The Northeastern Society of Plastic Surgeons

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Impact of Surgical Volume on Outcomes in Cleft Repair: A Kids' Inpatient Database Analysis
Alexandra Bucknor, MBBS, MRCS, MSc1, Anmol Chattha, BA1, Klaas Ultee, PhD2, Salim Afshar, MD, DMD3, Samuel J. Lin, MD, MBA, FACS1.
1Beth Israel Deaconess Medical Center, Boston, MA, USA, 2Erasmus University Rotterdam, Boston, MA, USA, 3Boston Children's Hospital, Boston, MA, USA.

Background
Cleft defects are among the commonest congenital abnormalities in the US.1 Increasing centralization of specialist services, including cleft service delivery, is occurring worldwide, with the aim of improving the provision of cost-efficient, quality services.2,3 The aim of this study is to investigate the impact of hospital volume on complications, charges and length of stay after cleft palate repair in the US.
Methods
A retrospective analysis of the Kids' Inpatient Database (KID) was undertaken. Children ≤3 years of age undergoing cleft palate repair in 2012 were identified. Hospital volume was categorized by cases/year as low (LV, 0-14), intermediate (IV, 15-46) or high (HV, 47-99); differences in hospital charges and length of stay (LOS) were determined using a gamma log-link generalized linear model. Logistic regression was used to assess hospital volume as a predictor of overall complications.
Results
Data for 2,389 children were retrieved; 24.9% (595) of cases were LV, 50.1% (1,196) were IV and 25.0% (596) were HV. There were significant differences in ethnicity (p<0.000), co-morbidity number (p=0.002), hospital bed size (p<0.000) and concomitant procedure performed (cleft lip, p=0.025, or myringotomy, p=0.041) between LV, IV and HV centers. HV centers were more frequently located in the West (71.9%) compared with LV (19.9%) or IV (24.5%) centers (p<0.000 for hospital region). Median household income was more commonly highest quartile in HV centers compared with IV or LV centers (32.3% vs. 21.7% vs. 18.1%)(p<0.000 for household income). There was no significant difference in major complications between different volume centers (p=0.74). Compared to HV centers, there was a significant decrease in mean hospital costs for LV centers ($9,682 vs. $8,378, p<0.000) but no significant difference in cost for IV centers ($9,260, p=0.103). Intermediate and LV centers had a significantly greater LOS when compared with HV centers (1.97 vs. 2.10 vs. 1.74, p<0.001).
Discussion and Conclusion
Despite improvement in length of stay in high-volume centers, our findings conflict with other literature demonstrating that concentration of resources in high-volume centers generates cost-savings, as our results do not show a reduction in cost in the high-volume centers. High volume centers may undertake more complex cases, increasing costs although there was no significant difference in complications between centers of differing volumes. Further research is needed to ensure widespread cost-efficiency.
References
1.
Parker SE, Mai CT, Canfield MA, Rickard R, Wang Y, Meyer RE, et al. Updated
national birth prevalence estimates for selected birth defects in the United States, 2004-2006. Birth Defects Res Part A - Clin Mol Teratol. 2010;88:100816.
2.
Fitzsimons KJ, Mukarram S, Copley LP, Deacon SA, van der Meulen JH. Centralisation of services for children with cleft lip or palate in England: a study of hospital episode statistics. BMC Health Serv Res [Internet]. BioMed Central; 2012 [cited 2017 Feb 21];12:148. Available from: http://www.ncbi.nlm.nih.gov/pubmed/22682355
3.
Aquina CT, Probst CP, Becerra AZ, Iannuzzi JC, Kelly KN, Hensley BJ, et al. High volume improves outcomes: The argument for centralization of rectal cancer surgery. Surgery. 2016;159:73648.


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