Search

Objective: To evaluate the outcomes of Secondary Alveolar Bone Grafting (SABG) in patients treated either in daycare or with multiple day hospitalization (MDH) in relation to costs and complication rates., Design: Retrospective comparative cohort study., Setting: The data was collected from two settings: Postoperative daycare or MDH after oral cleft surgery in an Academic Medical Center in The Netherlands., Patients: Data of 137 patients with unilateral Cleft lip, alveolus, and palate (CLAP) treated between 2006-2018 were evaluated. Registered clinical variables: age, gender, cleft subtype, bone donor site, type of hospitalization, length of stay, additional surgery, complications, surgeons, and costs., Interventions: Closure of the alveolar cleft with/without closure of the anterior palate., Main Outcome Measures: Univariate analyses., Results: Of the 137 patients, 46.7% were treated in MDH, and 53.3% in daycare. Total costs for daycare were significantly lower ( P  < .001). All patients treated in daycare received mandibular symphysis bone, whereas in MDH, 46.9% received iliac crest bone instead. Bone donor site was associated with postoperative care type. Complication rates were slightly but not significantly higher in daycare (26%) vs. MDH (14.1%) ( P  = .09). Most were Grade I (minor) according to Clavien Dindo classification., Conclusions: Daycare after alveolar cleft surgery is about as safe as MDH, but significantly cheaper., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Introduction: Most studies on the treatment of cleft lip and palate (CLP) in low-income and middle-income countries have reported on the experience of urban centers or surgical mission trips to rural locations. There is a paucity of literature on the experience of local teams providing orofacial cleft surgery in rural Sub-Saharan Africa. This study reports the efficacy and cost-effectiveness of cleft surgery performed by an all-local team in rural Kenya., Methods: A retrospective chart review was performed on all patients who received CLP repair at Kapsowar Hospital between 2011 and 2023. Information regarding patient age, sex, cleft etiology, surgical management, and home location was retrieved. For the most recent year of study (2023), the authors performed a financial audit of all costs related to the performance of unilateral cleft lip surgery. Descriptive statistics were performed., Results: The authors identified 381 CLP surgeries performed on 311 patients (197 male, 63.3%). The most common etiology of the cleft was left unilateral (28.3%). The average age of primary lip repair decreased from 46.3 months in 2008 to 2009 to 20.2 months in 2022 to 2023 ( P <0.001). The average age of primary cleft palate repair decreased from 38.0 months in 2008 to 2009 to 25.3 months in 2022 to 2023 ( P <0.001). Patients traveled from 23 districts to receive treatment. Age of treatment was not different when distinguished by sex, county poverty level, or travel time from the hospital. The total costs associated with cleft lip repair was $201.6., Conclusions: Adequately staffed hospitals in rural locations can meaningfully address a regional CLP backlog more cost-effectively than surgical mission trips., Competing Interests: The authors report no conflicts of interest., (Copyright © 2024 by Mutaz B. Habal, MD.)

Abstract: Accessing treatment at ACPA (American Cleft Palate-Craniofacial Association)-approved centers is challenging for individuals in rural communities. This study aims to assess how pediatric plastic surgery outreach clinics impact access for patients with orofacial cleft and craniosynostosis in Mississippi. An isochrone map was used to determine mean travel times from Mississippi counties to the sole pediatric hospital and the only ACPA-approved team in the state. This analysis was done before and after the establishment of two outreach clinics to assess differences in travel times and cost of travel to specialized plastic surgery care. Two sample t-tests were used for analysis.The addition of outreach clinics in North and South Mississippi led to a significant reduction in mean travel times for patients with cleft and craniofacial diagnoses across the state's counties (1.81 hours vs 1.46 hours, P < 0.001). Noteworthy travel cost savings were observed after the introduction of outreach clinics when considering both the pandemic gas prices ($15.27 vs $9.80, P < 0.001) and post-pandemic prices ($36.52 vs $23.43, P < 0.001).The addition of outreach clinics in Mississippi has expanded access to specialized healthcare for patients with cleft and craniofacial differences resulting in reduced travel time and cost savings for these patients. Establishing specialty outreach clinics in other rural states across the United States may contribute significantly to reducing burden of care for patients with clefts and craniofacial differences. Future studies can further investigate whether the inclusion of outreach clinics improves follow-up rates and surgical outcomes for these patients., Competing Interests: Conflicts of interest and sources of funding: none declared., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Background: Health economic evaluation is a methodology to maximize health benefits and minimize opportunity costs and is of increasing importance in informing resource allocation decisions in healthcare., Objective: This systematic review aims to assess the availability and quality of economic evaluations of any orthodontic interventions and summarize the conclusions of these studies., Search Methods: A thorough search of the literature was carried out including terms related to orthodontic interventions and economic evaluation between January 2000 and February 2022. MEDLINE, EMBASE, SCOPUS, Web of Science, NHS Economic Evaluation Database, and Cochrane were searched. Grey literature was searched and further hand-searching was performed on the reference lists of relevant systematic reviews., Selection Criteria: Studies on cleft lip and palate surgery and sleep apnoea were excluded due to the multi-disciplinary nature of these conditions which might alter the applicability of the result to orthodontic interventions. Two independent reviewers selected studies for inclusion., Data Collection and Analysis: Data extraction was carried out through full text analysis of included studies by two authors. The quality of each study was assessed according to the Drummond 10-point Checklist and the National Institute for Health and Care Excellence (NICE) Quality Appraisal Checklist for Economic Evaluations. Characteristics and conclusions of included articles were descriptively summarized., Results: Sixteen articles met inclusion criteria. Most of the included articles were trial-based studies, with only one model-based study. Orthodontic interventions assessed included crossbite correction, functional appliance treatment and orthognathic surgery. Most studies were carried out in Europe and specifically in Sweden. The quality of included studies was generally low with 69% of studies reported as having serious limitations according to the NICE Checklist., Conclusion: This review highlighted a lack of economic evaluations for orthodontic interventions, and limitations of existing economic evaluations. Recommendations on future research are provided., Registration: The protocol for the systematic review was registered on the NIHR Database (www.crd.york.ac.uk/prospero, CRD42021220419)., (© The Author(s) 2022. Published by Oxford University Press on behalf of the European Orthodontic Society. All rights reserved. For permissions, please email: journals.permissions@oup.com.)

Background: The relationship between poverty and incidence of cleft lip and cleft palate remains unclear. The authors investigated the association between socioeconomic status and cleft lip with or without cleft palate and cleft palate only in the United States after controlling for demographic and environmental risk factors., Methods: The U.S. 2016 and 2017 natality data were utilized. Proxies for socioeconomic status included maternal education, use of the Special Supplemental Nutrition Program for Women, Infants, and Children, and payment source for delivery. Multiple logistic regression controlled for household demographics, prenatal care, maternal health, and infant characteristics., Results: Of 6,251,308 live births included, 2984 (0.05 percent) had cleft lip with or without cleft palate and 1180 (0.02 percent) had cleft palate only. Maternal education of bachelor's degree or higher was protective against, and delayed prenatal care associated with, cleft lip with or without cleft palate (adjusted ORs = 0.73 and 1.14 to 1.23, respectively; p < 0.02). Receiving assistance under the Special Supplemental Nutrition Program for Women, Infants, and Children was associated with cleft palate only (adjusted OR = 1.25; p = 0.003). Male sex, first-trimester tobacco smoking, and maternal gestational diabetes were also associated with cleft lip with or without cleft palate (adjusted ORs = 1.60, 1.01, and 1.19, respectively; p < 0.05). Female sex, prepregnancy tobacco smoking, and maternal infections during pregnancy were associated with cleft palate only (adjusted ORs = 0.74, 1.02, and 1.60, respectively; p < 0.05)., Conclusions: Increased incidence of orofacial clefts was associated with indicators of lower socioeconomic status, with different indicators associated with different cleft phenotypes. Notably, early prenatal care was protective against the development of cleft lip with or without cleft palate., Cliincal Question/level of Evidence: Risk, III., (Copyright © 2021 by the American Society of Plastic Surgeons.)

