Choosing a Multidisciplinary Cleft and Craniofacial Team: Medical, Surgical, and Social Considerations

Cleft and craniofacial conditions often present with a variety of functional and esthetic sequelae optimally treated by a multidisciplinary approach. Diagnosis of such conditions pre- or postnatally may evoke parental uncertainty and anxiety, and an important primary consideration is the selection of a cleft and craniofacial team. Identifying an optimal team may be particularly important for developing long-term relationships with clinicians who will ideally work intimately with the family from diagnosis to adulthood. While families, parents, and providers should consider several factors, a dearth of evidence-based suggestions preclude critical appraisal of cleft and craniofacial teams. In this article, the authors summarize medical, surgical, and social considerations for selecting a cleft and craniofacial team to optimize patient outcomes and the family/caregiver experience.

Presurgical Infant Orthopedic Videos on YouTube™: A Thematic Analysis of Caregiver Narratives

OBJECTIVE

Information regarding how caregivers cope when using presurgical infant orthopedic (PSIO) appliances is sparse. This study aimed to understand caregivers' perspectives and experiences with contemporary PSIO treatment.

DESIGN

PSIO videos shared on the YouTube™ platform were used as the data source. Videos with caregivers were identified (n = 21) and portions with caregiver narratives were transcribed. This was followed by the application of a six-step thematic analysis as conceptualized by Braun and Clarke (2006, 2019).

RESULTS

Two themes were identified from the caregiver narratives in the PSIO videos. The Family Journey theme included reaction to diagnosis, choice of center, burden of care, care commitment, coping, and testimonials. The Information theme included PSIO techniques and PSIO benefits.

CONCLUSION

Multifaceted challenges and coping strategies were described by caregivers during the PSIO phase. Caregivers remained committed to treatment despite the burden of care, were motivated by an understanding of the benefits of PSIO, and customized care based on their individual strengths and needs. Study results can help providers gain an understanding of what caregivers experience outside the clinical environment.

Are We Together in This? Relationship Experiences of Parents of Children with Craniofacial Anomalies

OBJECTIVE

The birth of a child with a craniofacial anomaly (CFA) can have a profound psychological impact on the family and the parental relationship. The purpose of this study was to qualitatively investigate how a child's CFA condition affected parents' couple relationship.

SETTING

All patients with a CFA are followed-up by the National Unit for Craniofacial Surgery, a specialized and multidisciplinary team. Hence, participants were recruited within a centralized treatment setting.

DESIGN

We used a qualitative approach to explore the relationship experiences of parents of children with CFAs. The interviews were analysed using a hermeneutic-phenomenological approach.

PARTICIPANTS

The study included 13 parents, nine mothers and four fathers of children with a range of different CFAs. At the time of the interview, 10 participants were married, one was cohabiting, and two were divorced.

RESULTS

Most participants perceived their partners as committed and engaged in caring for their affected child and involved in the family's everyday life, and described a strengthened relationship to their partner after the child with a CFA was born. However, some participants struggled in their relationships with their partners, and did not receive the comfort and support they needed during this critical time, leading to feelings of distance and loneliness.

CONCLUSIONS

Craniofacial teams should be mindful of the importance of the environment surrounding the child, such as parental relationship and family function. Therefore, a comprehensive approach should be included in team-based care, and couples and families in need of extra support should be referred to relevant specialists.

"When the surgery was over, I felt like the worst part had passed": experiences of parents of children with craniosynostosis

PURPOSE

Parents of children scheduled for surgery often experience emotional distress and anxiety. This study aimed to explore parents' experiences of hospital care after their child's craniosynostosis surgery and their perception of support during the year after discharge.

DESIGN AND METHODS

A purposive sample of 19 parents of 12 children with nonsyndromic craniosynostosis, who had undergone surgery, was recruited from one of two national centers in Sweden. An interview was conducted ~1 year after the child's surgery, from September 2017 to August 2018. The interviews followed a semistructured interview guide, were recorded, transcribed verbatim, and analyzed using inductive content analysis.

RESULTS

The analysis yielded six categories with subcategories as follows: (1) cared for and confident: the hospital staff was perceived as kind, professional, and reliable. (2) Alone and abandoned: sometimes, parents found it hard to initiate contact with professionals during hospitalization and after discharge. (3) The importance of information: thorough information was perceived as essential and the need for information varied during postsurgery period. (4) Feelings of worry: some parents remained worried about risks during recovery and were concerned about comorbidities and development. (5) Alright after all: parents felt that the worst part had been before surgery. (6) The need for support: parents were generally satisfied with the support offered and they often received support from family and friends, or other parents through social media/online forums.

