Age at Primary Cleft Lip Repair: A Potential Bellwether Indicator for Pediatric Surgery

  • Plastic and Reconstructive Surgery - Global Open, Volume 9, No. 6, Year 2021

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Study Justification:
The study aims to identify a potential bellwether indicator for pediatric surgery by examining the age at primary cleft lip (CL) repair. This is important because there is a need for pediatric surgery bellwether indicators that can help assess the capacity and quality of pediatric surgical services in different countries. By identifying a routine procedure for a common condition that should ideally be treated with surgery at a standard age, policymakers and healthcare providers can better understand the state of pediatric surgical care and make informed decisions to improve it.
Highlights:
– The study reviewed surgical records of 71,346 primary cleft surgery patients from 73 countries.
– Age at CL repair was studied in 40,179 patients treated by Smile Train partners in 2019.
– Countries with delayed access to CL repair had higher maternal, infant, and child mortality rates.
– Delayed CL repair was also associated with a greater risk of catastrophic health expenditure for surgery.
– There was a negative correlation between delayed CL repair and specialist surgical workforce numbers, life expectancy, percentage of deliveries by C-section, total health expenditure per capita, and Lancet Commission on Global Surgery procedure rates.
– These findings suggest that age at CL repair has the potential to serve as a bellwether indicator for pediatric surgical capacity in Lower- and Middle-income Countries.
Recommendations:
Based on the study findings, the following recommendations can be made:
1. Improve access to early CL repair: Efforts should be made to ensure timely access to primary cleft lip repair for children in Lower- and Middle-income Countries. This may involve increasing the availability of surgical services, reducing barriers to access, and improving diagnosis and referral systems.
2. Strengthen pediatric surgical workforce: Countries with delayed CL repair should focus on increasing the number of specialist surgeons trained in pediatric surgery. This can help meet the demand for timely surgical interventions and improve overall pediatric surgical capacity.
3. Enhance healthcare infrastructure: Investments should be made to improve healthcare infrastructure, including surgical facilities and equipment, to support timely and safe CL repair procedures.
4. Increase healthcare funding: Governments and policymakers should allocate sufficient resources to pediatric surgical services to ensure adequate funding for CL repair and other essential procedures. This can help reduce the risk of catastrophic health expenditure for families seeking surgical care.
Key Role Players:
1. Surgeons: Pediatric surgeons play a crucial role in performing primary cleft lip repair and other pediatric surgical procedures. Their expertise and availability are essential to address the recommendations.
2. Healthcare Administrators: Administrators in healthcare facilities and organizations need to prioritize pediatric surgical services and allocate resources accordingly.
3. Policy Makers: Government officials and policymakers have the authority to implement policies and allocate funding to improve pediatric surgical capacity and access to CL repair.
4. Non-Governmental Organizations (NGOs): Organizations like Smile Train, which support cleft surgical procedures, can continue to play a vital role in providing resources, training, and support to healthcare providers in different countries.
Cost Items for Planning Recommendations:
1. Surgeon Training and Education: Budget allocation for training and education programs to increase the number of specialist surgeons trained in pediatric surgery.
2. Healthcare Infrastructure Development: Funds for building and upgrading surgical facilities, including operating rooms, recovery areas, and equipment.
3. Surgical Supplies and Equipment: Budget for procuring surgical supplies, instruments, anesthesia equipment, and other necessary tools for performing CL repair.
4. Outreach and Awareness Programs: Resources for conducting outreach programs to raise awareness about the importance of early CL repair and to facilitate early diagnosis and referral.
5. Health System Strengthening: Investments in strengthening healthcare systems, including improving referral networks, diagnostic capabilities, and overall healthcare delivery.
Note: The provided cost items are general categories and do not represent actual cost estimates. The actual cost will vary depending on the specific context and country.