Summary: Since the introduction of the Bundled Payments for Care Improvement initiative, progress has been made in piloting bundled payment models to improve care coordination and curtail health care expenditures. In light of improvements in patient outcomes and the concomitant reduction in health care spending for certain high-volume and high-cost procedures, such as total joint arthroplasty and breast reconstruction, the authors discuss theoretical considerations for bundling payments for the care of patients with orofacial clefts. The reasons for and against adopting such a payment model to consolidate cleft care, as well as the challenges to implementation, are discussed. The authors purport that bundled payments can centralize components of cleft care and offer financial incentives to reduce costs and improve the value of care provided, but that risk adjustment based on the longitudinal nature of care, disease severity, etiologic heterogeneity, variations in outcomes reporting, and varying definitions of the episode of care remain significant barriers to implementation., Competing Interests: Disclosure:The authors have no financial disclosures or conflicts of interest to report., (Copyright © 2021 by the American Society of Plastic Surgeons.)

Background: Value-based health-care reform requires assessment of outcomes and costs of medical interventions. In cleft care, presurgical infant orthopedics is still being evaluated for clinical benefits and risks; however, the cost of these procedures has been largely ignored. This study uses robust accounting methods to quantify the cost of providing two types of presurgical infant orthopedics: Latham appliance treatment and nasoalveolar molding., Methods: This is a prospective study of patients with nonsyndromic cleft lip and/or palate who underwent treatment with presurgical infant orthopedics from 2017 to 2019 at two academic centers. Costs were measured using time-driven activity-based costing. Personnel costs, facility costs (operating room, clinic, and inpatient ward), and equipment costs were included. Travel expenses were incorporated as an estimate of direct costs borne by the family, but indirect costs (e.g., time off from work) were not considered., Results: Twenty-three patients were treated with Latham appliance treatment and 14 were treated with nasoalveolar molding. For Latham appliance treatment, average total cost was $7553 per patient ($1041 for personnel, $637 for equipment, $4871 for facility, and $1004 for travel over 6.5 visits). Unilateral and bilateral costs were $6891 and $8860, respectively. For nasoalveolar molding, average cost totaled $2541 ($364 for personnel, $151 for equipment, $300 for facility, and $1726 for travel over 13 visits); $2120 for unilateral and $3048 for bilateral treatment., Conclusions: The major difference in cost is attributable to operative placement of the Latham device. Travel cost for nasoalveolar molding is often higher because of frequent clinical encounters required. Future investigation should focus on whether outcomes achieved by presurgical infant orthopedics justify the $2100 to $8900 expenditure for these adjunctive procedures., (Copyright © 2021 by the American Society of Plastic Surgeons.)

Background: No national epidemiological investigations have been conducted on several aspects of cleft lip and palate surgery., Methods: The study was performed using the data of 5727 people who underwent cleft lip and palate surgery during the 6-year period from 2013 to 2018 archived by the National Health Information Database (NHID) of the Health Insurance Review and Assessment Service. Disease and operation codes were utilized for the analysis., Results: Most patients underwent surgery during the first 5 years of life. The number of operations per patient remained almost constant during the study period, but hospital costs per patient gradually increased. When hospital costs per patient were subdivided by institution type, they were found to have steadily increased on an annual basis at all types with the exception of hospital .Since 2016, average hospital stay per operation decreased slightly, but the number of outpatient visits tended to increase., Conclusions: Accessibility to tertiary hospitals has improved and patients increasingly choose to be treated at larger hospitals in metropolitan areas. Furthermore, these tendencies are expected to be maintained. Despite reductions in hospitalization stays, the cost of treatment, including operation costs, have increasing considerably. Changes in the insurance system are required to reduce financial burdens imposed on patients and on the National Health Insurance Service., Competing Interests: Declaration of Competing Interest None declared., (Copyright © 2020 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.)

Objective: To better understand the capacity for orthodontic care, service features, and finances among members of the American Cleft Palate-Craniofacial Association (ACPA)., Design: Cross-sectional survey., Setting: ACPA-approved multidisciplinary cleft teams., Participants: Cleft team coordinators., Interventions: Coordinators were asked to complete the survey working together with their orthodontists., Main Outcome Measure: Model for orthodontic care., Results: Coordinators from 82 out of 167 teams certified by ACPA completed the survey (response rate = 49.1%). Most orthodontists were private practice volunteers (48%) followed by university/hospital employed (22.8%). Care was often delivered in community private practice facilities (44.2%) or combination of university and private practice facilities (39.0%). Half of teams reported offering presurgical infant orthopedics (PSIO), with nasoalveolar molding being the most common. Cleft/craniofacial patients typically comprise 25% or less of the orthodontists' practices. The presence of a university/hospital-based orthodontist was associated with higher rates of offering PSIO ( P < .001) and an increased percentage dedication of their practice to cleft/craniofacial care ( P < .001)., Conclusion: Orthodontic models across ACPA-certified teams are highly varied. The employment of full-time craniofacial orthodontists is less common but is highly correlated with a practice with a high percentage of cleft care and the offering of advanced services such as PSIO. Future work should focus on how to effectively promote such roles for orthodontists to ensure high-level care for cleft/craniofacial patients requiring treatment from infancy through skeletal maturity.

Introduction: Cleft lip and palate is one of the more common congenital malformation and the most common craniofacial anomalies in children. The treatment is expensive and requires specialised care. Access to this care in middle and low income countries is compounded by socioeconomic status of patients and their relation and also the inadequacy of expertise in medical personnel and infrastructure. Objective: the study aimed to review the techniques of anaesthesia used in a low resource setting in terms of the techniques, outcome, and safety., Methods: This is a retrospective review of 79 cases done in a resource poor setting. Information regarding the patients, surgeries and modes of anaesthesia were retrieved from the case notes., Results: A total of 62 patients were operated with incomplete cleft accounting for 37 (59.7%), complete 23(37.1%), and 2 (3.2%) as bilateral. Forty-six (74.2%) of patients had their surgery done with ketamine anaesthesia without endotracheal intubation, 14 (22.6%) had regional anaesthesia and 2 patients (3.2%) had general anaesthesia with endotracheal intubation., Conclusion: This study demonstrates that with careful planning and expertise, cleft lip repair can be done safely in resource poor setting., Competing Interests: The author declare no competing interest.