PRACTICE IMPLICATIONS

Healthcare professionals must be responsive to what support parents need at different stages in the care process and be aware that parents sometimes hesitate to initiate contact and ask for help and support. Support from healthcare professionals to everyone in the follow-up program, as a default, might be more accessible or acceptable for some parents. Providing online support from professionals should be considered and caregivers could also facilitate peer support among parents, either face-to-face or online.

"Will You Still Feel Beautiful When You Find Out You Are Different?": Parents' Experiences, Reflections, and Appearance-Focused Conversations About Their Child's Visible Difference

To investigate parents' reflections and experiences of having a child born with an appearance-altering condition, interviews with 33 parents of children born with rare craniofacial conditions were analyzed using inductive thematic analysis. Three themes emerged: "Managing emotions: A dynamic process," "Through another lens: External reminders of difference," and "Awareness of difference: Approaching the child." Findings suggest that although parents learned to accept and love their child's visible difference, external factors such as appearance-altering surgery and other people's reactions activated difficult emotions in parents. Parents struggled to decipher whether and when to raise appearance-related issues with their child, and how this could be done without distressing the child. Anticipatory guidance that facilitates positive appearance-focused conversations both within and outside the home seems to be needed. Parenting skills could also be strengthened by preparing parents for social reactions to the child's visible difference, and their child's changed appearance following surgery.

Cross-sectoral video consultation in cancer care: GPs' evaluation of a randomised controlled trial

Background

Shared care models present an opportunity for patients to receive the benefits of specialist care combined with the continuity of care provided by a GP.

Aim

To test the effects on GP-perceived involvement in cancer care and their satisfaction with this cross-sectoral information after bringing the patient, GP, and oncologist together in a shared video consultation.

Design & setting

GPs from the Region of Southern Denmark evaluated a randomised controlled trial testing shared video consultations.

Method

This study describes secondary outcomes based on a 4 months' follow-up survey from GPs participating in The Partnership Project (PSP). Patient perception of coordination of care at 7 months' follow-up was the primary outcome of the PSP. A tripartite video consultation was conducted during cancer treatment to share tasks and roles between health professionals with the patient.

Results

The study included 281 patients, and 105 unique GPs returned 124 questionnaires. Video consultations were accomplished in 68% of scheduled cases. The study found an increased odds ratio (OR) of 3.03 for GP satisfaction with the distribution of tasks and roles, and they experienced more involvement in the cancer patients' trajectory. The study found an increased OR of 6.95 for the GP perception of more direct contact and dialogue with the Department of Oncology. There was a decreased OR of 0.88 for the GP to be engaged in handling anxiety and psychological concerns.

Conclusion

The study showed that involving the GP in one shared consultation increased the odds of the GP being satisfied with the distribution of tasks and roles, and feeling more involved in the cancer patient’s trajectory. However, recruitment and response rates from GPs were limiting factors.

Parental perceptions and expectations concerning speech therapy-related cleft care - a qualitative study

AIMS

Speech (i.e., resonance, nasal airflow and articulation) is one of the primary outcomes in individuals with a cleft of the palate with or without a cleft of the lip (CP ± L). Therefore, it is highly important to obtain information regarding parental perceptions and expectations concerning speech therapy-related cleft care. Literature investigating these parental perspectives is scarce. The present study investigated perceptions and expectations of parents of children with CP ± L concerning (outcomes of) speech therapy.

METHODS

Eleven parents of nine children with CP ± L were recruited from the multidisciplinary craniofacial team at the Ghent University hospital. A qualitative design, using semi-structured interviews, was used to collect data. Data were managed using NVIVO software version 10 and analyzed thematically.

RESULTS

The analysis resulted in three major themes: (1) service provision, (2) patient-centered care, and (3) seeking health care. Each of these identified themes were divided into three subthemes. Service provision included the effectiveness of the provided service, interdisciplinary collaboration, and expertise of the speech therapist. Information provision, child-friendly attitude and connection were categorized under patient-centered care. Seeking health care included affordability, practical considerations and the selection of a speech therapist.

CONCLUSION

The most prominent expectation of the parents was that they wanted to see their children progress during the speech intervention. This finding supported the importance of experienced and specialized speech-language pathologists (SLPs) in the provision of care to children with a CP ± L. Moreover, the results showed that the majority of the parents wanted more clear and comprehensive information particularly about the treatment progress, the transfer to the home environment and the prognosis. The present findings might aid SLPs, and more generally all health professionals, in gaining insight into parental perceptions and expectations concerning speech therapy-related cleft care. Thereby, treatment quality might be improved.