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Background: The bellwether procedures described by the Lancet Commission on Global Surgery represent the ability to deliver adult surgical services after there is a clear and easily made diagnosis. There is a need for pediatric surgery bellwether indicators. A pediatric bellwether indicator would ideally be a routinely performed procedure, for a relatively common condition that, in itself, is rarely lethal at birth, but that should ideally be treated with surgery by a standard age. Additionally, the condition should be easy to diagnose, to minimize the confounding effects of delays or failures in diagnosis. In this study, we propose the age at primary cleft lip (CL) repair as a bellwether indicator for pediatric surgery. Method: We reviewed the surgical records of 71,346 primary cleft surgery patients and ultimately studied age at CL repair in 40,179 patients from 73 countries, treated by Smile Train partners for 2019. Data from Smile Train’s database were correlated with World Bank and WHO indicators. Results: Countries with a higher average age at CL repair (delayed access to surgery) had higher maternal, infant, and child mortality rates as well as a greater risk of catastrophic health expenditure for surgery. There was also a negative correlation between delayed CL repair and specialist surgical workforce numbers, life expectancy, percentage of deliveries by C-section, total health expenditure per capita, and Lancet Commission on Global Surgery procedure rates. Conclusion: These findings suggest that age at CL repair has potential to serve as a bellwether indicator for pediatric surgical capacity in Lower- and Middle-income Countries.

Surgeons in 73 countries, across 1110 hospital sites perform cleft surgical procedures supported by Smile Train and upload details of all cleft surgical procedures to Smile Train’s online database, Smile Train Express. We selected the most recent complete calendar year (2019) for analysis. Surgical procedures include primary surgery (repair of the original CL and/or CP) and secondary (or revision) surgery. Variables such as patient choice and quality of original surgery influence whether, and at what age, secondary lip surgery is performed. Therefore, secondary surgery was not included in this analysis. Data on all CL repairs for 2019 were exported from Smile Train Express. Number of procedures per country/center, age at surgery, and type of anesthesia were studied. Patients recorded as treated in “Palestinian territories” were excluded from the analysis due to the lack of available economic and health statistics. Patients who present at an older age with an unrepaired CL and CP require unique consideration. Surgeons may opt to do primary CL repair and primary CP repair simultaneously (CLP) due to concerns about the patient and family’s capacity to return for further surgery. These patients were included in the analysis of age at CL repair but are reported separately for clarity. Additionally, some older patients with isolated CL (no palatal involvement) may have surgery under a local anesthetic. These patients are reported for clarity, but only patients who had a general anesthetic are included in the analysis of age at CL repair. Country-level indicators were extracted from the World Bank and WHO24 databases (Table ​(Table1).1). The authors chose to use LCoGS procedure rates versus World Bank procedure rates, which provided a more complete data set for comparison. Indicators (and Sources) Used for Comparison to Smile Train Data Data were imported to Microsoft Excel, version 16.43.1 (Microsoft Corporation). Bivariate correlations were conducted between age at surgery for CL repair and the national patient data and the health and economic indicators accessed from the World Bank and WHO.

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Based on the provided information, here are some potential innovations that can be used to improve access to maternal health:

1. Telemedicine: Implementing telemedicine technologies can allow healthcare providers to remotely assess and monitor pregnant women, provide prenatal care, and offer consultations without the need for in-person visits. This can help overcome geographical barriers and improve access to maternal health services, especially in remote or underserved areas.

2. Mobile health (mHealth) applications: Developing mobile applications that provide pregnant women with information, reminders, and access to healthcare resources can empower them to take control of their own maternal health. These apps can offer features such as appointment reminders, educational content, nutrition tracking, and emergency contact information.

3. Community health workers: Training and deploying community health workers who are knowledgeable about maternal health can help bridge the gap between healthcare facilities and pregnant women in rural or marginalized communities. These workers can provide education, support, and referrals, and act as a link between pregnant women and healthcare providers.

4. Transport and referral systems: Establishing efficient transport and referral systems can ensure that pregnant women have timely access to appropriate healthcare facilities for prenatal care, delivery, and emergency obstetric care. This can involve setting up emergency transportation services, coordinating with local transportation providers, and improving communication between healthcare facilities.

5. Financial incentives and subsidies: Implementing financial incentives or subsidies for pregnant women, especially those from low-income backgrounds, can help reduce financial barriers to accessing maternal health services. This can include providing free or subsidized prenatal care, delivery services, and essential medications.

6. Health education and awareness campaigns: Conducting targeted health education and awareness campaigns can help improve knowledge and understanding of maternal health issues among pregnant women and their families. These campaigns can focus on topics such as prenatal care, nutrition, breastfeeding, and recognizing warning signs during pregnancy.

