High Volume Centers are Associated with Improved Short-Term Outcomes Following Cleft Palate Repair

Purpose: High volume centers (HVC) are commonly associated with increased resources and improved patient outcomes. Little analysis of hospital volume in the context of cleft palate repair has not been reported. The purpose of our study was to compare patient demographics and post-operative outcomes of cleft palate repair in high and non-high volume centers.

Methods: Primary, revision, older (>15months), and total cleft palate procedures were identified in the the Kids’ Inpatient Database from 2003-2009. HVC were defined by 90^th percentile of case volume or higher (>48 cases/year). Data were combed for demographics, perioperatives, complications, and hospital data. Charleston Comorbidity Index was calculated and compared. Bivariate and multivariate analyses analyses were conducted between high volume and non-high volume centers (NHVC) across all cohorts of cleft repair.

 

Results: 4563 (61.7%) total cleft palate surgeries were performed in HVC and 3388 (38.3%) were performed in NHVC. NHVC treated a higher percentage of Medicaid patients, while HVC treated more patients with private insurance (p=0.005). Older and total patients treated at HVC were more often from higher income quartiles (p<0.001; p=0.018). HVC across all 4 groups had larger bedsizes (p<0.001), were more often government/private owned (p<0.001), and were more often teaching hospitals (p<0.001) located exclusively in urban settings (p<0.001).

 

Primary patients treated at HVC were repaired at significantly younger ages (p=0.008) and were more often males (p=0.032). Across total, primary, and older patients, the most common diagnosis at HVC was complete cleft palate with incomplete cleft lip, while the most common diagnosis at NHVC was incomplete cleft palate without lip. In older patients, both HVC and NHVC patients were most commonly diagnosed with complete cleft palate with incomplete lip. In the primary, revision, and total cohort, significantly more concurrent procedures were performed in HVC (p=0.047; p=0.001; p<0.001).

 

Overall, primary, and revision length of stay (LOS) was significantly longer in NHVC (p=0.048; p=0.001; p=0.010) and approached significance in the older group (p=0.060). Overall, HVC were associated with a lower specific complication rate (p=0.042). Primary HVC experienced lower specific complication rates (p=0.023) and pneumonia rates (p=0.009). Revision HVC were associated with fewer cardiac complications (p=0.040) and older HVC with less wound disruption, approaching significance (p=0.050), but also more hemorrhage (p=0.040).

 

 

Conclusions: The majority of cleft palate cases nationwide are performed at the top 10% case volume centers. Our analysis revealed HVC are associated with better short-term outcomes across all patient groups and surgery types. HVC may be better equipped to handle complex patients, such as those with more extensive defects receiving multiple concurrent procedures. Furthermore, HVC treated patients from higher income brackets with private insurance, while NHVC treated lower income patients paying with Medicaid. Among many factors, this may reflect challenges faced by disadvantaged patients living in rural areas in accessing HVC. We recommend future efforts to focus on equilibrating access to care for all patients seeking cleft palate surgeries, particularly to HVC.