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CRANIOMAXILLOFACIAL DEFORMITIES/COSMETIC SURGERY
Effect of Hospital Volume on Outcomes of Surgery for Cleft Lip and Palate Sachiko Ono, DDS, MPH,* Miho Ishimaru, DDS,y Hiroki Matsui, MPH,z Kiyohide Fushimi, MD, PhD,x and Hideo Yasunaga, MD, PhDk
Q4
Purpose:
Cleft lip and cleft palate are the most common craniofacial anomalies. However, the effect of hospital volume on outcomes of surgery for cleft lip and palate is unknown.
Materials and Methods:
The Japanese Diagnosis Procedure Combination database was searched to identify patients who underwent surgery for cleft lip and palate from July 2010 through March 2013. Hospital volume was divided into tertiles (#28, 29 to 82, and $83 admissions/yr). Outcomes included total cost, length of hospital stay, duration of anesthesia, and length of antibiotic use. The relation between hospital volume and surgical outcomes was analyzed by multivariable regression analyses. Results:
The authors identified 7,405 admissions for cleft lip alone, cleft palate alone, or cleft lip and palate during the study period. Compared with the reference low-volume hospital category, a shorter duration of anesthesia was seen in the medium-volume group (15 minutes; 95% confidence interval, 37 to 7 minutes) and high-volume group (22 minutes; 95% confidence interval, 65 to 3 minutes). No statistical associations were observed between hospital volume and total cost or length of stay. Although not statistically important, a higher hospital volume was associated with a shorter length of antibiotic use after adjusting for duration of anesthesia. Conclusion:
In the present study of surgical outcomes for cleft lip and palate, hospital volume was inversely associated with duration of anesthesia and length of antibiotic use but was not statistically associated with length of hospital stay or total cost. Ó 2015 American Association of Oral and Maxillofacial Surgeons J Oral Maxillofac Surg -:1-7, 2015
Cleft lip and cleft palate are the most common congenital craniofacial anomalies. The reported occurrence of cleft lip and palate is 1 in 700 births worldwide and 1 in 500 births in Asians and Native Americans.1 Cleft lip and palate affect facial appearance, psychiatric functions, and physical functions (speech, hearing, and feeding). Patients with cleft lip and palate require professional care from birth through early adulthood.
Care for children with these defects generally spans several areas of medicine: nursing, plastic surgery, maxillofacial surgery, speech therapy, counseling, orthodontic treatment, and dental treatment.2 In many countries, these treatments have tended to be fragmented and decentralized, leading to variations in the management of cleft care and a resultant lack of standardized care.
*Graduate Student, Department of Clinical Epidemiology and Health Economics, School of Public Health, The University of
This work was supported by grants from the Ministry of Health, Q1 Labour and Welfare, Japan (grants H26-Policy-011 and H26-Special-
Tokyo, Tokyo, Japan.
047).
yGraduate Student, Department of Clinical Epidemiology and
Address correspondence and reprint requests to Dr Yasunaga:
Health Economics, School of Public Health, The University of
Department of Clinical Epidemiology and Health Economics, School
Tokyo, Tokyo, Japan.
of Public Health, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku,
zAssistant Professor, Department of Clinical Epidemiology and
Tokyo 113-0033, Japan; e-mail: [email protected]
Health Economics, School of Public Health, The University of
Received February 25 2015
Tokyo, Tokyo, Japan. xProfessor, Department of Health Policy and Informatics, Tokyo
Accepted April 4 2015
Medical and Dental University Graduate School of Medicine,
0278-2391/15/00367-5
Tokyo, Japan.
http://dx.doi.org/10.1016/j.joms.2015.04.003
Ó 2015 American Association of Oral and Maxillofacial Surgeons
kProfessor, Department of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo, Tokyo, Japan.
