Centre-level variation of treatment and outcome in 5-year-old children with non-syndromic unilateral cleft lip and palate: The Cleft Care UK study. Part 1: Methodology and results for dento-facial outcomes

Exploring the Needs of Young People Born With Cleft Lip and/or Palate Approaching End of Routine Care, in the UK

OBJECTIVE

The aim of this study was to understand the needs of young people, aged 16 to 20 years, born with cleft lip and/or palate (CL/P) approaching end of routine care, in the United Kingdom (UK).

DESIGN

Nominal group technique was used during 2 online focus groups to identify priorities for cleft care at transition to adult care. Focus group discussions were recorded, transcribed, and analyzed using reflexive thematic analysis.

PARTICIPANTS

Ten young people born with CL/P, 8 aged 18 to 20 years and 2 aged 16 to 17 years were recruited via the UK-based cleft charity, the Cleft Lip and Palate Association (CLAPA).

RESULTS

Three themes were identified from the analysis: Theme 1-Psychological well-being is not a constant. Theme 2-Asking and listening-the cleft clinic appointment. Theme 3-Approaching end of routine care and re-accessing cleft services.

CONCLUSIONS

Findings suggest that young people have ongoing needs in older adolescence. Psychological well-being, taking control of their own treatment and re-accessing the cleft team were highlighted as particular issues. Whilst further research with a larger and more representative sample is needed, these results support the need for continued access to and provision from the cleft team at this age.

Healthcare Trajectories of Adolescent Patients With Cleft Lip and/or Palate According to Health Insurance Coverage in Medellin, Colombia

To describe and compare the healthcare trajectories of patients with CL/P under two different income-based programs for health coverage in Colombia, known in Colombia as a health insurance regime (contributory and subsidized), in Medellín, 2021.

Non-experimental, cross-sectional questionnaire-based study.

Primary level of clinical care in Medellín, Colombia.

Twenty-eight 15- to 21-year-olds with CL/P and primary caregivers.

Individuals with CL/P answered the survey. Patients with syndromic CL/P and patients with cognitive disabilities were excluded. The calculation of the probabilistic sample was performed based on the formula for finite populations using databases from 2 health insurance companies. The analysis was descriptive and bivariate. Chi-square and Fisher tests were used to analyze the variables of interest.

Continuity of the care pathway was measured with proxy indicators: (1) access to comprehensive CL/P treatment; (2) timeliness of access to comprehensive CL/P treatment; (3) differences in access to and timeliness of comprehensive CL/P treatment between patients under both health insurance coverage.

No differences were found when comparing the healthcare trajectories of young patients with CL/P who were in both health coverage. Differences were observed in the timeliness of care for patients with CL/P under the subsidized coverage who were more economically vulnerable. Delays in care were mainly linked to administrative procedures required for orthodontic procedures, bone grafts, and maxillofacial surgeries.

Despite the health system's guarantee of equal care across income levels, differences in the timeliness of care persist for patients from lower-income families.

Lips and noses in 10-year old patients with repaired complete unilateral clefts of lip, alveolus, and palate. A prospective three-centre study of the Baltic Cleft Network

This multicenter study aimed at comparing different techniques of lip and nose repair with or without NAM and primary anterior rhinoplasty in pre-adolescent children. Patients with unilateral clefts of lip, alveolus, and palate who had undergone cleft lip and nose repair were evaluated in a prospective three-centre study using standardized monochromatic, cropped photographs. Four cleft surgeons evaluated the aesthetics of the central part of the face when the patients had reached age ten years. Seventy-six sets of photographs out of 87 patients were evaluated. The overall ratings of lips and noses did not differ much between centres. However, noses of centres 1 (mean 0.74; SD 0.57) and 2 (mean 0.76; SD 0.60) had been rated better than centre 3 (mean 1.32; SD 0.78; p = 0.0078), especially "Deformation of upper part of nostril rim or poor position of alar cartilage". Centre 3 had produced better looking scars (mean 0.33; SD 0.48); p = 0.0036. Within the limitations of the study it seems that NAM and primary anterior rhinoplasty including postoperative nasal stents should be performed whenever possible in order to achieve a favorable shape of the nose and to reduce the need for secondary corrective surgery.