Background: This project explores the costs of cleft lip and/or palate surgeries in Palestine and Sudan, two low- and middle-income countries (LMIC), in the Middle East. Our purpose is to examine the veracity of advertisements from international cleft organizations claiming that "250 US dollars (USD) covers the cost of a single cleft surgery." We hypothesize that the actual cost of surgery is greater than 250 USD., Methods: Costs for each cleft surgery were organized broadly into 5 categories: hospital charges, personnel (time and money spent for health professionals to travel to LMIC, including lost wages), tests, consumables, and reusables. Each item was priced at market value during the time of data collection. Following itemization of actual costs, we compared the costs per cleft surgery among four surgical practice models: (1) visiting international surgical teams, (2) visiting international surgeon working with local teams, (3) local teams working at government hospitals, and (4) local teams working at private hospitals., Results: Our results suggest that 250 USD is an underestimate of actual costs per cleft surgery in all models. The most expensive model in both Palestine and Sudan was the first model, visiting international teams performing all team functions; the cheapest surgical model in both countries was a local team working at government hospitals. The largest cost for any of these models is travel and lost wages for international team members. Eliminating this single cost (travel) decreases overall cost tremendously, but still does not approach the advertised cost of 250 USD., Conclusions: We conclude that 250 USD underestimates the actual costs to perform a single cleft surgery in Palestine and Sudan. If international cleft organizations are genuinely committed to creating sustainable international cleft programs, they should focus exclusively on training local professionals to perform surgery in hospitals of their own choosing.

Introduction: Cleft lip with or without cleft palate (CLP) is a congenital malformation that causes significant morbidity in low and middle income countries. Amref Health Africa has partnered with Smile Train to provide CLP surgeries since 2006., Methods: We analyzed anonymized data of 37,274 CLP patients from the Smile Train database operated on in eastern and central Africa between 2006 and 2014. Cases were analyzed by age, gender, country and surgery type. The impact of cleft surgery was determined by measuring averted Disability-Adjusted Life Years (DALYs) and delayed averted DALYs. We used mean Smile Train costs to calculate cost-effectiveness. We calculated economic benefit using the human capital approach and Value of Statistical Life (VSL) methods., Results: The median age at time of primary surgery was 5.4 years. A total of 207,879 DALYs were averted at a total estimated cost of US$13 million. Mean averted DALYs per patient were 5.6, and mean cost per averted DALY was $62.8. Total delayed burden of disease from late age at surgery was 36,352 DALYs. Surgical correction resulted in $292 million in economic gain using the human capital approach and $2.4 billion using VSL methods., Conclusion: Cleft surgery is a cost-effective intervention to reduce disability and increase economic productivity in eastern and central Africa. Dedicated programs that provide essential CLP surgery can produce substantial clinical and economic benefits.

Plastic surgeons around the globe are implementing projects that mix audit with medical research to ensure and improve the level of care offered to patients with cleft lip and palate. Drawing on recent literature on "audit culture" and the global growth of "performance indicators" as a form of governance, I demonstrate the conjugation of ethics and the production of numerical indicators in cleft treatment. By standardizing documentation, cleft treatment audit programs facilitate evidence-based medicine and a form of reflexive self-governance. However, the abstraction that accompanies standardization is amplified as corollary data practices travel. In emerging as the answer to improving treatment, these projects lock out the politico-economic factors that mediate medical care in resource poor settings. This danger is compounded by the tendency of numerical governance to replace political conversation with technocratic expertise., (© 2016 by the American Anthropological Association.)

The objective of this study was to investigate the prevalence of live births with orofacial clefts in Brazil from 2009 to 2013, according to Brazil's federative units and regions, and correlate it with the number of corrective surgery procedures for cleft lip and palate performed through the Brazilian National Health System in the same period. The data were collected from the National Live Birth System (SINASC in Portuguese) and the Hospital Information System (SIH-SUS in Portuguese). The results showed that the average prevalence of oral clefts in the period was 5.86 per 10,000 live births, with differences observed between the federative units and the regions. The correlation between the prevalence of orofacial clefts and the number of medical procedures associated with this anomaly was statistically significant (r=0.94; p <0.001). This result indicates that greater investments are being made in areas with a higher number of cases. The relationship between supply and demand for corrective surgeries suggests that only 18.91% of the live births with orofacial clefts in this period may have received this service under the Brazilian National Health System.

Objective: To provide national estimates of the number and cost of primary and revision cleft lip and palate surgeries in the U.S. and to determine patient and hospital characteristics associated with disproportionate use of revision surgery., Design: Retrospective cross-sectional study using data obtained from the 2003, 2006, and 2009 Kids' Inpatient Database., Setting: Inpatient., Patients: Children with CL, CP, or CLP undergoing inpatient cleft lip and/or palate surgery., Interventions: Inpatient cleft lip and/or palate surgery., Main Outcome Measures: Orofacial cleft surgery estimates, estimates of primary versus revision surgeries, and estimated inflation-adjusted hospitalization costs., Results: In 2009, there were a total of 2824 and 5431 hospitalizations for cleft lip and palate surgeries, respectively. Revision surgery accounted for 24.2% of cleft lip surgeries and 36.8% of cleft palate surgeries. Children with CLP (OR 1.87, 95% CI: 1.48-2.38), a syndromic diagnosis (OR 1.47, 95% CI: 1.16-1.87), or private insurance (OR 1.71, 95% CI: 1.41-2.09) were more likely to undergo cleft lip revision surgery. Similar risk factors were found for children undergoing cleft palate revision. Mean cost per hospitalization ranged from $7564 to $8393 in 2009, depending on surgery type, and did not change significantly (in 2009 U.S. $) between 2003 and 2009., Conclusions: Interventions to reduce revision surgery by improving results of primary surgery should be targeted in the population of identified high-risk (e.g., syndromic) patients. In addition, the association of health insurance status with revision surgery highlights the need to understand and address the impact of economic disparities on cleft care delivery.

Objective: This study sought to determine the timing of alveolar bone grafting (ABG) surgery among children with cleft lip with or without cleft palate (CL±P) with regard to race and insurance status., Design: A retrospective chart review of consecutive patients receiving ABG surgery was conducted. A multivariate regression model was constructed using predetermined clinical and demographic variables., Setting: A large, urban cleft referral center., Patients, Participants: Nonsyndromic patients with CL±P were eligible for study inclusion., Interventions: ABG surgery using autogenous bone harvested from the anterior iliac crest., Main Outcome Measure: The primary outcome of interest was age at ABG surgery., Results: A total of 233 patients underwent ABG surgery at 8.1 ± 2.3 years of age. African American and Hispanic patients received delayed ABG surgery compared with Caucasian patients by approximately 1 year (P < .05). There was no difference in ABG surgery timing by insurance status (P > .05)., Conclusions: The timing of ABG surgery varied by race but not by insurance status. Greater resources may be needed to ensure timely delivery of cleft care to African American and Hispanic children.

Background: Despite health system advances, residents of low- and middle-income countries continue to experience substantial barriers in accessing health care, particularly for specialized care such as plastic and reconstructive surgery., Methods: A cross-sectional household survey of patients seeking surgical care for cleft lip and/or cleft palate was completed at five Operation Smile International mission sites throughout Vietnam (Hanoi, Nghe An, Hue, Ho Chi Minh City, An Giang, and Bac Lieu) in November of 2014., Results: Four hundred fifty-three households were surveyed. Cost, mistrust of medical providers, and lack of supplies and trained physicians were cited as the most significant barriers to obtaining surgery from local hospitals. There was no significant difference in household income or hospital access between those who had and had not obtained cleft surgery in the past. Fewer households that had obtained cleft surgery in the past were enrolled in health insurance (p < 0.001). Of those households/patients who had surgery previously, 83 percent had their surgery performed by a charity. Forty-three percent of participants did not have access to any other surgical cleft care and 41 percent did not have any other access to nonsurgical cleft care., Conclusions: The authors highlight barriers specific to surgery in low- and middle-income countries that have not been previously addressed. Patients rely on charitable care outside the centralized health care system; as a result, surgical treatment of cleft lip and palate is delayed beyond the standard optimal window compared with more developed countries. Using these data, the authors developed a more evidence-based framework designed to understand health behaviors and perceptions regarding reconstructive surgical care.

