat® dressings.

Farsi version of the CLEFT-Q: translation, cultural adaptation process and reliability

Background

The purpose of this study was the translation and cultural adaptation of the CLEFT-Q to Farsi and evaluating the reliability of it.

Methods

The English version of the CLEFT-Q was translated to Farsi following the guidelines set forth by the International Society for Pharmacoeconomics and Outcomes Research (ISPOR). To calculate the reliability, 50 participants filled out the Farsi version of the questionnaire twice at 2-week intervals.

Results

The difficulties during the translation and cultural adaptation process were as follows: 7.56% of items from the independent forward translations, 62.18% of items from the comparison between two forward translations, and 21% of items from the comparison between post-back translation and the original version. The internal consistency and stability of the Farsi version of the CLEFT-Q were 0.979 and 0.997, which both were categorized as excellent.

Conclusion

The Farsi version of the CLEFT-Q is a valid and reliable tool currently available for Farsi-speaking families around the world.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12903-021-01957-7.

Deeper Understanding of Appearance in Orofacial Clefts: A Structural Equation Model of the CLEFT-Q Appearance Scales

Background

The CLEFT-Q is a patient-reported outcome measure with seven scales measuring elements of facial appearance in cleft lip and/or palate. We built on the validated CLEFT-Q structural model to describe conceptual relationships between these scales, and tested our hypothesis through structural equation modeling (SEM). In our hypothesized model, the appearance of the nose, nostrils, teeth, jaw, lips, and cleft lip scar all contribute to overall facial appearance.

Methods

We included 640 participants from the international CLEFT-Q field test. Model fit was assessed using weighted least squares mean and variance adjusted regression. The model was then refined through modification indices. The fit of the hypothesized model was confirmed in an independent sample of 452 participants.

Results

The refined model demonstrated excellent fit to the data (comparative fit index 0.999, Tucker-Lewis index 0.999, root mean square error of approximation 0.036 and standardized root mean square residual 0.036). The confirmatory analysis also demonstrated excellent model fit.

Conclusion

Our structural model, based on a clinical understanding of appearance in orofacial clefting, aligns with CLEFT-Q field test data. This supports the instrument's use and the exploration of a wider range of applications, such as multidimensional computerized adaptive testing.

Recursive Partitioning vs Computerized Adaptive Testing to Reduce the Burden of Health Assessments in Cleft Lip and/or Palate: Comparative Simulation Study

BACKGROUND

Computerized adaptive testing (CAT) has been shown to deliver short, accurate, and personalized versions of the CLEFT-Q patient-reported outcome measure for children and young adults born with a cleft lip and/or palate. Decision trees may integrate clinician-reported data (eg, age, gender, cleft type, and planned treatments) to make these assessments even shorter and more accurate.

OBJECTIVE

We aimed to create decision tree models incorporating clinician-reported data into adaptive CLEFT-Q assessments and compare their accuracy to traditional CAT models.

METHODS

We used relevant clinician-reported data and patient-reported item responses from the CLEFT-Q field test to train and test decision tree models using recursive partitioning. We compared the prediction accuracy of decision trees to CAT assessments of similar length. Participant scores from the full-length questionnaire were used as ground truth. Accuracy was assessed through Pearson's correlation coefficient of predicted and ground truth scores, mean absolute error, root mean squared error, and a two-tailed Wilcoxon signed-rank test comparing squared error.

RESULTS

Decision trees demonstrated poorer accuracy than CAT comparators and generally made data splits based on item responses rather than clinician-reported data.

CONCLUSIONS

When predicting CLEFT-Q scores, individual item responses are generally more informative than clinician-reported data. Decision trees that make binary splits are at risk of underfitting polytomous patient-reported outcome measure data and demonstrated poorer performance than CATs in this study.

Clinical Practice Patterns and Evidence-Based Medicine in Secondary Cleft Rhinoplasty: A 14-Year Review of Maintenance of Certification Tracer Data From the American Board of Plastic Surgery

OBJECTIVE

To evaluate evolving practice patterns in secondary cleft rhinoplasty.

DESIGN

Retrospective review of data submitted during Maintenance of Certification (MOC).

SETTING

Evaluation of MOC data from the American Board of Plastic Surgery.

PARTICIPANTS

Tracer data for secondary cleft rhinoplasty were reviewed from August 2006 through March 2020, and the data subdivided from 20062012 and 20132020 to evaluate changes in practice patterns.

INTERVENTIONS

Practice patterns in tracer data were compared to those from evidence-based medicine (EBM) literature over this time period.

MAIN OUTCOME MEASURES

Practice patterns were compared to EBM trends during the study period.

RESULTS

A total of 90 cases of secondary cleft rhinoplasty were identified. The average age at operation was 13 years (range 4-77). Cumulative data demonstrated 61% to present with nasal airway obstruction and 21% to have undergone primary nasal correction at the time of cleft lip repair; 72% of patients experienced no complications, with the most common complications being asymmetry (10%) and vertical asymmetry of alar dome position (6%). Cartilage graft was used in 68% of cases, with 32% employing septal cartilage. Change in practice patterns between 2006 to 2012 and 2013 to 2020 demonstrated increase in dorsal nasal surgery (26% vs 43%, P = .034), use of osteotomies (14% vs 38%, P = .010), septal resection and/or straightening (26% vs 48%, P = .034), and turbinate reduction (8% vs 30%, P = .007).

CONCLUSIONS

These tracer data provide long-term data by which to evaluate evolving practice patterns for secondary cleft rhinoplasty. When evaluated relative to EBM literature, future research to further improve outcomes can be better directed.