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.

Investigating whether shared video-based consultations with patients, oncologists, and GPs can benefit patient-centred cancer care: a qualitative study

Background

Guidelines have proposed that GPs should have a central role as coordinators of care and support patients with cancer during all stages of treatment, follow-up, and rehabilitation. Multidisciplinary video consultation involving the patient with cancer, the oncologist, and the GP may help to define roles and tasks, and this resulting clarity may enable greater support for patients with cancer.

Aim

To explore the consultation structure, content, and task clarification when a GP and an oncologist are attending a video consultation with a patient with cancer.

Design & setting

A qualitative study took place in the Region of Southern Denmark to investigate multidisciplinary video consultations, based on thematic analysis.

Method

Recordings of 12 video consultations were analysed using the framework method. A combined deductive and inductive approach was undertaken. The deductive themes were selected based on a consultation guide given to the doctors before the consultations.

Results

The study identified 15 themes, which were grouped into the following three categories: the implications of sharing a consultation; consultation structure; and health concerns.

Conclusion

Multidisciplinary video-based consultations with a patient and two health professionals succeeded in having a patient-centred communication style. In clarifying tasks between the GP and oncologist to support the patient, work-related issues and professional support for psychosocial challenges were always a task for the GP. Dissemination of this first-line evidence may improve acceptability among medical specialists and help assist GPs in supporting patients with cancer. However, focus on the involvement of relatives should be emphasised.

Cross-sectoral video consultations in cancer care: perspectives of cancer patients, oncologists and general practitioners

Purpose

Multidisciplinary video consultations are one method of improving coherence and coordination of care in cancer patients, but knowledge of user perspectives is lacking. Continuity of care is expected to have a significant impact on the quality of cancer care. Enhanced task clarification and shared responsibility between the patient, oncologist and general practitioner through video consultations might provide enhanced continuity in cancer care.

Method

We used descriptive survey data from patients and doctors in the intervention group based on a randomised controlled trial to evaluate the user perspectives and fidelity of the intervention.

Results

Patients expressed that they were able to present their concerns in 95% of the consultations, and believed it was beneficial to have both their doctors present in 84%. The general practitioner and oncologist found that tripartite video consultation would lead to better coordination of care in almost 90% of the consultations. However, the benefits of handling social issues and comorbidity were sparser. Consultations were not accomplished in 11% due to technical problems and sound and video quality were non-satisfactory in 20%.

Conclusion

Overall, multidisciplinary video consultations between cancer patient, general practitioner and oncologist were feasible in daily clinics. Initial barriers to address were technical issues and seamless planning. Patients reported high satisfaction, patient centredness and clarity of roles. General practitioners and oncologists were overall positive regarding role clarification and continuity, although less pronounced than patients.

Trial registration

www.clincialtrials.gov, NCT02716168.

“Exposed and Vulnerable”: Parent Reports of Their Child’s Experience of Multidisciplinary Craniofacial Consultations

Objective:

Childhood is a period of extensive socioemotional development, which can be impacted by the presence of a congenital craniofacial anomaly (CFA). Complex multidisciplinary treatment and long-term follow-up are normally required, yet understanding of children’s treatment experiences is limited. The objective of this study was to investigate children’s experiences of multidisciplinary team (MDT) consultations from the perspective of their parents.

Design:

Thirty-eight parents of children with a rare CFA were interviewed in person or over the telephone. Interviews were transcribed verbatim, translated into English, and explored using thematic analysis.

Results:

Background factors influencing the child’s experience of the consultation included age, developmental stage, personality, and prior treatment experiences. Participants tried to prepare their child for meeting the MDT, but did not fully understand what to expect themselves. During consultations, participants were acutely focused on their child’s emotional state, making it difficult to balance their desire to protect the child from potentially negative experiences, and the need to engage in a constructive dialogue with health professionals. Participants believed that health professionals’ conduct could considerably influence the child’s well-being and subsequent treatment decisions. Finally, participants highlighted the need to debrief their child to help them adjust positively.

Conclusions:

The ultimate goal of craniofacial care is to help children develop into confident adults who are able to cope with the challenges associated with their condition. Multidisciplinary teams play a vital role in creating a safe and supportive environment in which children feel genuinely informed and involved in key aspects of their care.