1 FLA 5.2.0 DTD YJOMS56761_proof 28 April 2015 7:10 pm CE AH
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2
HOSPITAL VOLUME AND CLEFT SURGERY
The relation between hospital volume and outcomes of cleft repair remains unknown. In 1996, a nationwide study on surgeon volume and outcomes of cleft repair was conducted in the United Kingdom.3 The study found that approximately 40% of surgeons performing cleft repair performed only 1 case per year, and the outcomes were generally poorer than those in other European countries.4,5 These results prompted the centralization of cleft care in the United Kingdom. Centralization results in a lower rate of corrective surgery, a shorter in-hospital stay, and standardization of the timing of surgery.6,7 However, these studies did not account for possible effects of hospital volume or surgeon volume on the outcomes of surgery for cleft lip and palate because of their before-versus-after study design and limited adjustment for confounders. In addition, a few years after centralization, 1 study reported that surgeon volume did not affect the outcomes of cleft repair.8 Furthermore, few studies to date have focused on the volume-versus-outcome relation in cleft repair in countries other than the United Kingdom. The aim of this study was to examine the relation between hospital volume and short-term outcomes of surgery for cleft lip and palate.
following data were extracted: age, gender, type of institution (academic or nonacademic), additional anomalies, type of surgery, total cost, length of stay, duration of anesthesia, and length of antibiotic use. Age was categorized as no older than 2, 3 to 5, and at least 6 years. The authors also examined several additional procedures for patients with cleft lip and palate, including bone grafting and tympanostomy. Bone grafting of the maxillary and alveolar defect is a common part of cleft surgery.10 Tympanostomy is routinely performed in cleft repair because middle ear disease is almost universal in patients with cleft lip and palate.11 The list of ICD-10 codes from a previous study12 used to identify additional congenital anomalies and syndromes in these patients is presented in Appendix 1. OUTCOMES
The primary outcomes were total cost, length of hospital stay, and duration of anesthesia. The secondary outcome was the number of days that antibiotics were administered after surgery for cleft lip and palate. STATISTICAL ANALYSIS
Materials and Methods DATA
The authors searched the Diagnosis Procedure Combination database, a national inpatient database in Japan, from July 2010 through March 2013. The details of the database are described elsewhere.9 In brief, the database includes administrative claims data and discharge data. All 82 academic hospitals are obliged to participate in the database, whereas participation by community hospitals is voluntary. In 2012, approximately 7 million inpatient data were collected from approximately 1,000 hospitals, constituting approximately half of all acute hospitalizations in Japan. The database includes the following clinical information: age; gender; diagnoses, comorbidities at admission, and complications after admission recorded in accordance with the International Classification of Diseases, Tenth Revision (ICD-10) codes and text data in Japanese; Japanese original surgical codes (K-codes); duration of anesthesia (time of anesthetic induction to awakening in recovery); and length of hospital stay. The institutional review board at the University of Tokyo (Tokyo, Japan) approved this study. The requirement for informed consent was waived owing to the anonymous nature of the data. PATIENTS
The authors identified patients who underwent cleft repair from July 2010 through March 2013. The
Hospital volume was defined as the number of discharges for cleft repair procedures performed annually at each hospital and was categorized into 3 groups (low-, medium-, and high-volume groups), with approximately equal numbers of admissions in each group. The c2 test was used for categorical variables and 1-way analysis of variance was used for continuous variables. Multivariable linear regression analyses were conducted to examine the association between hospital volume and outcomes. Generalized estimating equations were applied for linear regression models to adjust for within-hospital clustering. All tests were 2-tailed, and P values less than .05 were considered statistically significant. All statistical computations were performed with SPSS 22 (IBM SPSS, Armonk, NY).