Design: Retrospective cohort study., Setting: Major international tertiary care referral center for cleft palate repair., Patients: One hundred thirty-eight patients at the Children's Hospital of Philadelphia who had palate repair performed between 2010 and 2013, excluding syndromic patients, patients undergoing palate revision, and patients with incomplete payment information., Interventions: None., Main Outcome Measure: Fees and charges for procedures., Results: Surgeon payment was significantly higher for international adoptees (Δ = $2047.51 [$128.35 to $3966.66], P = .038). Medicaid-adjusted surgeon payments averaged $1006 more for adoptees ([-$394.19 to $2406.98], P = .158)., Conclusions: Hospital and anesthesiology costs for adoptee palate repair were highly variable but did not differ significantly from those for nonadoptees. Partly due to payer mix, surgeon reimbursement was somewhat higher for international adoptees. No difference in total payment was found.

Background: This study compares hospital-based care and associated charges among children with cleft lip, cleft palate, or both, and identifies subgroups generating the greatest cumulative hospital charges., Methods: The authors conducted a retrospective cohort study of cleft lip, cleft palate, or cleft lip and palate who underwent initial surgery from 2006 to 2008 in four U.S. states. Primary outcome was hospital-based care-emergency, outpatient, inpatient-within 4 years of surgery. Regression models compared outcomes and classification tree analysis identified patients at risk for being in the highest quartile of cumulative hospital charges., Results: The authors identified 4571 children with cleft lip (18.2 percent), cleft palate (39.2 percent), or cleft lip and palate (42.6 percent). Medical comorbidity was frequent across all groups, with feeding difficulty (cleft lip, 2.4 percent; cleft palate, 13.4 percent; cleft lip and palate, 6.0 percent; p < 0.001) and developmental delay (cleft lip, 1.8 percent; cleft palate, 9.4 percent; cleft lip and palate, 3.6 percent; p < 0.001) being most common. Within 30 days of surgery, those with cleft palate were most likely to return to the hospital (p < 0.001). Hospital-based care per 100 children within 4 years was lowest among the cleft lip group, yet comparable among those with cleft palate and cleft lip and palate (p < 0.001). Cumulative 4-year charges, however, were highest among the cleft palate cohort (cleft lip, $56,966; cleft palate, $106,090; cleft lip and palate, $91,263; p < 0.001). Comorbidity, diagnosis (cleft lip versus cleft palate with or without cleft lip), and age at initial surgery were the most important factors associated with the highest quartile of cumulative hospital charges., Conclusions: Cleft lip and palate children experience a high rate of hospital-based care early in life, with degree of medical comorbidity being a significant burden. Understanding this relationship and associated needs may help deliver more efficient, patient-centered care.

Background: This study attempts to quantify the burden of disease averted through the global surgical work of a large cleft charity, and estimate the economic impact of this effort over a 10-year period., Methods: Anonymized data of all primary cleft lip and cleft palate procedures in the Smile Train database were analyzed and disability-adjusted life years (DALYs) calculated using country-specific life expectancy tables, established disability weights, and estimated success of surgery and residual disability probabilities; multiple age weighting and discounting permutations were included. Averted DALYs were calculated and gross national income (GNI) per capita was then multiplied by averted DALYs to estimate economic gains., Results: 548,147 primary cleft procedures were performed in 83 countries between 2001 and 2011. 547,769 records contained complete data available for the study; 58 % were cleft lip and 42 % cleft palate. Averted DALYs ranged between 1.46 and 4.95 M. The mean economic impact ranged between USD 5510 and 50,634 per person. This corresponded to a global economic impact of between USD 3.0B and 27.7B USD, depending on the DALY and GNI values used. The estimated cost of providing these procedures based on an average reimbursement rate was USD 197M (0.7-6.6 % of the estimated impact)., Conclusions: The immense economic gain realized through procedures focused on a small proportion of the surgical burden of disease highlights the importance and cost-effectiveness of surgical treatment globally. This methodology can be applied to evaluate interventions for other conditions, and for evidence-based health care resource allocation.

Background: Patients with complete cleft lip and palate may benefit from cleft lip adhesion or nasoalveolar molding before formal cleft lip repair. The authors compared the relative costs to insurers of these two treatment modalities and the burden of care to families., Methods: A retrospective analysis was performed of cleft lip and palate patients treated with nasoalveolar molding or cleft lip adhesion at The Children's Hospital of Philadelphia between January of 2007 and June of 2012. Demographic, appointment, and surgical data were reviewed; surgical, inpatient hospital, and orthodontic charges and costs were obtained. Multivariate linear regression and two-sample, two-tailed independent t tests were performed to compare cost and appointment data between groups., Results: Forty-two cleft adhesion and 35 nasoalveolar molding patients met inclusion criteria. Mean costs for nasoalveolar molding were $3550.24 ± $667.27. Cleft adhesion costs, consisting of both hospital and surgical costs, were $9370.55 ± $1691.79. Analysis of log costs demonstrated a significant difference between the groups, with the mean total cost for nasoalveolar molding significantly lower than that for adhesion (p < 0.0001). Nasoalveolar molding patients had significantly more made, cancelled, no-show, and missed visits and a higher missed percentage than adhesion patients (p < 0.0001) for all except no-show appointments, (p = 0.0199), indicating a higher burden of care to families., Conclusions: Nasoalveolar molding may cost less before formal cleft lip repair treatment than cleft lip adhesion. Third-party payers who cover adhesion and not nasoalveolar molding may not be acting in their own best interest. Nasoalveolar molding places a higher burden of care on families, and this fact should be considered in planning treatment.

Cleft lip and palate (CLP) constitute a significant global disease burden. There are two general models that exist to deliver cleft care: surgical missions and comprehensive cleft centers (CCC). While surgical missions offer high quality surgical care to patients who would be unlikely to ever receive treatment, they may fail to provide sustainable solutions. The development of CCC is growing in popularity worldwide. CCC are permanent centers that offer a multidisciplinary team approach to the treatment of cleft lip and palate. Operation Smile has adopted the concept of specialized surgical care centers. These centers are shown to be safe, cost-effective, and provide sustainable solutions for cleft care. The authors discuss some of the benefits and drawbacks of the classic mission-based model and highlight why there may be a paradigm shift towards CCC.

