Cleft and Craniofacial Multidisciplinary Team Clinic: A Look at Attrition Rates for Patients With Complete Cleft Lip and Palate and Nonsyndromic Single-Suture Craniosynostosis

Sociodemographic Factors Predict Long-Term Attrition from Multidisciplinary Cleft Clinic

OBJECTIVE

Identify and describe factors associated with retention and attrition of patients during longitudinal follow-up at multidisciplinary cleft clinic.

DESIGN

Retrospective cohort study.

SETTING

Single, tertiary care center.

PATIENTS, PARTICIPANTS

Patients born between 1995 and 2007 with a diagnosis of cleft palate with or without cleft lip attending multidisciplinary cleft clinic.

INTERVENTIONS

None tested, observational study.

MAIN OUTCOME MEASURE(S)

Age at last clinical appointment with a multidisciplinary cleft team provider. Attrition was defined as absence of an outpatient appointment following 15 years of age.

RESULTS

Six hundred seventy-eight patients were included. The average age at last appointment across the entire cohort was 13.1 years (IQR 6.6-17.2). Patients who were Black (HR 1.60, 95% CI 1.10-2.32, p = 0.014) and other races (HR 1.90, 95% CI 1.22-2.98, p = 0.004) were more likely to be lost to follow-up compared to white patients. Publicly insured patients were more likely to experience attrition than those who were privately insured (HR 1.30, 95% CI 1.03-1.65, p = 0.030). Estimated income was not significantly associated with length of follow-up (p = 0.259). Those whose residence was in the fourth quartile of driving distance from our center experienced loss to follow-up significantly more than those who lived the closest (HR 2.04, 95% CI 1.50-2.78, p < 0.001).

CONCLUSIONS

There is a high degree of follow-up attrition among patients with cleft lip and palate. Race, insurance status, and driving distance to our center were associated with attrition in a large, retrospective cohort of patients who have reached the age of cleft clinic graduation.

Impact of Neighborhood Deprivation and Social Vulnerability on Outcomes and Interventions in Patients with Cleft Palate

OBJECTIVE

To examine whether neighborhood disadvantage impacts length of follow-up, interventions, and outcomes for patients with cleft palate.

DESIGN

Retrospective cohort.

SETTING

Cleft Palate Craniofacial Institute Database at St. Louis Children's Hospital.

PATIENTS/PARTICIPANTS

Patients with cleft palate following in St. Louis Children's Hospital Cleft Palate Multidisciplinary Team Clinic.

INTERVENTIONS

Primary palatoplasty between 2012-2017. Patients were divided into quartiles across area deprivation index (ADI) and social vulnerability index (SVI), two validated, composite metrics of neighborhood disadvantage, to examine whether living in neighborhoods from different deprivation quartiles impacts outcomes of interest.

MAIN OUTCOME MEASURE

Follow-up through age 5, surgeries and surgical complications, speech, developmental, and behavioral outcomes.

RESULTS

205 patients were included. 39% of patients belonged to the most deprived ADI quartile, while 15% belonged to the most vulnerable SVI quartile. There were no differences between ADI or SVI quartiles in number of operations received (p ≥ 0.40). Patients in the most deprived ADI quartile were significantly more likely to have speech/language concerns (OR 2.32, 95% CI [1.20-4.89], p = 0.01). Being in a more vulnerable SVI quartile was associated with developmental delay (OR 2.29, 95% CI [1.04-5.15], p = 0.04). ADI and SVI quartile did not impact risk of loss to follow-up in the isolated and combined cleft lip and palate subgroups (p ≥ 0.21).

CONCLUSIONS

Neighborhood disadvantage impacts speech and developmental outcomes in patients with cleft palate despite comparable length of follow-up in multidisciplinary team clinic.

Interdisciplinary Team Care for Children with Facial Differences

Children who have cleft and craniofacial diagnoses require coordinated, interdisciplinary treatment planning from birth to young adulthood. Teams that adhere to the Parameters of Care and maintain annual review by the American Cleft Palate Craniofacial Association Commission on Approval of Teams are published at www.acpa-cpf.org to assist families in obtaining that care. The six critical components to this interdisciplinary care focus on the team's composition, the team's management and responsibilities, the inclusion of patient and family/caregiver communication, an ongoing commitment to cultural competence, the importance of psychosocial and social services provided for the child and family, and the dedication to outcomes assessment. Primary care physicians are in a unique position to help direct families to this online directory for the best possible outcomes. [Pediatr Ann. 2023;52(1):e18-e22.].