Results During the study period, the authors identified a total of 7,405 surgeries for cleft lip and palate performed in 248 institutions. At the time of surgery, approximately 30% of patients were 0 year old and 37% were at least 7 years old. The mean and median annual hospital volumes were 33.5 and 59.0 discharges per year, respectively. Hospital volume was divided into tertiles (low, #28 discharges/yr; medium, 29 to 82 discharges/yr; high, $83 discharges/yr). Table 1 lists the patient demographics divided into the 3 hospital volume categories. The proportions of surgical procedures performed for cleft palate alone and tympanostomy were highest in the
FLA 5.2.0 DTD YJOMS56761_proof 28 April 2015 7:10 pm CE AH
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3
ONO ET AL
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Table 1. CHARACTERISTICS BY HOSPITAL VOLUME
Patients Age (yr) #2 3-5 $6 Gender Male Female Additional anomalies No Yes Surgery type Cleft lip Cleft palate Cleft lip and palate Tympanostomy Bone graft Type of hospital Academic Nonacademic
Total
Low Volume (#28 Discharges/yr), n (%)
Medium Volume (29-82 Discharges/yr), n (%)
High Volume ($83 Discharges/yr), n (%)
7,405
2,410
2,467
2,528
3,578 721 3,106
1,146 (47.6) 235 (9.8) 1,029 (42.7)
1,102 (44.7) 240 (9.7) 1,125 (45.6)
1,330 (52.6) 246 (9.7) 952 (37.7)
4,136 3,269
1,353 (56.1) 1,057 (43.9)
1,373 (55.7) 1,094 (44.3)
1,410 (55.8) 1,118 (44.2)
7,134 271
2,292 (95.1) 118 (4.9)
2,394 (97.0) 73 (3.0)
2,448 (96.8) 80 (3.2)
4,006 3,031 368 527 1,796
1,366 (56.7) 978 (40.6) 66 (2.7) 122 (5.1) 495 (20.5)
1,206 (48.9) 1,048 (42.5) 213 (8.6) 250 (10.1) 614 (24.9)
1,434 (56.7) 1,005 (39.8) 89 (3.5) 155 (6.1) 687 (27.2)
5,267 2,138
1,240 (51.5) 1,170 (48.5)
2,022 (82.0) 445 (18.0)
2,005 (79.3) 523 (20.7)
P Value
CRANIOMAXILLOFACIAL DEFORMITIES/COSMETIC SURGERY
Effect of Hospital Volume on Outcomes of Surgery for Cleft Lip and Palate Sachiko Ono, DDS, MPH,* Miho Ishimaru, DDS,y Hiroki Matsui, MPH,z Kiyohide Fushimi, MD, PhD,x and Hideo Yasunaga, MD, PhDk
Q4
Purpose:
Cleft lip and cleft palate are the most common craniofacial anomalies. However, the effect of hospital volume on outcomes of surgery for cleft lip and palate is unknown.
Materials and Methods:
The Japanese Diagnosis Procedure Combination database was searched to identify patients who underwent surgery for cleft lip and palate from July 2010 through March 2013. Hospital volume was divided into tertiles (#28, 29 to 82, and $83 admissions/yr). Outcomes included total cost, length of hospital stay, duration of anesthesia, and length of antibiotic use. The relation between hospital volume and surgical outcomes was analyzed by multivariable regression analyses. Results:
The authors identified 7,405 admissions for cleft lip alone, cleft palate alone, or cleft lip and palate during the study period. Compared with the reference low-volume hospital category, a shorter duration of anesthesia was seen in the medium-volume group (15 minutes; 95% confidence interval, 37 to 7 minutes) and high-volume group (22 minutes; 95% confidence interval, 65 to 3 minutes). No statistical associations were observed between hospital volume and total cost or length of stay. Although not statistically important, a higher hospital volume was associated with a shorter length of antibiotic use after adjusting for duration of anesthesia. Conclusion:
In the present study of surgical outcomes for cleft lip and palate, hospital volume was inversely associated with duration of anesthesia and length of antibiotic use but was not statistically associated with length of hospital stay or total cost. Ó 2015 American Association of Oral and Maxillofacial Surgeons J Oral Maxillofac Surg -:1-7, 2015
Cleft lip and cleft palate are the most common congenital craniofacial anomalies. The reported occurrence of cleft lip and palate is 1 in 700 births worldwide and 1 in 500 births in Asians and Native Americans.1 Cleft lip and palate affect facial appearance, psychiatric functions, and physical functions (speech, hearing, and feeding). Patients with cleft lip and palate require professional care from birth through early adulthood.
Care for children with these defects generally spans several areas of medicine: nursing, plastic surgery, maxillofacial surgery, speech therapy, counseling, orthodontic treatment, and dental treatment.2 In many countries, these treatments have tended to be fragmented and decentralized, leading to variations in the management of cleft care and a resultant lack of standardized care.