Cleft lip and palate (CLP) care is the longest sustained global effort in humanitarian surgical care. However, the relative cost-effectiveness of surgical delivery approaches remains largely unknown. We assessed the cost-effectiveness of two strategies of CLP surgical care delivery in low resource settings: medical mission and comprehensive care center. We evaluated the medical records and costs for 17 India-based medical missions and a Comprehensive Cleft Care Center in Guwahati, India, from Operation Smile, a humanitarian nongovernmental organization. Age, sex, diagnosis, and procedures were extracted and cost/Disability-Adjusted Life Year (DALY) averted was calculated using a provider's perspective. The disability weights for CLP from the Global Burden of Disease (GBD) 2010 update were used as the reference case. Sensitivity analysis was performed using various disability weights, age-weighting, discounting, and cost perspective. The medical missions treated 3503 patients for first-time cleft procedures and averted 6.00 DALYs per intervention with a cost-effectiveness of $247.42/DALY. The care center cohort included 2778 patients with first-time operations for CLP and averted a mean of 5.96 DALYs per intervention with a cost-effectiveness of $189.81/DALY. The Incremental Cost-Effectiveness Ratio (ICER) of choosing medical mission over care center is $462.55. The care center provides cleft care with a higher cost-effectiveness, although both models are highly cost-effective in India, in accordance with WHO guidelines. Compared to other global health interventions, cleft care is very cost-effective and investment in cleft surgery might be realistic and achievable in similar resource-constrained environments.

Objective: The objective of this investigation was to describe the characteristics of the current cleft treatment situation in a hospital-based cleft center in Shanghai and provide references to clinical diagnosis, treatment, and nursing., Methods: A total of 1584 patients from the Center for Cleft Lip and Palate, Department of Oral and Cranio-Maxillofacial Science, Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine during June 2006 to February 2008 were analyzed retrospectively. Data regarding sex, native place, type of cleft, cleft side, accompanied malformations, family history, and age at surgery were analyzed in detail. Length of stay after surgery, the primary operation fee, and some other hospitalized information were also investigated., Results: From 1584 patients(1590 operations; 6 patients had 6 operations), there were 939 male and 645 female patients (M:F = 1.46:1). The number of Shanghai local patients is 249 (15.72%), whereas the other 1335 patients were from out of Shanghai. Approximately 15% of the patients had certain family history. The age at operating varied from 2 months to 36 years; the mean value was 6.95 years. The postoperation hospital stay varied from 1 day to 15 days; the mean value was 5.54 days. The primary operation fee was 235 to 673 USD depending on the different surgical procedures. The number of cleft types or other malformation, which had not been treated in the statistics varied from zero to 3; the mean value was 0.4375. The cleft morphology was classified as follows: cleft lip, 591 cases (37.31%); cleft palate, 651 cases (41.10%); alveolar cleft, 144 cases (9.10%); facial traverse cleft, 27 cases (1.70%); velopharyngeal insufficiency, 105 cases (6.63%); velocardiofacial syndrome, 57 cases (3.60%); and Pierre Robin sequence, 15 cases (0.95%). In all the classifications, left was more than right (L:R = 2.10:1)., Conclusion: As a busy hospital-based cleft care center, most of the patients are from out of Shanghai. The current multidisciplinary protocol for cleft care in such specialist cleft center is cost-effective. There may be a tendency that the patients with cleft palate are more than the patients with cleft lips in recent years, which may due to the popularization of prenatal examination in China.

Background: Little is known about population-based maternal, child, and system characteristics associated with high hospital resource use for children with orofacial clefts (OFC) in the US., Methods: This was a statewide, population-based, retrospective observational study of children with OFC born between 1998 and 2006, identified by the Florida Birth Defects Registry whose records were linked with longitudinal hospital discharge records. We stratified the descriptive results by cleft type [cleft lip with cleft palate, cleft lip, and cleft palate] and by isolated versus nonisolated OFC (accompanied by other coded major birth defects). We used Poisson regression to analyze associations between selected characteristics and high hospital resource use (≥90th percentile of estimated hospitalized days and inpatient costs) for birth, postbirth, and total hospitalizations initiated before age 2 years., Results: Our analysis included 2,129 children with OFC. Infants who were born low birth weight (<2500 grams) were significantly more likely to have high birth hospitalization costs for CLP (adjusted prevalence ratio: 1.6 [95% confidence interval: 1.0-2.7]), CL (adjusted prevalence ratio: 3.0 [95% confidence interval: 1.1-8.1]), and CP (adjusted prevalence ratio: 2.3 [95% confidence interval: 1.3-4.0]). Presence of multiple birth defects was significantly associated with a three- to eleven-fold and a three- to nine-fold increase in the prevalence of high costs and number of hospitalized days, respectively; at birth, postbirth before age 2 years and overall hospitalizations., Conclusion: Children with cleft palate had the greatest hospital resources use. Additionally, the presence of multiple birth defects contributed to greater inpatient days and costs for children with OFC., (© 2015 Wiley Periodicals, Inc.)

Background: To determine the views of Clinical Directors working in the United Kingdom (U.K.) Cleft Service with regard to centralisation, commissioning and impact on cleft service provision., Methods: In-depth qualitative interviews were conducted with 11 Clinical Directors representing regional cleft services. Interviews were transcribed verbatim, a coding frame was developed by two researchers and transcripts were coded using a thematic, 'interpretive' approach., Results: Clinical Directors perceived the commissioning of cleft services in the U.K. to be dependent upon historical agreements and individual negotiation despite service centralisation. Furthermore, Clinical Directors perceived unfairness in the commissioning and funding of cleft services and reported inconsistencies in funding models and service costs that have implications for delivering an equitable cleft service with an effective Multidisciplinary Team., Conclusions: National Health Service (NHS) commissioning bodies can learn lessons from the centralisation of cleft care. Clinical Directors' accounts of their relationships with specialist commissioning bodies and their perspectives of funding cleft services may serve to increase parity and improve the commissioning of cleft services in the U.K.

Background: The lifetime cost of a child with an orofacial cleft is estimated at $101,000, which amounts to $697 million total for those born each year with orofacial clefts. There has been a trend toward outpatient procedures for cleft lip repair (CLR) and alveolar bone grafting (ABG), and studies have shown no disparities in safety or outcome between inpatient and ambulatory treatment. The financial implications of outpatient versus inpatient procedures have not been compared., Methods: Financial data were collected for outpatient (n = 33) and inpatient (n = 2) CLR, as well as outpatient (n = 7) and inpatient (n = 5) ABG during a 5-year period at our institution. We examined hospital charges and reimbursement for these procedures by private insurance plans and Medicaid Managed Care (MMC) plans., Results: The average total reimbursements for inpatient and outpatient CLR were similar at $6848 and $5557, respectively. Average facility reimbursement for CLR was greater for inpatient ($5344) than outpatient ($4291) procedures. Average professional reimbursement was similar between inpatient ($1504) and outpatient ($1266) CLR.For ABG, the average total inpatient reimbursement was $14,573, whereas outpatient was $8877. Average facility reimbursements were greater for inpatient ($12,398) than outpatient ($7183) ABG. Average professional reimbursement was similar between inpatient ($2175) and outpatient ($1693) ABG, with 35% and 31% of charges reimbursed, respectively.A substantial difference existed between reimbursements based on insurance types for both outpatient CLR and outpatient ABG. On average for CLR, commercial payers reimbursed 52% ($7344) of overall charges, whereas Medicaid and MMC reimbursed 9% ($1447). For ABG, commercial payers reimbursed an average of 78% ($11,950) of overall charges, whereas Medicaid and MMC reimbursed 10% ($1192)., Conclusions: Fewer patients' insurance companies are reimbursing for inpatient stays; in many cases, even patients who remain hospitalized up to 48 hours are treated as "day surgery" from a reimbursement perspective. For outpatient surgery, a greater percentage of CLR and ABG charges were successfully recouped compared to inpatient surgery. Awareness of higher payment for inpatient surgery and potential savings through use of the outpatient setting is crucial for hospitals and the US health care system as a whole.

