|Program and Abstracts
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Maintenance of Certification: Do Current Practice Patterns in Craniomaxillofacial Surgery Follow Evidence-Based Medicine?
Michael S. Gart, MD1, Arun K. Gosain, MD2.
1Nowthwestern University, Chicago, IL, USA, 2Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA.
PURPOSE:Maintenance of Certification in Plastic Surgery (MOC-PS) has been collecting data from surgeons who are 10 years or more past initial certification by the American Board of Plastic Surgery (ABPS) since 2003. Participation in MOC-PS is mandatory for all diplomates from 1995 on, and voluntary for diplomates certified before 1995. These data represent the most powerful tool available by which to track clinical practice trends of ABPS-certified plastic surgeons. The present report seeks to evaluate these practice patterns specific to the craniomaxillofacial module of MOC.
METHODS:ABPS data from 2003-2014 were reviewed to determine practice patterns based on the four craniomaxillofacial tracers tracked by MOC-PS. These data were compared with the two most recent evidence-based medicine articles published on each subject to determine (1) the highest evidence level evidence available for guiding operative management and (2) the correlation between these recommendations and self-reported clinical practice. Evidence-based treatment guidelines not tracked in MOC modules were noted, as were practice patterns without clear consensus and no reported evidence-based guidelines.
RESULTS:(1) Cleft Palate: 79% of patients are assessed by dedicated cleft palate teams and 81% undergo some form of intravelar veloplasty, consistent with best-evidence recommendations. Two-stage repairs were performed in 4% of cases. There is no high-level evidence to suggest one- versus two-stage palate repair.
(2) Zygoma fractures: 32% of respondents report the use of a subciliary incision for orbital floor access, despite high-level evidence suggesting improved outcomes with alternative approaches. 18% of cases utilized titanium mesh alloplasts for orbital floor reconstruction, which are supported by Level II evidence. There is no consensus on appropriate perioperative antibiotic administration.
(3) Non-syndromic craniosynostosis: Preoperative CT imaging is obtained in 92% of cases despite high-level evidence suggesting it is not routinely necessary. Moreover, Level II evidence suggests that ultrasound may be an acceptable alternative. The ideal method of fixation in cranial vault remodeling remains unknown. Spring cranioplasty may decrease operative morbidity, but was rarely used in the MOC-PS dataset.
(4) Secondary cleft rhinoplasty: 61% of cases are performed by a different surgeon than the one who performed primary cleft lip/nose repair. 9% of respondents used a closed approach to secondary cleft rhinoplasty despite evidence suggesting an open approach provides superior visualization and correction. Only 14% of cases were known to have undergone primary rhinoplasty at the time of cleft lip repair, despite Level II evidence suggesting routine primary rhinoplasty in conjunction with cleft lip repair.
CONCLUSION:The four MOC-PS tracers assessed in the present study demonstrate disparities between clinical practice and the best available evidence. These differences may be reflective of previous clinical training and/or evolving practice patterns. The present study also demonstrates areas for potential improvement in the MOC-PS tracers that may allow the ABPS to more accurately track practice patterns currently supported by evidence-based medicine. Diplomates of the ABPS for whom participation is voluntary (i.e., certified prior to 1995) should be strongly encouraged to participate in MOC-PS in order to improve the quality of care and advance evidence-based practice recommendations.
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