Geospatial Analysis of Medical Reach and Barriers to Surgical Cleft Care in Los Angeles
Naikhoba C.O. Munabi, M.D.1, Madeleine S. Williams, B.A.2, Pedram Goel, B.S.1, Eric S. Nagengast, M.D.1, Jeffrey A. Hammoudeh, M.D., D.D.S.1, Mark M. Urata, M.D., D.D.S.1, William P. Magee, III, M.D., D.D.S.1.
1Children's Hospital Los Angeles, Los Angeles, CA, USA, 2Children's Hospital Los Angeles, 4650 Sunset Blvd., #96, CA, USA.
PURPOSE: Internationally, transportation distance is a major barrier to obtaining cleft care. Current guidelines recommend that all persons live within 2 hours of a facility with life saving general surgery procedures available. However, ideal accessibility of subspecialized surgery remains unknown. This study evaluates distribution, demographics, and socioeconomic factors of patients undergoing primary cleft surgery at Children's Hospital Los Angeles in order to better understand the ideal geospatial dynamics of cleft care.
METHODS: Following IRB approval, retrospective review was performed of all patients undergoing primary cleft lip or palate repair over 4 years. Variables included patient demographics, cleft type, insurance type, distance from hospital, and length of follow up. Four cohorts were established based on distance to hospital (<15, 15-30, 30-35, >45 miles) and analyzed in relation to other variables. Subgroup analysis was performed for cleft type and ethnicity. Statistical analysis was performed in Excel and SPSS17 with significance at p<0.05.
RESULTS: 307 patients - 18.6% (n=57) cleft lip (CL), 35.5% (n=109) cleft palate (CP), 46.3% (n=142) cleft lip and palate (CLP) - were included. Patients ethnically were 52.1% hispanic (n=160) and 27.0% non-hispanic (n=83) (20.8% unreported, n=64). Racial identification was 21.5% white (n= 66), 9.8% asian/pacific (n=30), 3.6% black (n=11), and 65.1% other (n=200). Primary languages were English (n=205, 66.8%), Spanish (n=84, 27.4%), and other (n=4, 1.3%).
64.5% of patients (n=198) had state insurance, 20.5% (n=63) PPO, 11.7% (n=36) HMO, and 3.3% (n=10) other. Average patient distance from hospital was 47.9±138.9 miles. Average patient follow up time was 5.0±2.8 years. With increasing distance to hospital, patients were significantly more likely to be non-hispanic, English speaking, have PPO insurance, and decreased length of follow-up (p<0.01, p<0.005, p<0.01, p< 0.005 respectively). Hispanic patients had significantly more state compared to PPO insurance (p=<0.001). No significance was observed between race (p=0.146) or cleft type (p=0.264) and distance to hospital. In subgroup analysis, CL and CLP patients were more likely to have PPO than state insurance with increasing distance from hospital (p<0.01, p<0.05). In CLP patients, language was significant, with more English versus Spanish speakers at greater distance from hospital (p<0.05). For CP patients, no associations were statistically significant. CONCLUSION: In this study, further distance from hospital is negatively correlated with being hispanic, Spanish speaking, and having government insurance, particularly in CL and CLP patients. Therefore ethnicity, language, and socioeconomic status (assuming insurance type as a proxy) are potential barriers to cleft care in Los Angeles. Additional data including income, transportation method, and proximity to other cleft centers is needed to better understand these trends. Evaluation of additional patients and geospatial mapping may identify populations with unmet need for cleft care and determine ideal accessibility of cleft services.
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