Variation among cleft centres in the use of secondary surgery for children with cleft palate: a retrospective cohort study.
Variation among cleft centres in the use of secondary surgery for children with cleft palate: a retrospective cohort study.
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唇裂中心对腭裂儿童二次手术使用的差异：一项回顾性队列研究。
DOI：
10.1136/bmjpo-2017-000063
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发表时间：
2017
影响因子：
2.6
通讯作者：
Britto,MariaT
中科院分区：
文献类型：
--
作者：
Sitzman,ThomasJ;Hossain,Monir;Carle,AdamC;Heaton,PamelaC;Britto,MariaT
目的测试腭裂中心在使用二次腭裂手术（也称为腭裂修复手术）方面是否存在差异，如果存在差异，则确定与二次手术相关的可修改医院因素和外科医生因素。设计回顾性队列研究。美国43家儿科医院。1999年至2013年接受初次腭裂修复术的唇腭裂儿童。主要观察指标从初次腭裂修复到二次腭裂手术的时间。结果：我们确定了4939名儿童谁接受了初级腭裂修复术。在初次腭修复后10年，44%的儿童接受了二次腭手术。各医院之间存在显著差异（p<0.001）; 10年前接受二次手术的儿童比例在各医院之间的范围为9%至77%。在调整患者人口统计学特征后，9个月龄前进行初次腭修复与二次腭手术的风险增加相关（初始HR 6.74，95% CI 5.30至8.73）。术后抗生素、外科医生手术量和医院手术量与二次手术时间无关（p>0.05）。在归因于医院和外科医生的结果差异中，医院间差异占59%（p<0.001），而外科医生间差异占41%（p<0.001）。结论二次腭裂手术的危险性存在很大的差异，这取决于孩子在初次腭裂修复术时的年龄以及进行修复术的医院和外科医生。在9个月大之前进行初次腭裂修复会大大增加二次手术的风险。需要进一步的研究来确定医院和外科医生之间腭手术结果差异的其他因素。
Objectives To test whether cleft centres vary in their use of secondary cleft palate surgery, also known as revision palate surgery, and if so to identify modifiable hospital factors and surgeon factors that are associated with use of secondary surgery. Design Retrospective cohort study. Setting Forty-three paediatric hospitals across the USA. Patients Children with cleft lip and palate who underwent primary cleft palate repair from 1999 to 2013. Main outcome measures Time from primary cleft palate repair to secondary palate surgery. Results We identified 4939 children who underwent primary cleft palate repair. At 10 years after primary palate repair, 44% of children had undergone secondary palate surgery. Significant variation existed among hospitals (p<0.001); the proportion of children undergoing secondary surgery by 10 years ranged from 9% to 77% across hospitals. After adjusting for patient demographics, primary palate repair before 9 months of age was associated with an increased hazard of secondary palate surgery (initial HR 6.74, 95% CI 5.30 to 8.73). Postoperative antibiotics, surgeon procedure volume and hospital procedure volume were not associated with time to secondary surgery (p>0.05). Of the outcome variation attributable to hospitals and surgeons, between-hospital differences accounted for 59% (p<0.001), while between-surgeon differences accounted for 41% (p<0.001). Conclusions Substantial variation in the hazard of secondary palate surgery exists depending on a child’s age at primary palate repair and the hospital and surgeon performing their repair. Performing primary palate repair before 9 months of age substantially increases the hazard of secondary surgery. Further research is needed to identify other factors contributing to variation in palate surgery outcomes among hospitals and surgeons.