Hospital Volume for Orofacial Cleft Repair and Risk of Complications

描述(由申请者提供)：口腔裂是最常见的先天性畸形之一，在美国，每750名活产儿中约有1名发生。在发达国家，出生时患有唇裂和/或腭裂(CL/CP)的儿童通常会接受一次或两次重建手术。在美国，每年进行的此类初级CL/CP修复程序超过8000例。在欧洲的医疗保健系统中，标准化的护理和更高的病人数量预示着患有CL/CP的儿童的长期功能和美学结果更好。然而，在美国，几乎没有人努力评估颅面护理的质量，包括手术结果。在英国，对体积-结果关系的研究导致了裂隙护理的集中化。对2000年数据的初步分析表明，大多数(75%)进行CL/CP修复手术的美国医院数量较少，但67%的唇裂(CL)和73%的腭裂(CP)修复手术发生在大容量医院。低流量医院的并发症发生率较高。然而，集中化可能会进一步将提供者集中在有限的地理位置，潜在地恶化获得唇裂护理的机会。因此，集中化可能会改善或夸大口腔裂术后的差异。我们建议通过分析儿童住院数据库(KID)来量化口腔裂隙修复手术的体积-结果关联，KID是一个大型管理数据集，可通过卫生研究和质量机构获得。我们将使用1997年至2009年的KID数据集，以及(待定)2012至1a)根据程序量和其他医院和儿童层面的特征，CL和CP修复程序如何在全国范围内分布，以及1)分布是否随着时间的推移而变化；2)在小容量医院或低容量外科医生中，CL或CP修复后的并发症发生率是否更高；以及3)来自传统服务不足群体的患者是否更有可能在低容量医院接受护理。拟议的项目将解决有关CL/CP护理的成本和分配方面的知识差距。结果还将加强对集中化的评估，以证据表明其对医疗保健差异的可能影响，无论是积极的还是消极的。对各种外科手术的量-结果关系进行了量化，经常导致正式的计划，将程序量作为报销或认证的衡量标准。尤其是对于服务不足的人群，在美国推行类似的计划或集中进行唇裂护理之前，量化潜在的好处是至关重要的。因此，我们提议的项目的结果将直接影响美国为患有CL/CP的婴儿改善护理质量的努力。

DESCRIPTION (provided by applicant): Orofacial clefts are among the most frequent congenital anomalies, occurring in approximately 1 in 750 live births in the U.S. During the first year of a life, children born with cleft lip and/or cleft palate (CL/CP) in developed countries typically undergo one two reconstructive surgeries. Over 8,000 such primary CL/CP repair procedures are performed in the U.S. each year. In European health care systems, standardization of care and higher patient volume predict better long-term functional and aesthetic outcomes in children with CL/CP. In the U.S., however, there has been little effort to evaluate the quality of craniofacial care, including surgical outcomes. In the United Kingdom, studies of the volume-outcome relationship have led to the centralization of cleft care. Preliminary analysis of year 2000 data indicates that the majority (75%) of U.S. hospitals performing CL/CP repair procedures had low volumes, yet 67% of cleft lip (CL) and 73% of cleft palate (CP) repair procedures occurred in high-volume hospitals. Complication rates were higher in low-volume hospitals. However, centralization could further concentrate providers in a limited number of geographic locations, potentially worsening access to cleft care. Thus centralization could either ameliorate or exaggerate disparities in orofacial cleft outcomes. We propose to quantify the volume-outcome association for orofacial cleft repair procedures by analyzing the Kids' Inpatient Database (KID), a large administrative dataset available through the Agency for Health Research and Quality. We will use the KID datasets from the years 1997 to 2009, and (pending availability) 2012 to 1a) how CL and CP repair procedures are distributed nationally, according to procedure volumes and other hospital- and child-level characteristics, and 1b) whether the distributions have changed over time; 2) whether complication rates following CL or CP repair are higher in low-volume hospitals or with low-volume surgeons; and 3) whether patients from traditionally underserved groups are likelier to receive care in low-volume hospitals. The proposed project will address gaps in knowledge about the costs and distribution of CL/CP care. The results will also enhance evaluations of centralization with evidence regarding its likely effect on health care disparities, whether positive or negative. Quantification of volume-outcome associations has been performed for a wide variety of surgical procedures, frequently leading to formal programs that incorporate procedure volume as a metric for reimbursement or accreditation. Particularly with regard to underserved populations, it is critical to quantify the potential benefits before pursuing similar programs or centralization of cleft care in the U.S. Thus the results of our proposed project will directly infrm efforts to improve quality of care for infants with CL/CP in the U.S.