Background: Little is known about the barriers faced by families of children with birth defects in obtaining healthcare. We examined reported perceived barriers to care and satisfaction with care among mothers of children with orofacial clefts., Methods: In 2006, a validated barriers to care mail/phone survey was administered in North Carolina to all resident mothers of children with orofacial clefts born between 2001 and 2004. Potential participants were identified using the North Carolina Birth Defects Monitoring Program, an active, state-wide, population-based birth defects registry. Five barriers to care subscales were examined: pragmatics, skills, marginalization, expectations, and knowledge/beliefs. Descriptive and bivariate analyses were conducted using chi-square and Fisher's exact tests. Results were stratified by cleft type and presence of other birth defects., Results: Of 475 eligible participants, 51.6% (n = 245) responded. The six most commonly reported perceived barriers to care were all part of the pragmatics subscale: having to take time off work (45.3%); long waits in the waiting rooms (37.6%); taking care of household responsibilities (29.7%); meeting other family members' needs (29.5%); waiting too many days for appointments (27.0%); and cost (25.0%). Most respondents (72.3%, 175/242) felt "very satisfied" with their child's cleft care., Conclusion: Although most participants reported being satisfied with their child's care, many perceived barriers to care were identified. Due to the limited understanding and paucity of research on barriers to care for children with birth defects, including orofacial clefts, additional research on barriers to care and factors associated with them are needed., (© 2014 Wiley Periodicals, Inc.)

© 2014 The Authors Birth Defects Research Part A: Clinical and Molecular Teratology Published by Wiley Periodicals, Inc., (© 2014 Wiley Periodicals, Inc.)

Background: According to the 2014 Surgeon General's Report, smoking in early pregnancy can cause orofacial clefts. We sought to examine the implications of this causal link for the potential prevention of orofacial clefts in the United States., Methods: Using published data on the strength of the association between orofacial clefts and smoking in early pregnancy and the prevalence of smoking at the start of pregnancy, we estimated the attributable fraction for smoking as a cause of orofacial clefts. We then used the prevalence of orofacial clefts in the United States to estimate the number of orofacial clefts that could be prevented in the United States each year by eliminating exposure to smoking during early pregnancy. We also estimated the financial impact of preventing orofacial clefts caused by maternal smoking based on a published estimate of attributable healthcare costs through age 10 for orofacial clefts., Results: The estimated attributable fraction of orofacial clefts caused by smoking in early pregnancy was 6.1% (95% uncertainty interval 4.4%, 7.7%). Complete elimination of smoking in early pregnancy could prevent orofacial clefts in approximately 430 infants per year in the United States, and could save an estimated $40.4 million in discounted healthcare costs through age 10 for each birth cohort., Conclusion: Understanding the magnitude of the preventable burden of orofacial clefts related to maternal smoking could help focus smoking cessation efforts on women who might become pregnant., (© 2014 Wiley Periodicals, Inc.)

Background: The study ofcost management with regard to cleft lip patients under the Universal Health Coverage Program at Tawanchai Cleft Center Srinagarind Hospital, Faculty of Medicine, Khon Kaen University, was conducted in order to provide fundamental information for the administrative team on how best to administrate and manage the organization., Objective: To study the cost management of cleft lip patients under the Universal Health Coverage Program. To compare individual patient management costs and costs from the National Health Security Office (NHSO), and to offer proper guidelines for cost management to the organization., Material and Method: The study was performed retrospectively. The data were collected by reviewing secondary sources of information from patients with cleft lips who consistently underwent treatment at Tawanchai Cleft Center. As for the provider prospects, the cost management did not address the other expenses. The study analyzed the comparison between cost management and income from the Universal Health Coverage Program, which it receivedfrom the National Health Security Office (NHSO). The study was conducted over 2 years (October 1, 2010 to 30 September, 2013). There were 21patients in this study. Microsoft excel was the instrument used to calculate the cost ofmanagement., Results: (1) Total costs were lower than real payments because this cost did not take into account the total cost of the operation room, patient room, common bed, and costs of the medical equipment. Moreover the information regarding the building's price and the facility were not clear enough. The database of materials and equipment was also not yet complete. (2) The average cost ofpatient management was 12,025.14 Bahtperperson, but the compensation receivedfrom the National Health Security Office (NHSO) averaged 10,527.63 Bahtperperson, which was 87.55% ofthe total cost management. The department with the largest expenses was Anesthesia (36.42%)., Conclusion: This study indicated that the cost of patient management is lower than usual due to the lack of clear cost information. The cost of medical care, which was received from the National Health Security Office (NHSO), was only 87.55%; the department with the highest costs was Anesthesia (36.42%).

Background: The purpose of this study was to identify variables that may preoperatively predict successful outcomes in ambulatory cleft lip repair and to quantify the potential cost savings., Methods: A retrospective chart review of all patients who underwent cleft lip repair at a tertiary cleft care center from January of 2010 to May of 2013 was performed. Because inpatient stay is the authors' current practice, overnight desaturations, poor oral intake, and failure to stop intravenous narcotics during the first day were considered indicators of a poor candidate. Charge data were also collected., Results: Twenty-nine of 111 patients were deemed likely to fail ambulatory surgery. American Society of Anesthesiologists score greater than 2 (p=0.019), low birth weight (p=0.022), bilateral cleft lip-cleft palate (p=0.003), central nervous system or neurologic diagnosis (p=0.046), syndromic and/or multiple congenital abnormalities (p=0.024), prior emergency room visits (p=0.021), failure to thrive (p=0.046), and age older than 7 months (p=0.028) were associated with poor candidacy. A diagnosis of cleft lip was protective (p=0.015). Fifty-five patients had no risk factors for a poor ambulatory outcome and did not stay more than 1 day. The average savings per patient who met the authors' criteria was $4261., Conclusions: The authors found that 49.5 percent of children may be safely eligible for ambulatory cleft lip repair. Patients with risk factors may be best served by a short hospital admission. This would lead to a national savings of $8,765,183 per year.

"Value" has become a buzzword in current health-care discussions. This study demonstrates a provider-led strategy to measuring costs, an understudied component of the value equation, for a complex diagnosis for the purposes of improvement. A retrospective, microcosting methodology was used to measure costs for all hospital and physician services and costs to the patient over 18 months of multidisciplinary care for patients with cleft lip and palate. Short-term outcomes were also recorded. Overall costs to all parts of the system ranged from $35,826 to $56,611 for different subtypes, and insight was gained into major cost drivers and variations in care that will drive internal improvement efforts. It is critical that providers learn to work together and become familiar with their own costs in conjunction with outcomes as insurers increase pressure to reduce payments or accept alternative payments so that well-informed decisions can be made.