*Graduate Student, Department of Clinical Epidemiology and Health Economics, School of Public Health, The University of
This work was supported by grants from the Ministry of Health, Q1 Labour and Welfare, Japan (grants H26-Policy-011 and H26-Special-
Tokyo, Tokyo, Japan.
047).
yGraduate Student, Department of Clinical Epidemiology and
Address correspondence and reprint requests to Dr Yasunaga:
Health Economics, School of Public Health, The University of
Department of Clinical Epidemiology and Health Economics, School
Tokyo, Tokyo, Japan.
of Public Health, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku,
zAssistant Professor, Department of Clinical Epidemiology and
Tokyo 113-0033, Japan; e-mail: [email protected]
Health Economics, School of Public Health, The University of
Received February 25 2015
Tokyo, Tokyo, Japan. xProfessor, Department of Health Policy and Informatics, Tokyo
Accepted April 4 2015
Medical and Dental University Graduate School of Medicine,
0278-2391/15/00367-5
Tokyo, Japan.
http://dx.doi.org/10.1016/j.joms.2015.04.003
Ó 2015 American Association of Oral and Maxillofacial Surgeons
kProfessor, Department of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo, Tokyo, Japan.
1 FLA 5.2.0 DTD YJOMS56761_proof 28 April 2015 7:10 pm CE AH
57 58 59 60 61 62 63 64 65 66 67 68 69 70 71 72 73 74 75 76 77 78 79 80 81 82 83 84 85 86 87 88 89 90 91 92 93 94 95 96 97 98 99 100 101 102 103 104 105 106 107 108 109 110 111 112
113 114 115 116 117 118 119 120 121 122 123 124 125 126 127 128 129 130 131 132 133 134 135 136 137 138 139 140 141 142 143 144 145 146 147 148 149 150 151 152 153 154 155 156 157 158 159 160 161 162 163 164 165 166 167 168
2
HOSPITAL VOLUME AND CLEFT SURGERY
The relation between hospital volume and outcomes of cleft repair remains unknown. In 1996, a nationwide study on surgeon volume and outcomes of cleft repair was conducted in the United Kingdom.3 The study found that approximately 40% of surgeons performing cleft repair performed only 1 case per year, and the outcomes were generally poorer than those in other European countries.4,5 These results prompted the centralization of cleft care in the United Kingdom. Centralization results in a lower rate of corrective surgery, a shorter in-hospital stay, and standardization of the timing of surgery.6,7 However, these studies did not account for possible effects of hospital volume or surgeon volume on the outcomes of surgery for cleft lip and palate because of their before-versus-after study design and limited adjustment for confounders. In addition, a few years after centralization, 1 study reported that surgeon volume did not affect the outcomes of cleft repair.8 Furthermore, few studies to date have focused on the volume-versus-outcome relation in cleft repair in countries other than the United Kingdom. The aim of this study was to examine the relation between hospital volume and short-term outcomes of surgery for cleft lip and palate.
following data were extracted: age, gender, type of institution (academic or nonacademic), additional anomalies, type of surgery, total cost, length of stay, duration of anesthesia, and length of antibiotic use. Age was categorized as no older than 2, 3 to 5, and at least 6 years. The authors also examined several additional procedures for patients with cleft lip and palate, including bone grafting and tympanostomy. Bone grafting of the maxillary and alveolar defect is a common part of cleft surgery.10 Tympanostomy is routinely performed in cleft repair because middle ear disease is almost universal in patients with cleft lip and palate.11 The list of ICD-10 codes from a previous study12 used to identify additional congenital anomalies and syndromes in these patients is presented in Appendix 1. OUTCOMES
The primary outcomes were total cost, length of hospital stay, and duration of anesthesia. The secondary outcome was the number of days that antibiotics were administered after surgery for cleft lip and palate. STATISTICAL ANALYSIS
Materials and Methods DATA