Cleft lip and palate: the psychological burden of affected parents during the first three years of their children's lives

The surgical treatment of cleft lip and palate (CLP) has been well described in the literature. Nevertheless, little is known about the psychological burden of affected parents. The aim of this study was to investigate the psychological burden in parents of children with CLP within the first 3 years of the children's lives. A standardized questionnaire (Parenting Stress Index, PSI) was administered to 33 parents of children with CLP to evaluate their psychological burden. The corresponding interview was conducted independent of any operative procedure during the yearly routine CLP consultation. Each participant's stress profile was assessed and compared with the average values of parents with non-cleft children. Psychological stress was substantially increased in all participants when compared to the parents of healthy children. This result was highly significant (P < 0.001). Parent depression (P < 0.001) and child-related requirements (P < 0.001) were the most critical subscales in the stress profile. Overall, the child-related burden was greater than the parent-related burden. These results indicate that parents of children with CLP have a higher level of psychological stress than parents of non-cleft children. This psychological stress might be reduced if addressed by specialist clinical psychologists in cleft-treating centres.

School-age outcomes in patients with unilateral coronal synostosis: comparison of fronto-orbital advancement and endoscopic strip craniectomy

OBJECTIVE

Outcomes research on unilateral coronal synostosis is mostly limited to the early postoperative period. This study examines facial asymmetry, desire for revision, and patient-reported outcomes at school age in children who received either endoscopic strip craniectomy with helmet therapy or fronto-orbital advancement (open repair).

METHODS

Patients with repaired unilateral coronal synostosis born between 2000 and 2017, with 3D photographs taken when they were between 3.5 and 8 years of age, were eligible for study inclusion. Three pairs of bilateral linear measurements and two angular measurements were taken. Parent- and physician-reported desire for revision and patient-reported outcomes (Patient-Reported Outcomes Measurement Information System cognitive function and Quality of Life in Neurological Disorders stigma scores) were collected from patient charts.

RESULTS

Thirty-five patients qualified, including 25 with open repair and 10 with endoscopic repair. The median patient ages at repair were 3 months and 8 months in the endoscopic and open groups, respectively. The average ages at final 3D photography were 5.8 years and 5.5 years in the endoscopic and open groups, respectively. Digital anthropometry revealed no significant differences in measures of facial asymmetry between the repair groups (p ≥ 0.211). Midface depth (tragion to subnasale) was significantly less symmetric at school age than other linear measures (F(2,102) = 9.14, p < 0.001). Forehead asymmetry was significantly associated with parent- and physician-reported desire for revision (p ≤ 0.006). No significant associations were found between physical asymmetry and patient-reported stigma or cognitive function (p > 0.046, Holm-Bonferroni correction).

CONCLUSIONS

Children who underwent open or endoscopic repair for unilateral coronal synostosis have comparable facial symmetry at school age, but midface depth remains highly asymmetrical in both groups. Forehead asymmetry at school age correlates with parent- and physician-reported desire for revision.

Cost of Cleft Team Care at an Academic Children's Hospital

BACKGROUND

The financial burden of cleft-craniofacial team care is substantial, and high costs can hinder successful completion of team care.

SOLUTION

Collaboration with multiple stakeholders including providers, insurers, and patient guardians, as well as hospital administrators, is critical to increase patient retention and improve final clinical outcomes.

WHAT WE DO THAT IS NEW

At our cleft and craniofacial center, charges for a team care visit fall into one of three categories-hospital fees, professional fees, or external fees. There are four types of hospital fees depending on (1) whether the patient is new or returning, and (2) whether the patient saw ≤4 or ≥5 providers. To further elucidate the financial burden (out-of-pocket costs) directly borne by families of children with cleft lip and/or palate, we conducted a retrospective review of billing records of team care visits made between September 2019 and March 2020. Out-of-pocket costs for a single team care visit (on a commercial insurance plan) ranged from $4 to approximately $1220 and had a median (IQR) of $445 ($118, $749).

