Not All Clefts Are Created Equal: Patterns of Hospital Based Care Utilization Among Children with Cleft Lip and Palate within 4 Years of First Surgery

Purpose: Children with cleft lip (CL), cleft palate (CP) or both (CLP) seem to have varying healthcare needs beyond their initial surgery.  We sought to compare hospital based care and associated charges among this cohort and identify subgroups of children who generate the greatest cumulative hospital charges.

Methods: Using healthcare data from 4 U.S. states, we conducted a retrospective cohort study of children with CL, CP, or CLP who underwent their first surgery from 2006-2008. The primary outcome was hospital based care (ED visits and inpatient encounters) within 4 years of surgery. Regression models were used to compare outcomes across groups while classification tree analysis identified patients at-risk for being in the highest quartile of cumulative hospital charges.

Results: We identified 4,571 children with CL (18.2%), CP (39.2%), or CLP (42.6%). Children with CL were youngest at initial surgery (CL=74 days vs. CP=161 days vs. CLP=108 days, p <0.001). Medical comorbidity was frequent across all groups with feeding difficulty (CL=2.4% vs. 13.4% vs. 6.0%, p <0.001) and developmental delay (CL=1.8% vs. 9.4% vs. 3.6%, p <0.001) most common. Within 30 days of surgery, those with CP were most likely to return to the hospital (CL=3.5% [reference] vs. CP=10.6% [AOR=2.83, 1.85-4.30] vs. CLP=8.6% [AOR=2.48, 1.63-3.77], p <0.001). This was most often for feeding difficulty or upper respiratory infections. Hospital based care per 100 children within 4 years was lowest among the CL group, yet comparable among those with CP and CLP (CL=175.5 [reference] vs. CP=325.3[IRR=1.52, 1.30-1.78] vs. CLP=321.9 [IRR=1.66, 1.43-1.94], p <0.001; Figure 1). Cumulative 4-year charges, however, was highest among the CP group (CL=$56,966 vs. CP=$106.090 vs. CLP=$91,263, p <0.001). Associated comorbidity, specific diagnosis (CL vs. CP+/-CL), and age at first surgery were the most important factors associated with highest quartile of cumulative hospital charges (Figure 2).

Conclusions: Children with cleft lip and palate experience a high rate of hospital based care in their early life with degree of MCM being a significant burden. Better understanding this relationship and associated needs may help deliver more efficient, patient-centered care.

Figure 1: Comparison of healthcare use across groups.
Figure 2: Regression-tree analysis exploring factors associated with high healthcare utilization where colored blocks show percentage of children in the top quartile of cumulative hospital charges.

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