7. Strengthening healthcare infrastructure: Investing in and improving healthcare infrastructure, including facilities, equipment, and healthcare workforce, is crucial for ensuring access to quality maternal health services. This can involve building or upgrading healthcare facilities, providing necessary medical equipment, and training healthcare professionals in maternal health care.

It’s important to note that these are general recommendations and may need to be tailored to specific contexts and resource availability.
AI Innovations Description
Based on the provided description, the recommendation to improve access to maternal health is to use the age at primary cleft lip repair as a bellwether indicator for pediatric surgical capacity in Lower- and Middle-income Countries. This means that monitoring the age at which cleft lip repair surgeries are performed can provide insights into the overall surgical capacity and access to pediatric surgical services in a country.

The study found that countries with delayed access to cleft lip repair surgeries had higher maternal, infant, and child mortality rates, as well as a greater risk of catastrophic health expenditure for surgery. There was also a negative correlation between delayed cleft lip repair and specialist surgical workforce numbers, life expectancy, percentage of deliveries by C-section, total health expenditure per capita, and Lancet Commission on Global Surgery procedure rates.

By using the age at primary cleft lip repair as a bellwether indicator, policymakers and healthcare providers can identify areas where there is a need for improvement in pediatric surgical capacity. This can help prioritize resources and interventions to ensure timely access to surgical services for children with cleft lip and other pediatric surgical conditions.

It is important to note that this recommendation is specific to improving access to pediatric surgical services and may not directly address all aspects of maternal health. However, by improving access to pediatric surgical care, it indirectly contributes to better maternal health outcomes by reducing the risk of complications and improving overall healthcare infrastructure.
AI Innovations Methodology
To improve access to maternal health, here are some potential recommendations:

1. Telemedicine: Implementing telemedicine programs can provide remote access to healthcare professionals, allowing pregnant women in remote or underserved areas to receive prenatal care and consultations without the need for travel.

2. Mobile clinics: Setting up mobile clinics that travel to rural or underserved areas can provide essential maternal health services, including prenatal care, vaccinations, and screenings.

3. Community health workers: Training and deploying community health workers can help bridge the gap between healthcare facilities and pregnant women in remote areas. These workers can provide education, support, and basic healthcare services to pregnant women, improving access to maternal health.

4. Maternal health vouchers: Introducing voucher programs that provide financial assistance for maternal health services can help reduce the financial barriers that prevent women from accessing necessary care.

5. Health information systems: Implementing robust health information systems can improve coordination and communication between healthcare facilities, ensuring that pregnant women receive timely and appropriate care.

To simulate the impact of these recommendations on improving access to maternal health, a methodology could include the following steps:

1. Define the indicators: Identify key indicators that measure access to maternal health, such as the number of prenatal visits, percentage of births attended by skilled health personnel, maternal mortality rate, and infant mortality rate.

2. Collect baseline data: Gather data on the current state of access to maternal health in the target population or region. This can include information on healthcare facilities, healthcare providers, infrastructure, and utilization of maternal health services.

3. Define the simulation model: Develop a simulation model that incorporates the potential recommendations and their expected impact on the identified indicators. This model should consider factors such as population demographics, geographical distribution, and existing healthcare infrastructure.

4. Input data and parameters: Input the collected baseline data into the simulation model, along with the parameters related to the potential recommendations. This can include the number of telemedicine consultations, frequency and coverage of mobile clinics, number of community health workers, and the distribution of maternal health vouchers.

5. Run simulations: Run multiple simulations using different scenarios and combinations of the potential recommendations. This can help assess the potential impact of each recommendation individually and in combination with others.

6. Analyze results: Analyze the simulation results to evaluate the projected impact of the recommendations on the identified indicators of access to maternal health. This can include comparing the simulated outcomes with the baseline data and identifying areas of improvement.

7. Refine and optimize: Based on the simulation results, refine and optimize the recommendations to maximize their impact on improving access to maternal health. This can involve adjusting parameters, reallocating resources, or identifying additional interventions.

8. Implement and monitor: Implement the refined recommendations and closely monitor the actual impact on access to maternal health. Continuously collect data and compare it with the simulation results to assess the effectiveness of the interventions and make further adjustments if needed.

Statistics:
Citations: 2
Authors: 7
Identifiers:
DOI: 10.1097/GOX.0000000000003657
Research Areas:
Health System and Policy, Maternal and Child Health, Quality of Care, Social Determinants
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