Persistence, strength, isolation, and trauma: An ethnographic exploration of raising children with cleft palate

BACKGROUND

The lives of families of young children with cleft palate (±lip) are complex. Multiple interventions are required as part of the long-term multidisciplinary treatment for children with CP±L, with an impairment-focused approach prevailing. Research with young children with CP±L has focused on treatment and intervention, and previous qualitative research has been collected predominantly via interviews, so little is understood about the day-to-day lives of families of young children with CP±L.

AIMS

(1) To increase understanding of the lives of children with CP±L and their families by applying an ethnographic lens to improve clinical practice (2) to identify key interactions and encounters that shape the experiences of children with CP±L and their families (3) to examine how family-centered practice can enhance practitioner-family relationships in providing effective and evidence-based care for children with CP±L.

METHOD

Ethnographic observations of seven families of children with CP±L and their families and educators including parents, siblings, aunts, grandparents, and teachers involved multiple site visits. Rich data were collected to gather information about different aspects of their lives (such as their strengths, routines, preferences, challenges and experiences). There were 84 artefacts collected: 18 interviews, 29 videos, one extended audio recording of a mealtime, seven photos contributed by families, seven case history questionnaires, and 22 field notes. These data were analyzed inductively using thematic analysis.

RESULTS

Three overarching themes and 11 subthemes were identified: (1) the whole child (persistence, communication, activities, mealtimes), (2) family strength and support (strong families, external support, attitudes, advocacy, positive medical experiences) and (3) family isolation and trauma (negative medical experiences, traumatic and challenging experiences).

CONCLUSION

This is the first study to use ethnographic methodology to facilitate the collection of unique insights into the lives of young children with CP±L and their families to improve clinical practice for SLPs. The unique application of family-centered practice with these families promoted trust and highlighted their challenges and strengths which could be considered by SLPs to provide holistic intervention.

Family-Centered Pediatric Plastic Surgery Care

Our multidisciplinary cleft palate and craniofacial center was established in 1978 and manages more than 5,000 active patients from birth to skeletal maturity. Over the past four years we have implemented a complex family-centered reorganization, with the goal of improving care and patient retention. Through our implementation of a familycentered approach, we have also decreased treatment burden, need for secondary procedures and cost of care. 1-12.

Evaluation of Discipline-Specific Outcomes Through a Multidisciplinary Team Clinic for Patients With Isolated Cleft Palate

OBJECTIVE

To describe the incidence and timing of provider-specific interventions for children with isolated cleft palate.

DESIGN

This was a retrospective cohort study involving review of medical records.

SETTING

Multidisciplinary team care clinic at a tertiary academic children's hospital between January 2000 and July 2019.

PATIENTS

Patients with isolated nonsyndromic cleft palate seen by an American Cleft Palate-Craniofacial Association-approved team; 138 children were included.

MAIN OUTCOME MEASURES

Study outcomes included incidence of secondary velopharyngeal management, tympanostomy tube insertion, speech therapy, hearing loss, dental/orthodontic treatment, and psychology interventions. Provider-specific outcomes were calculated for patients at ages 0 to 3, 3 to 5, and >5 years.

RESULTS

Median follow-up time was 7.0 years (interquartile range: 3.3-11.8 years). At their last team assessment, 42% of patients still had conductive hearing loss. The rate of tympanostomy tube insertions not done alongside a palatoplasty was highest for ages 3 to 5 and dropped after new American Academy of Otolaryngology-Head and Neck Surgery Foundation guidelines in 2013 (P = .015); 54% of patients received speech-language therapy during follow-up. Palatoplasty, psychology, and dental/orthodontic treatment were all less common than speech or ENT treatment (P < .01). Secondary palatoplasty was performed in 31 patients (22%). Patients who received speech, dental/orthodontic, or psychology intervention followed up longer than those who did not (9.8 vs 2.1 years, P < .001).

CONCLUSION

Half of the patients terminated team follow-up by age 7, suggesting that burden of care outweighed perceived benefits of continued follow-up for many families. These results can be used to adjust protocols for children with isolated cleft palate.