Objectives: There are over 96 million people in the Philippines. Close to 77 thousand persons in this country have orofacial clefting. We estimate nearly 64 thousand are unrepaired. Unemployment and underemployment because of the communication disorders associated with unrepaired clefts will affect family income and hence tax revenues. The purpose of this study is to understand the financial impact of unrepaired cleft lip and/or palate on families and identify how that would translate to the Philippine government in tax revenues., Methods: The incidence of orofacial cleft in the Philippines was estimated to be at least 1 in 750 people, with only 16% anticipated to be repaired under current conditions. Assuming a 21% unemployment rate in subjects with untreated clefts, and a tax rate of 6-12.4%, projected lost personal income and federal tax revenue was calculated., Results: In 2012 alone the financial impact on the families may be as much as $US 73-88 million in lost revenue from unemployment and underemployment. This would cost the government between $8.0 and $9.8 million dollars in lost tax revenue. Over a 20 year period at least $US 1.7 billion dollars in family income would be affected costing the government at least $US 194 million in taxes., Conclusion: By appropriately caring for the cleft population tax revenues should increase substantially. The development of the infrastructure for surgical care of this problem would be costly but could be more than offset by revenues. Inattention to surgically correctable causes of communication disorders is not affordable., (Copyright © 2013 Elsevier Ireland Ltd. All rights reserved.)

Background: Information on travel distance and time to care for children with birth defects is lacking. We examined factors associated with travel distance and time to cleft care among children with orofacial clefts., Methods: In 2006, a mail/phone survey was administered in English and Spanish to all resident mothers of children with orofacial clefts born 2001 to 2004 and identified by the North Carolina birth defects registry. We analyzed one-way travel distance and time and the extent to which taking a child to care was a problem. We used multivariable logistic regression to examine the association between selected sociodemographic factors and travel distance (≤60 miles and >60 miles) and time (≤60 min and >60 min) to cleft care., Results: Of 475 eligible participants, 51.6% (n = 245) responded. Of the respondents, 97.1% (n = 238) were the child's biological mother. Approximately 83% (n = 204) of respondents were non-Hispanic White; 33.3% (n = 81) were college educated; and 50.0% (n = 115) had private health insurance. One-way mean and median travel distances were 80 and 50 miles, respectively (range, 0-1058 miles). One-way mean and median travel times were 92 and 60 min, respectively (range, 5 min to 8 hr). After adjusting for selected sociodemographics, travel distance varied significantly by maternal education, child's age, and cleft type. Travel time varied significantly by child's age. Approximately 67% (n = 162) reported taking their child to receive care was not a problem., Conclusion: Approximately 48% of respondents traveled > 1 hr to receive cleft care. Increasing access to care may be important for improving health outcomes among this population., (Copyright © 2013 Wiley Periodicals, Inc.)

Background: The IOFS (Impact On Family Scale) questionnaire is a useful instrument to assess the impact of chronic childhood conditions on general family quality of life. As this instrument was not validated in French, we proposed to translate, adapt and validate the IOFS questionnaire for clinical and research use in French-speaking populations., Findings: The sample studied comprised French-speaking parents with a child presenting a cleft lip or cleft lip and palate, aged 6 to 12 years and treated in the University Hospital of Strasbourg, France. The 15-item version of the IOFS was translated into French and then sent to the parents by post. The structure of the measure was studied using Exploratory Factor Analysis (EFA), internal consistency was assessed using Cronbach's alpha coefficient and test-retest reliability was studied by calculating the Intraclass Correlation Coefficient (ICC)., Conclusions: The French version of the IOFS questionnaire exhibited very good psychometric properties. For practitioners, this instrument will facilitate the assessment of the impact of chronic childhood conditions on quality of life among French-speaking families.

Background: The purpose of this study was to determine the financial impact of cleft care on the hospital and to evaluate trends in reimbursement over the past 6 years., Methods: Medical and accounting records of 327 consecutive infants undergoing cleft repair between 2005 and 2011 were reviewed. Charges, payments, and direct cost data were analyzed to illustrate hospital revenue and margins., Results: Hospital payments for all inpatient services (cleft and noncleft) during the first 24 months of life were $9,483,168. Mean hospital payment varied from $5525 (Medicaid) to $10,274 (managed care) for a cleft lip repair (p < 0.0001) and from $6573 (Medicaid) to $12,933 (managed care) for a cleft palate repair (p < 0.0001). Hospital charges for a definitive lip or palate repair to both Medicaid and managed care more than doubled between 2005 and 2011 (p < 0.0001). Overall, mean hospital margins were $3904 and $3520, respectively, for a cleft lip repair and cleft palate repair. Medicaid physician payments for cleft lip and palate were, respectively, $588 and $646. From 2005 to 2006, 2007 to 2008, and 2009 to 2010, 41 percent, 43 percent, and 63 percent of patients, respectively, were enrolled in Medicaid., Conclusions: Cleft care generates substantial revenue for the hospital. For their mutual benefit, hospitals should join with their cleft teams to provide administrative support. Bolstered reimbursement figures, based on the overall value of cleft care to the hospital system, would better attract and retain skilled clinicians dedicated to cleft care. This may become particularly important if Medicaid enrollment continues to increase.

Background: Although surgery provided by international volunteers is increasingly common in the developing world, there have been few assessments of the cost-effectiveness of these activities. In this context, this study covered 15 years of experience of one international nongovernmental organization, Smile for Children, in providing cleft lip (CL) and cleft palate (CP) surgical services in Vietnam., Methods: We analyzed the cost-effectiveness of the program and its contributions to building local capacity. To assess the cost-effectiveness of CL/CP surgery performed during Smile for Children's missions in Vietnam, we analyzed the data from four annual missions, from 2007 to 2010. According to the 2003 World Health Organization Guide to Cost-Effectiveness Analysis, we calculated cost per disability-adjusted life years (DALYs) averted with and without age weighting. For the data from the 2010 mission, we repeated the same calculation but with and without considering opportunity cost for labor., Results: The discounted cost per DALY averted averaged $68, ranging from $52 to $79 depending on the year of the mission. The average discounted cost per DALY averted with age weighting was $56 (range $43-$65). For the calculation that takes into account the volunteers' possible income loss as the labor cost of the mission in 2010, the cost per DALY averted without age weighting increased by 28%, from $76 to $97; and the cost per DALY averted with age weighting increased by 27%, from $63 to $80. Under all of these varying assumptions, the CL/CP program operated by Smile for Children is a cost-effective intervention using international criteria for cost-effectiveness., Conclusions: The contribution of the international volunteer surgical team to building in-country capacity is notable. It was achieved primarily through training Vietnamese surgeons during the mission trips and through sending these surgeons to Korea for training. Other staff, including anesthesiologists, were also trained; and equipment and supplies were provided.

Background: Most cleft surgeons require children to wear postoperative arm restraints although the literature suggests that there is no difference in early complications. The aim of this study was to determine if the use of postoperative arm restraints was effective in preventing early postoperative complications., Methods: We reviewed 120 consecutive primary cleft surgeries in which 1 surgeon used arm restraints in all patients and the other surgeon did not. Demographic information was obtained and complications were reviewed. We compared infection, fistula, and dehiscence between the 2 groups., Results: In 120 primary cleft surgeries, there was no difference in early complications in patients who were required to wear arm restraints versus those who were not (P<0.05)., Discussion: Arm restraints are unnecessary and may cause distress in both patients and their families. Eliminating arm restraints from cleft care would save the health care system an estimated $234,000 annually.

