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Five-Fold Variation Among Surgeons and Hospitals in the Use of Secondary Palate Surgery.

ABSTRACT: OBJECTIVE:To identify child-, surgeon- and hospital-specific factors at the time of primary cleft palate repair that are associated with the use of secondary palate surgery. DESIGN:Retrospective cohort study. SETTING:Forty-nine pediatric hospitals. PARTICIPANTS:Children who underwent cleft palate repair between 1998 and 2015. MAIN OUTCOME MEASURE:Time from primary cleft palate repair to secondary palate surgery. RESULTS:By 5 years after the primary palate repair, 27.5% of children had undergone secondary palate surgery. In multivariable analysis, cleft type and age at primary palate repair were both associated with secondary surgery ( P < .01). Children with unilateral cleft lip and palate had a 1.69-fold increased hazard of secondary surgery (95% confidence interval [CI]: 1.54-1.85) compared to children with cleft palate alone. Primary palate repair before 9 months had a 3.99-fold increased hazard of secondary surgery (95% CI: 3.39-4.07) compared to repair at 16 to 24 months of age. After adjusting for cleft type, age at repair, and procedure volume, there remained substantial variation in secondary surgery use among surgeons and hospitals ( P < .01). For children with isolated cleft palate, the predicted proportion of children undergoing secondary surgery within 5 years of primary repair ranged from 8.5% to 46.0% across surgeons and 9.1% to 49.4% across hospitals. CONCLUSIONS:There are substantial differences among surgeons and hospitals in the rates of secondary palate surgery. Further work is needed to identify causes for this variation among providers and develop interventions to reduce the need for secondary surgery.

SUBMITTER: Sitzman TJ

PROVIDER: S-EPMC6431573 | biostudies-literature | 2019 May

REPOSITORIES: biostudies-literature

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Five-Fold Variation Among Surgeons and Hospitals in the Use of Secondary Palate Surgery.

Sitzman Thomas J TJ Carle Adam C AC Heaton Pamela C PC Helmrath Michael A MA Britto Maria T MT

The Cleft palate-craniofacial journal : official publication of the American Cleft Palate-Craniofacial Association 20180924 5

<h4>Objective</h4>To identify child-, surgeon- and hospital-specific factors at the time of primary cleft palate repair that are associated with the use of secondary palate surgery.<h4>Design</h4>Retrospective cohort study.<h4>Setting</h4>Forty-nine pediatric hospitals.<h4>Participants</h4>Children who underwent cleft palate repair between 1998 and 2015.<h4>Main outcome measure</h4>Time from primary cleft palate repair to secondary palate surgery.<h4>Results</h4>By 5 years after the primary pala ...[more]

PMID: 30244603

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Project description:ImportanceRacial differences in breast cancer treatment may result in part from differences in the surgeons and hospitals from whom patients receive their care. However, little is known about differences in patients' selection of surgeons and hospitals.ObjectiveTo examine racial/ethnic differences in how women selected their surgeons and hospitals for breast cancer surgery.Design, setting, and participantsWe surveyed 500 women (222 non-Hispanic white, 142 non-Hispanic black, 89 English-speaking Hispanic, and 47 Spanish-speaking Hispanic) from northern California cancer registries with stage 0 to III breast cancer diagnosed during 2010 through 2011. We used multivariable logistic regression to assess the reasons for surgeon and hospital selection by race/ethnicity, adjusting for other patient characteristics. We also assessed the association between reasons for physician selection and patients' ratings of their surgeon and hospital.Main outcomes and measuresReasons for surgeon and hospital selection and ratings of surgeon and hospital.ResultsThe 500 participants represented a response rate of 47.8% and a participation rate of 69%. The most frequently reported reason for surgeon selection was referral by another physician (78%); the most frequently reported reason for hospital selection was because it was a part of a patient's health plan (58%). After adjustment, 79% to 87% of black and Spanish-speaking Hispanic women reported selecting their surgeon based on a physician's referral vs 76% of white women (P = .007). Black and Hispanic patients were less likely than white patients to report selecting their surgeon based on reputation (adjusted rates, 18% and 22% of black and Hispanic women, respectively, vs 32% of white women; P = .02). Black and Hispanic women were also less likely than white women to select their hospital based on reputation (adjusted rates, 7% and 15% vs 23%, respectively; P = .003). Women who selected their surgeon based on reputation more often rated the care from their surgeon as excellent (adjusted odds ratio, 2.21; 95% CI, 1.24-3.93); those reporting their surgeon was one of the only surgeons available through the health plan less often reported excellent quality of surgical care (adjusted odds ratio, 0.56; 95% CI, 0.34-0.91).Conclusions and relevanceCompared with white patients with breast cancer, minority patients were less actively involved in physician and hospital selection, relying more on physician referral and health plans rather than on reputation. Interventions to promote involvement in surgeon and hospital selection may have potential for addressing disparities related to lower-quality care from surgeons and hospitals.

Project description:To determine whether (1) black and white women with endometrial cancer were treated by different surgical specialties and in different types of hospitals and (2) differences in specialty and hospital type contributed to racial differences in survival.Retrospective cohort study of 12,307 women aged 65 years and older who underwent surgical treatment of endometrial cancer between 1991 and 1999 in the 11 Surveillance Epidemiology and End Results registries.Black women were more likely to have a gynecologic oncologist to perform their surgery and to be treated at hospitals that were higher volume, larger, teaching, National Cancer Institute centers, urban, and where a greater proportion of the surgeries were performed by a gynecologic oncologist. In unadjusted models, black women were over twice as likely as white women who died because of cancer (hazards ratio [HR]: 2.33), but nearly all of the initial racial difference in survival was explained by differences in cancer stage, and grade as well as age and comorbidities at presentation (adjusted HR: 1.10). Surgical specialty was not associated with survival and, of the hospital characteristics studied, only surgical volume was associated with survival (P < 0.005). Adjusting for hospital characteristics did not change the racial difference in survival (HR: 1.10). Adjustment for the specific hospital where the woman was treated eliminated the association between race and surgeon specialty and slightly widened the residual racial difference in survival (HR: 1.23 vs. 1.10).In contrast to several studies suggesting that blacks with breast cancer, colon cancer, or cardiovascular disease are treated in hospitals with lower quality indicators, black women diagnosed with endometrial cancer in Surveillance Epidemiology and End Results regions between 1991 and 1999 were more likely to be treated by physicians with advanced training and in high volume, large, urban, teaching hospitals. However, except for a modest association with hospital surgical volume, these provider and hospital characteristics were largely unrelated to survival for women with endometrial cancer. The great majority of the difference in survival was explained by differences in tumor and clinical characteristics at presentation.

Dataset Information

Five-Fold Variation Among Surgeons and Hospitals in the Use of Secondary Palate Surgery.

Publications

Five-Fold Variation Among Surgeons and Hospitals in the Use of Secondary Palate Surgery.

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