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Clinical Practice Patterns And Evidence-based Medicine In Cleft Palate Repair: A Sixteen-year Review Of Maintenance Of Certification Tracer Data From The American Board Of Plastic Surgery
Aaron M. Kearney, Arun K. Gosain, MD.
Northwestern University, Chicago, IL, USA.

PURPOSE: As a component of the Maintenance of Certification (MOC) process from 2003 to 2019, the American Board of Plastic Surgery (ABPS) tracked 20 common plastic surgery operations, or tracer procedures. By evaluating the data collected over 16 years, we are able to examine the practice patterns of pediatric/craniofacial surgeons in the United States.
METHODS: Cumulative data for the tracer procedure on primary cleft palate repair that had been accumulated since 2003 were reviewed as of April, 2014 and September, 2019. To assess points covered by evidence-based medicine articles, cleft palate Evidence-Based Medicine (EBM) articles published in Plastic and Reconstructive Surgery were reviewed. Changes in tracer data from 2014 to 2019 were compared using a Chi square test, Fisher’s exact test, or Student’s t-test as appropriate.
RESULTS: 2,850 cases (1,507 male, 1,343 female) had been entered into the tracer as of September, 2019. The median age of patients operated on was 12 months. 15% of patients had a “previous airway problem”. 3% of patients receiving a two-stage repair. Several significant changes in operative techniques were noted (Table 1) including a decrease in pushback, Von Langenbeck and Furlow palatoplasty. Several additional questions in the ABPS tracer are not addressed in the EBM literature, a few of which provide potential topics for further study. These include use of greater than 24 hours of postoperative antibiotics, and injection of epinephrine, which changed significantly from 2014 to 2019. 94.2% of the 2850 patients reported in the ABPS tracer data experienced no postoperative adverse events (Table 2). 58 complications, or 34.9% of all complications, did not fit into any of the categories specified in the tracer data.
CONCLUSION: ABPS MOC tracer data enables surgeons to evaluate their outcomes in light of national statistics. We have used these tracer data combined with published evidence-based medicine articles relevant to cleft palate repair to identify trends in cleft palate repair from 2014 to 2019. By providing an overview of areas of focus in the MOC tracer data as well as EBM articles, we hope to provide a venue for surgeons to further evaluate their own practice through review of the literature. We have additionally identified areas of cleft palate research that have not been addressed by the tracer and may be valuable to include in the MOC tracer module in the future. Finally, areas collected in the tracer but not addressed in the literature provide opportunities for further research into aspects of cleft palate repair.

Table 1. Operative Techniques in Cleft Palate Repair
Technique2014n = 14702019n = 2850p
Two-Flap722 (25.3%)
Pushback223 (15.2%)280 (9.8%)< .0001
Von Langenbeck265 (18.0%)420 (14.7%).005
Vomer Flap349 (23.7%)668 (23.4%).824
Furlow474 (32.2%)525 (18.4%)< .0001
Intravelar veloplasty723 (49.2%)1496 (52.5%).039
More than one day of antibiotics675 (45.9%)1178 (41.3%).004
Injection of epinephrine before prep757 (51.5%)791 (27.8%)< .0001
Injection of epinephrine after prep663 (45.1%)1055 (37.0%)< .0001

Table 2. Complications
ComplicationNo. of patientsn = 2850% of complications
No complications2684 (94.2%)
Infection11 (0.4%)6.6%
Bleeding - return to OR2 (0.1%)1.2%
Bleeding - prolonged pressure1 (< 0.1%)0.6%
Bleeding - transfusion1 (< 0.1%)0.6%
Fistula - hard palate34 (1.2%)20.5%
Fistula - hard-soft junction43 (1.5%)25.9%
Fistula - soft palate16 (0.6%)9.6%
Unaccounted for58 (2.0%)34.9%

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