The Association of Neighborhood Disadvantage with Surgical Outcomes and Follow-Up Adherence in Patients with Cleft Palate

SDCC 

Purpose: Previous studies have characterized individual sociodemographic factors affecting care adherence and operative rates; however, there is limited data on how neighborhood-level disadvantage may affect surgical outcomes in patients with cleft palate. The area deprivation index (ADI) and the childhood opportunity index (COI) are novel measures of disadvantage, incorporating several US census indicators of poverty, education, housing, and income. Our study aims to elucidate whether neighborhood disadvantage, measured via ADI and COI, is associated with intervention outcomes and follow-up adherence in patients with cleft palates.

Methods: Pediatric patients with cleft palate who received repair, revision, and fistula repair procedures between 2013-2023 were included. Patients with a traumatic cleft, previously adopted, and 18 years of age or older were excluded. State ADI and COI scores, represented as quintiles, were determined based on zip codes or addresses. We collected basic demographic and clinical variables including opioid and antibiotic prescriptions at discharge, complications, ED return, PICU, and hospital readmissions within 30 days of discharge. Furthermore, postoperative follow-up adherence variables include no-shows, cancellations (patients and administrative), significant delay in follow-up (more than 2-year delay) and lost to follow-up. Univariable logistic regressions were used to assess the association of ADI and COI with binary variables and Spearman-ranked correlations were utilized to assess continuous variables.

Results: A total of 244 patients (138 Male) were included and had Veau classification breakdown of 25 Veau I, 73 II, 67 III, 38 IV, and 41 submucous. Our results reveal significant delays in follow-up in both high disadvantaged ADI (OR1.265, 95%CI [1.052–1.523]; p=0.013) and COI (OR1.263, 95%CI [1.017–1.567]; p=0.034) groups. In palate repair procedures, higher disadvantaged ADI quintiles revealed significant associations with greater total number of no-shows (rs(162)=0.200 [95%CI 0.043–0.348]; p=0.011), patient cancellations at 30 days post-op (OR1.400, 95%CI [1.056–1.858]; p=0.020), total number of patient cancellations (rs(162)=0.157 [95%CI -0.002–0.308]; p=0.047), and total number of overall cancellations (rs(162)=0.171 [95%CI 0.012–0.321]; p=0.030). Meanwhile, higher disadvantaged COI quintiles revealed significant associations with greater rates of no-shows at 60 days post-op (OR1.952, 95%CI [1.130–3.372]; p=0.016), and total number of no-shows (rs(162)=0.159 95%CI [0.001–0.310]; p=0.043). In palate revision surgeries, higher disadvantaged ADI quintiles were significantly associated with higher post-op complication rates (OR1.875, 95%CI [1.200–2.931]; p=0.006) and post-operative fistula rates (OR1.900, 95%CI [1.055–3.424] p=0.033), while higher disadvantaged COI quintiles were significantly associated with higher rates of hospital readmission (OR5.297, 95%CI [1.417 – 19.796]; p=0.013) and greater administrative cancellations at 30 days post-op (OR1.602, 95%CI [1.005–2.554]; p=0.048). In oronasal fistula repair procedures, higher disadvantaged COI quintiles showed significant negative associations with opioid prescriptions at discharge (OR0.524, 95%CI [0.276–0.994] p=0.048).

Conclusions: Our results showcased that neighborhood deprivation, as indexed by ADI and COI, had many significant associations to measured outcomes and follow-up adherence rates in cleft palate procedures. Understanding how neighborhood disadvantage impacts cleft repair outcomes is crucial to clinical care, policy making, and tackling health disparities for our patients. Future analyses will explore how ADI and COI intersects with demographic characteristics such as race, sex, age, insurance and their impact on management outcomes and follow-up adherence.

Craniomaxillofacial/Head and Neck

PSTM 2024