Identifying associations between dental arch relationship scores, relative deprivation and other cleft audit outcomes. Part 2

Identify associations between dental arch relationship scores, oral health status and deprivation index in patients with complete unilateral cleft lip and palate (UCLP) and bilateral cleft lip and palate (BCLP). Ninety-two 5-year-old children with non-syndromic complete UCLP and thirty-nine 5-year-old children with non-syndromic complete BCLP from the United Kingdom. Data were collected from the 5-year audit outcomes submitted to the Cleft Registry and Audit Network (CRANE). The index of multiple deprivation (IMD) and Welsh index of deprivation were used to assess a relative measure of deprivation. Comparisons of 5-year-old index/BCLP Deciduous Dentition Yardstick outcome against IMD and dmft are performed using multivariable linear regression models. Both UCLP and BCLP had a high percentage of children with dmft >0 (47% and 49%, respectively). The mean dmft for the UCLP cohort was 2.8 and 2.6 for the BCLP cohort. In the UCLP group, a poorer 5-year-old index was associated with an increased dmft score (P = .023) and higher level of deprivation (P = .010). In the BCLP group, there was no significant associations between BCLP Deciduous Dentition Yardstick, dmft and IMD. A poorer dental arch relationship outcome may be associated with higher level of area deprivation and oral health status, in children with UCLP. Those with a poor outcome for the 5-year-old Index are more likely to have increased caries experience.

Identifying associations between dental arch relationship scores, relative deprivation and other cleft audit outcomes. Part 1

OBJECTIVES

To assess whether dental arch relationship scores are associated with speech, audiological and psychology outcomes in patients with complete unilateral cleft lip and palate (UCLP) and bilateral cleft lip and palate (BCLP).

SETTING AND SAMPLE POPULATION

One hundred 5-year-old children with non-syndromic complete UCLP and forty-two 5-year-olds with non-syndromic complete BCLP from the United Kingdom.

MATERIAL AND METHODS

Data were collected from five-year audit clinics for dental arch relationships, speech, hearing and psychology outcomes. Associations were assessed between ordinal prognostic covariates and the dental arch relationship outcome using a Cochrane-Armitage test for trend and comparisons with binary prognostic covariates using chi-square/Fisher's exact test. This was extended to assess associations between five-year audit outcomes and a measure of deprivation.

RESULTS

There was no evidence of associations between dental arch relationships and outcomes for audiology and speech. Individual domain analysis of the psychology outcomes within the UCLP cohort reported a poor outcome for Pro-social score to be associated with a poor 5-year-old index score (P = .018). For the BCLP sample, a good outcome for the BCLP Deciduous Dentition Yardstick was associated with a good conduct score (P = .01).

CONCLUSION

There was no association with the 5-year-old index/BCLP Deciduous Dentition Yardstick score and outcomes reported for audiology and speech. For the UCLP and BCLP cohorts, a poor dental arch relationship outcome may be associated with issues with some aspects of psychological well-being, associated with peer interactions and conduct. The deprivation index of samples had no association with the outcomes assessed.

Centre-level variation in outcomes and treatment for otitis media with effusion and hearing loss and the association of hearing loss with developmental outcomes at ages 5 and 7 years in children with non-syndromic unilateral cleft lip and palate: The Cleft Care UK study. Part 2

OBJECTIVES

To explore centre-level variation in otitis media with effusion (OME), hearing loss and treatments in children in Cleft Care UK (CCUK) and to examine the association between OME, hearing loss and developmental outcomes at 5 and 7 years.

SETTING AND SAMPLE POPULATION

Two hundred and sixty-eight 5-year-old British children with non-syndromic unilateral cleft lip and palate (UCLP) recruited to CCUK.