Purpose: The objective of this study is to provide nationally representative estimates of cleft palate correction and revision procedures performed in hospitalized patients, as well as to examine patient- and hospital-level factors associated with hospitalization charges., Materials and Methods: The Nationwide Inpatient Sample for the year 2007 was used. All hospitalizations that had a cleft palate correction or revision of cleft palate repair were selected. Estimates of concomitant procedures performed during the index hospitalization were obtained. The roles of different patient- and hospital-level variables on hospitalization charges were examined by use of multivariable linear regression analysis., Results: A total of 5,969 repairs and/or revisions of cleft palate procedures were performed in hospitals in the entire United States. The mean age per hospitalization was 3.2 years. Whites accounted for 51.3% of procedures, whereas blacks, Hispanics, Asian/Pacific Islanders, Native Americans, and other races accounted for 4.9%, 26.4%, 9.2%, 3.2%, and 5%, respectively. The mean charge per each hospitalization was $19,227, and the total hospitalization charge for the entire United States was $112.96 million. Patients aged less than 1 year (P = .02) and those aged between 8 and 12 years (P = .03) had significantly lower charges compared with those aged 18 years or older. Use of bone morphogenetic protein was associated with higher hospital charges (P = .0006). Compared with the uninsured, those covered by Medicaid (P = .04), private insurance plans (P = .02), and other insurance plans (P = .0005) were associated with higher charges., Conclusion: This study identified an association between hospital charges and insurance payer, race, treatments performed, and age. Our results provide insights into nationally representative estimates on management of cleft palate corrections and revisions., (Copyright © 2012 American Association of Oral and Maxillofacial Surgeons. Published by Elsevier Inc. All rights reserved.)

Introduction: Previous reports on free surgeries have tended to focus on the numbers of patients treated. Little has been documented on the impact on training hence this report. Such grants should positively impact training, patient outcome and volume of patients., Methods: A retrospective review of all cleft surgeries carried out two years before and after the commencement of free surgical treatment at the hospital (from November 2004 to October 2008) was undertaken. The demographics were studied for both primary and revisional surgeries. The primary surgeons were noted. Excluded from the study are procedures to remove sutures. Simple arithmetic analysis was used., Results: Seventy-three cleft procedures had been carried out before, while 168 procedures were carried out after October 2006. Eight patients aged over 15 years had lip repairs before while 42 patients over 15 years had lip repair after commencement. Fourteen procedures were carried out by three trainee surgeons before; while 29 procedures were carried out by nine trainees after October 2006. In 2005 an average of four procedures a month were undertaken; this increased by 2008 to eight., Conclusion: Free treatment positively impacts patient turnout and training, and are encouraged to improve the quality of healthcare in the country.

Background: The development of surgery in low- and middle-income countries has been limited by a belief that it is too expensive to be sustainable. However, subspecialist surgical care can provide substantial clinical and economic benefits in low-resource settings. The goal of this study is to describe the clinical and economic impact of recurrent short-term plastic surgical trips in low- and middle-income countries., Methods: The authors conducted a retrospective review of clinic and operative logbooks from Hands Across the World's surgical experience in Ecuador. The authors calculated the disability-adjusted life-years averted to estimate the clinical impact of cleft repair and then calculated the economic impact of surgical intervention for cleft disease., Results: One thousand one hundred forty-two reconstructive surgical cases were performed over 15 years. Surgery was most commonly performed for scar contractures [449 cases (39.3 percent)], of which burn scars comprised a substantial amount [215 cases (18.8 percent)]. There were 40 postoperative complications within 7 days of operation (3.5 percent), and partial wound dehiscence was the most common complication [16 of 40 (40 percent)]. Cleft disorders constituted 277 cases (24.3 percent), and 102 cases were primary cleft lip and/or palate cases. Between 396 and 1042 total disability-adjusted life-years were averted through surgery for these 102 cases of primary cleft repair. This translates to an economic benefit between $4.7 million (human capital approach) and $27.5 million (value of a statistical life approach)., Conclusions: Plastic surgical disease is a significant source of morbidity for patients in resource-limited regions. Dedicated programs that provide essential reconstructive surgery can produce substantial clinical and economic benefits to host countries.

Vietnam has had a long history of international mission teams that volunteer needed surgical care to underserved populations for various medical problems. As senior medical students, we joined a non-profit organization's surgical mission trip led by a community practice surgeon and staffed by 32 health care professionals to provide cleft lip and palate reconstructions for 75 patients at a local hospital in Nha Trang, Vietnam. As a surgical mission team in a resource-poor country, we intended to fill gaps and unmet areas of need by offering care that patients would otherwise not receive. But in doing so, we encountered other gaps in health care for which we did not have adequate preparation or solutions: insufficient primary care, lack of understanding of others' cultural contexts, absence of knowledge of patients' socioeconomic contexts, and problems in other countries' health care systems. Although the purpose of our mission was to provide a specific service, we felt it is important to examine the service in the context of these broader issues. We considered these concerns from two different perspectives: what a medical mission gives and what it does not. In this article, we present several issues that our medical mission confronted and how they were both addressed and overlooked.

Background: Acceptance of basic surgical care as an essential element of any properly functioning health system is growing. To justify investment in surgical interventions, donors require estimates of the economic benefit of treating surgical disease. The present study aimed to establish a methodology for valuing the potential economic benefit of surgical intervention using cleft lip and palate (CLP) in sub-Saharan Africa (SSA) as a model., Methods: Economic modeling of cleft lip and cleft palate (CLP) in SSA was performed with retrospective demographic and economic data from 2008. The total number of Disability-Adjusted Life-Years (DALYs) secondary to CLP in 2008 was calculated from accepted clefting incidence rates and disability weights taken from the Global Burden of Disease Project. DALYs were then converted to monetary terms ($US), using both a human capital approach and Value of a Statistical Life (VSL) approach., Results: With the human capital approach, the potential economic benefit if all incident cases of CLP in SSA in 2008 were repaired at birth ranged from $252 million to $441 million. With VSL, the potential economic benefit of the same CLP repair would range from $5.4 billion to $9.7 billion., Conclusions: Cleft lip and cleft palate can have a substantial impact on the economic health of countries in the developing world. Further studies should be directed at quantifying the economic benefit of surgical interventions and quantifying their costs with an economically sound approach.

Background: The concept of value-based health care underlies many new improvement initiatives in U.S. health care. To determine value, accurate measures of both outcomes and costs are essential, which may then be compared for the same provider or system over time or between providers, to foster improvement. Although outcomes measurement has received a great deal of attention since the quality movement began in the United States, costing methodologies are lacking., Methods: A basic microcosting methodology was used to obtain direct medical costs, including physician compensation, for individuals with isolated, unilateral cleft lip deformity receiving their full course of care from one surgeon. The authors analyzed costs associated with the timeline of care during the first year of life., Results: The median cost for the first year of life was $13,013 (range, $10,426 to $16,115; n = 12). Ninety-one percent of costs were associated with the cleft lip repair, which occurred at a median age of 3.7 months. The majority of these costs stemmed from time in the operating room and the inpatient stay, which accounted for 68 and 19 percent of first-year costs, respectively., Conclusions: Using a microcosting approach, the authors identified specific cost drivers and outlined a distinct timeline of care for patients with isolated cleft lip in the first year of life. This approach may serve as a template for the cost side of the value equation, for which accurate methodologies are needed. When combined with key outcomes measures, it will be possible to measure and improve value at the patient and provider levels.