The authors searched the Diagnosis Procedure Combination database, a national inpatient database in Japan, from July 2010 through March 2013. The details of the database are described elsewhere.9 In brief, the database includes administrative claims data and discharge data. All 82 academic hospitals are obliged to participate in the database, whereas participation by community hospitals is voluntary. In 2012, approximately 7 million inpatient data were collected from approximately 1,000 hospitals, constituting approximately half of all acute hospitalizations in Japan. The database includes the following clinical information: age; gender; diagnoses, comorbidities at admission, and complications after admission recorded in accordance with the International Classification of Diseases, Tenth Revision (ICD-10) codes and text data in Japanese; Japanese original surgical codes (K-codes); duration of anesthesia (time of anesthetic induction to awakening in recovery); and length of hospital stay. The institutional review board at the University of Tokyo (Tokyo, Japan) approved this study. The requirement for informed consent was waived owing to the anonymous nature of the data. PATIENTS
The authors identified patients who underwent cleft repair from July 2010 through March 2013. The
Hospital volume was defined as the number of discharges for cleft repair procedures performed annually at each hospital and was categorized into 3 groups (low-, medium-, and high-volume groups), with approximately equal numbers of admissions in each group. The c2 test was used for categorical variables and 1-way analysis of variance was used for continuous variables. Multivariable linear regression analyses were conducted to examine the association between hospital volume and outcomes. Generalized estimating equations were applied for linear regression models to adjust for within-hospital clustering. All tests were 2-tailed, and P values less than .05 were considered statistically significant. All statistical computations were performed with SPSS 22 (IBM SPSS, Armonk, NY).
Results During the study period, the authors identified a total of 7,405 surgeries for cleft lip and palate performed in 248 institutions. At the time of surgery, approximately 30% of patients were 0 year old and 37% were at least 7 years old. The mean and median annual hospital volumes were 33.5 and 59.0 discharges per year, respectively. Hospital volume was divided into tertiles (low, #28 discharges/yr; medium, 29 to 82 discharges/yr; high, $83 discharges/yr). Table 1 lists the patient demographics divided into the 3 hospital volume categories. The proportions of surgical procedures performed for cleft palate alone and tympanostomy were highest in the
FLA 5.2.0 DTD YJOMS56761_proof 28 April 2015 7:10 pm CE AH
169 170 171 172 173 174 175 176 177 178 179 180 181 182 183 184 185 186 187 188 189 190 191 192 193 194 195 196 197 198 199 200 201 202 203 204 205 206 207 208 209 210 211 212 213 214 215 216 217 218 219 220 221 222 223 224
3
ONO ET AL
225 226 227 228 229 230 231 232 233 234 235 236 237 238 239 240 241 242 243 244 245 246 247 248 249 250 251 252 253 254 255 256 257 258 259 260 261 262 263 264 265 266 267 268 269 270 271 272 273 274 275 276 277 278 279 280
Table 1. CHARACTERISTICS BY HOSPITAL VOLUME
Patients Age (yr) #2 3-5 $6 Gender Male Female Additional anomalies No Yes Surgery type Cleft lip Cleft palate Cleft lip and palate Tympanostomy Bone graft Type of hospital Academic Nonacademic
Total
Low Volume (#28 Discharges/yr), n (%)
Medium Volume (29-82 Discharges/yr), n (%)
High Volume ($83 Discharges/yr), n (%)
7,405
2,410
2,467
2,528
3,578 721 3,106
1,146 (47.6) 235 (9.8) 1,029 (42.7)
1,102 (44.7) 240 (9.7) 1,125 (45.6)
1,330 (52.6) 246 (9.7) 952 (37.7)
4,136 3,269
1,353 (56.1) 1,057 (43.9)
1,373 (55.7) 1,094 (44.3)
1,410 (55.8) 1,118 (44.2)
7,134 271
2,292 (95.1) 118 (4.9)
2,394 (97.0) 73 (3.0)
2,448 (96.8) 80 (3.2)
4,006 3,031 368 527 1,796
1,366 (56.7) 978 (40.6) 66 (2.7) 122 (5.1) 495 (20.5)
1,206 (48.9) 1,048 (42.5) 213 (8.6) 250 (10.1) 614 (24.9)
1,434 (56.7) 1,005 (39.8) 89 (3.5) 155 (6.1) 687 (27.2)
5,267 2,138
1,240 (51.5) 1,170 (48.5)
2,022 (82.0) 445 (18.0)
2,005 (79.3) 523 (20.7)
P Value