School-Aged Anthropometric Outcomes After Endoscopic or Open Repair of Metopic Synostosis

BACKGROUND AND OBJECTIVES

Metopic craniosynostosis can be treated by fronto-orbital advancement or endoscopic strip craniectomy with postoperative helmeting. Infants younger than 6 months of age are eligible for the endoscopic repair. One-year postoperative anthropometric outcomes have been shown to be equivalent, with significantly less morbidity after endoscopic treatment. The authors hypothesized that both repairs would yield equivalent anthropometric outcomes at 5-years postoperative.

METHODS

This study was a retrospective chart review of 31 consecutive nonsyndromic patients with isolated metopic craniosynostosis treated with either endoscopic or open correction. The primary anthropometric outcomes were frontal width, interfrontal divergence angle, the Whitaker classification, and the presence of lateral frontal retrusion. Peri-operative variables included estimated blood loss, rates of blood transfusion, length of stay, and operating time.

RESULTS

There was a significantly lower rate of lateral frontal retrusion in the endoscopic group. No statistically significant differences were found in the other 3 anthropometric outcomes at 5-years postoperative. The endoscopic group was younger at the time of surgery and had improved peri-operative outcomes related to operating time, hospital stay and blood loss. Both groups had low complication and reoperation rates.

CONCLUSIONS

In our cohort of school-aged children with isolated metopic craniosynostosis, patients who underwent endoscopic repair had superior or equivalent outcomes on all 4 primary anthropometric measures compared with those who underwent open repair. Endoscopic repair was associated with significantly faster recovery and decreased morbidity. Endoscopic repair should be considered in patients diagnosed with metopic craniosynostosis before 6 months of age.

Facilitators and Barriers to Implementing Standardized Outcome Measurement for Children With Cleft Lip and Palate

OBJECTIVE

Identify facilitators and barriers to implementing standardized outcome measurement in cleft care.

DESIGN

Cross-sectional, qualitative study.

SETTING/PARTICIPANTS

Participants included 24 providers and staff from a large, multidisciplinary cleft team in the southwest United States, 5 caregivers of children with cleft palate (with or without cleft lip) treated by this team, and 3 experts involved in implementing a cleft-specific standardized outcome measurement in the United Kingdom.

INTERVENTIONS

Semistructured, qualitative interviews were conducted exploring perceived facilitators and barriers to implementing standardized outcome measurement in cleft care. Interviews were audio-recorded, transcribed, and analyzed for content. The Consolidated Framework for Implementation Research was used to guide the interviews and analysis. The analysis focused on the characteristics of standardized outcome measurement that directly influence its adoption.

RESULTS

Participants identified both facilitators and barriers to implementing standardized outcome measurement. Facilitators included the strength and quality of evidence supporting improvements in cleft care delivery following implementation of standardized outcome measurement and the relative advantage of standardized outcome measurement over continuing the status quo. Barriers included the difficulty adapting standardized outcome measurement to meet local context and patient-specific needs and the complexity of implementing standardized outcome measurement.

CONCLUSIONS

Providers, staff, and caregivers involved in cleft care perceive multiple benefits from standardized outcome measurement, while also recognizing substantial barriers to its implementation. Results from this study can be used to guide development of an implementation strategy for standardized outcome measurement that builds upon perceived strengths of the intervention and reduces perceived barriers.

One Multidisciplinary Cleft and Craniofacial Team's Experience in Shifting to Family-Centered Care

Family-centered care is a high-priority focus area in health care and is associated with increased family satisfaction and quality of life, better health outcomes and family follow-up, decreased burden of care, and improved efficiency of resource utilization. Motivated by our aim to improve clinic efficiency and patient retention, our multidisciplinary cleft palate and craniofacial center has been undergoing a complex family-centered reorganization over the past 3 years. We seek to share our experience in hope the information will be a useful starting point to other teams in structuring their own family-centered improvements. We suggest the following stepwise method to achieve a more family-centered process: (1) gathering preintervention data, (2) brainstorming challenges with stakeholders, (3) brainstorming solutions with stakeholders, (4) implementation, (5) follow-up and troubleshooting, (6) further implementation, and (7) gathering postintervention data. Additionally, we found the use of institutional resources added substantial value to our efforts.