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The effect of surgeon experience on velopharyngeal functional outcome following palatoplasty: is there a learning curve?

Abstract There is little information in the cleft palate literature concerning the relationship between surgeon volume and clinical outcomes. It is unknown whether such a relationship applies specifically to velopharyngeal dysfunction and the need for secondary physical management of the velopharynx. The purpose of this paper was to explore the concept of an operative learning curve for different surgeons with respect to palatoplasty. Impact of case volume and procedure type on the occurrence of secondary palatal management (the main outcome measure) was assessed. The charts of 472 consecutive palatoplasty patients were reviewed by one speech and language pathologist to determine when the palatoplasty was performed, which surgeon (n = 9) performed the palatoplasty, whether velopharyngeal status was documented at a minimum of 6 years of age, and whether secondary palatal management was prescribed. The results were analyzed by year of palatoplasty, by surgeon, and by number of operations per surgeon to determine total and individual surgeon rates of secondary palatal management. There were 401 palatoplasties (85 percent recovery) with adequate documentation of velopharyngeal status by at least 6 years of age. Palatoplasty rates ranged between 1 and 258 palatoplasties per surgeon. Over the 12 years reviewed, secondary palatal management was performed for 92 patients (23 percent) of the study population. Examination of the proportion of palatoplasty patients receiving secondary palatal management by surgeon and by year showed only one surgeon with a pattern suggesting a learning curve. The proportion of patients receiving secondary palatal management was plotted against the total number of surgeries the surgeon performed. There was a strong relationship between experience and success. The number of procedures this surgeon performed per year increased at approximately the same time as the success rate improved. The categories of "total procedures" and "procedure per year" were highly correlated with each other. Success rates were analyzed by number of procedures performed per year, and there was a clear association between the two variables. To separate the effect of the two variables, a multiple regression model was constructed. The category of "total procedures" was statistically significant in the model, whereas procedures per year was not, suggesting that the key to the dominant surgeon's improvement was cumulative experience rather than frequency of performance of the operation. Palatoplasties performed by high-volume surgeons are more likely to result in better postoperative outcomes (i.e., lower rates of secondary palatal management) as compared with palatoplasties performed by low-volume surgeons. The influence of the surgeon's cumulative experience on improvement seems to be more important than the frequency of performance of primary palatoplasty.
PMID
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Authors

Mayor MeshTerms

Clinical Competence

Keywords
Journal Title plastic and reconstructive surgery
Publication Year Start




PMID- 9773991
OWN - NLM
STAT- MEDLINE
DCOM- 19981029
LR  - 20150624
IS  - 0032-1052 (Print)
IS  - 0032-1052 (Linking)
VI  - 102
IP  - 5
DP  - 1998 Oct
TI  - The effect of surgeon experience on velopharyngeal functional outcome following
      palatoplasty: is there a learning curve?
PG  - 1375-84
AB  - There is little information in the cleft palate literature concerning the
      relationship between surgeon volume and clinical outcomes. It is unknown whether 
      such a relationship applies specifically to velopharyngeal dysfunction and the
      need for secondary physical management of the velopharynx. The purpose of this
      paper was to explore the concept of an operative learning curve for different
      surgeons with respect to palatoplasty. Impact of case volume and procedure type
      on the occurrence of secondary palatal management (the main outcome measure) was 
      assessed. The charts of 472 consecutive palatoplasty patients were reviewed by
      one speech and language pathologist to determine when the palatoplasty was
      performed, which surgeon (n = 9) performed the palatoplasty, whether
      velopharyngeal status was documented at a minimum of 6 years of age, and whether 
      secondary palatal management was prescribed. The results were analyzed by year of
      palatoplasty, by surgeon, and by number of operations per surgeon to determine
      total and individual surgeon rates of secondary palatal management. There were
      401 palatoplasties (85 percent recovery) with adequate documentation of
      velopharyngeal status by at least 6 years of age. Palatoplasty rates ranged
      between 1 and 258 palatoplasties per surgeon. Over the 12 years reviewed,
      secondary palatal management was performed for 92 patients (23 percent) of the
      study population. Examination of the proportion of palatoplasty patients
      receiving secondary palatal management by surgeon and by year showed only one
      surgeon with a pattern suggesting a learning curve. The proportion of patients
      receiving secondary palatal management was plotted against the total number of
      surgeries the surgeon performed. There was a strong relationship between
      experience and success. The number of procedures this surgeon performed per year 
      increased at approximately the same time as the success rate improved. The
      categories of "total procedures" and "procedure per year" were highly correlated 
      with each other. Success rates were analyzed by number of procedures performed
      per year, and there was a clear association between the two variables. To
      separate the effect of the two variables, a multiple regression model was
      constructed. The category of "total procedures" was statistically significant in 
      the model, whereas procedures per year was not, suggesting that the key to the
      dominant surgeon's improvement was cumulative experience rather than frequency of
      performance of the operation. Palatoplasties performed by high-volume surgeons
      are more likely to result in better postoperative outcomes (i.e., lower rates of 
      secondary palatal management) as compared with palatoplasties performed by
      low-volume surgeons. The influence of the surgeon's cumulative experience on
      improvement seems to be more important than the frequency of performance of
      primary palatoplasty.
FAU - Witt, P D
AU  - Witt PD
AD  - Department of Plastic and Reconstructive Surgery, St. Louis Children's Hospital
      at Washington University School of Medicine, MO 63110, USA.
FAU - Wahlen, J C
AU  - Wahlen JC
FAU - Marsh, J L
AU  - Marsh JL
FAU - Grames, L M
AU  - Grames LM
FAU - Pilgram, T K
AU  - Pilgram TK
LA  - eng
PT  - Journal Article
PL  - United States
TA  - Plast Reconstr Surg
JT  - Plastic and reconstructive surgery
JID - 1306050
SB  - AIM
SB  - IM
MH  - Cleft Palate/*surgery
MH  - *Clinical Competence
MH  - Female
MH  - Humans
MH  - Infant
MH  - Male
MH  - Palate/*surgery
MH  - Retrospective Studies
MH  - Speech Disorders/etiology
MH  - Surgery, Plastic/statistics & numerical data
MH  - Treatment Outcome
EDAT- 1998/10/17 00:00
MHDA- 1998/10/17 00:01
CRDT- 1998/10/17 00:00
PHST- 1998/10/17 00:00 [pubmed]
PHST- 1998/10/17 00:01 [medline]
PHST- 1998/10/17 00:00 [entrez]
PST - ppublish
SO  - Plast Reconstr Surg. 1998 Oct;102(5):1375-84.