MATERIALS AND METHODS

Children had air and bone conduction audiometry at age 5. Information on grommet and hearing aid treatment was obtained from parental questionnaire and medical notes. Hearing loss at age 5 was defined as >20 dB in the better ear and history of OME and hearing loss was determined from past treatment. Children with sensorineural hearing loss were excluded. Associations were examined with speech, behaviour and self-confidence at age 5 and educational attainment at age 7. Centre variation was examined using hierarchical models and associations between hearing variables and developmental outcomes were examined using logistic regression.

RESULTS

There was centre-level variation in early grommet placement (variance partition coefficient (VPC) 18%, P=.001) and fitting of hearing aids (VPC 8%, P=.03). A history of OME and hearing loss was associated with poor intelligibility of speech (adjusted odds ratio=2.87, 95% CI 1.42-5.77) and aspects of educational attainment.

CONCLUSIONS

Hearing loss is an important determinant of poor speech and treatment variation across centres suggest management of OME and hearing loss could be improved.

Centre-level variation of treatment and outcome in 5-year-old children with non-syndromic unilateral cleft lip and palate: The Cleft Care UK study. Part 1: Methodology and results for dento-facial outcomes

OBJECTIVES

Outline methods used to describe centre-level variation in treatment and outcome in children in the Cleft Care UK (CCUK) study. Report centre-level variation in dento-facial outcomes.

SETTING AND SAMPLE POPULATION

Two hundred and sixty-eight five-year-old British children with non-syndromic unilateral cleft lip and palate (UCLP).

MATERIALS AND METHODS

Between January 2011 and December 2012, data were collected on a comprehensive range of outcomes. Child facial appearance and symmetry were assessed using photographic pictures. Dental arch relationships were assessed from standardized dental study models. Hierarchical statistical models were used to predict overall means and the variance partition coefficient (VPC)-a measure of amount of variation in treatment or outcome explained by the centre.

RESULTS

Data on dento-alveolar arch relationships and facial appearance were available on 197 and 252 children, respectively. The median age of the children was 5.5 years, and 68% were boys. Variation was described across 13 centres. There was no evidence of centre-level variation in good or poor dento-alveolar arch relationships with a VPC of 4% and 3%, respectively. Similarly, there was no evidence of centre-level variation in good or poor facial appearance with a VPC of 2% and 5%, respectively.

CONCLUSIONS

There was no evidence of centre-level variation for dento-facial outcomes although this study only had the power to detect large variation between sites.

Centre-level variation in behaviour and the predictors of behaviour in 5-year-old children with non-syndromic unilateral cleft lip: The Cleft Care UK study. Part 5

OBJECTIVES

The aims of this study were to describe child behavioural and psychosocial outcomes associated with appearance and speech in the Cleft Care UK (CCUK) study. We also wanted to explore centre-level variation in child outcomes and investigate individual predictors of such outcomes.

SETTING AND SAMPLE POPULATION

Two hundred and sixty-eight five-year-old children with non-syndromic unilateral cleft lip and palate (UCLP) recruited to CCUK.

MATERIALS AND METHODS

Parents completed the Strengths and Difficulties questionnaire (SDQ) and reported their own perceptions of the child's self-confidence. Child facial appearance and symmetry were assessed using photographs, and intelligibility of speech was derived from audio-visual speech recordings. Centre-level variation in behavioural and psychosocial outcomes was examined using hierarchical models, and associations with clinical outcomes were examined using logit regression models.

RESULTS

Children with UCLP had a higher hyperactive difficulty score than the general population. For boys, the average score was 4.5 vs 4.1 (P=.03), and for girls, the average score was 3.8 vs 3.1 (P=.008). There was no evidence of centre-level variation for behaviour or parental perceptions of the child's self-confidence. There is no evidence of associations between self-confidence and SDQ scores and either facial appearance or behaviour.

CONCLUSIONS

Children born with UCLP have higher levels of behaviour problems than the general population.