A low-cost method of craniofacial distraction osteogenesis.

AIM: Distraction osteogenesis is an effective treatment modality for the correction of craniofacial deformities. The cost of these devices is significant and may preclude routine use of these distractors in developing countries. Hence, distraction osteogenesis was performed using medical equipment that was readily available in any hospital at minimal cost. PATIENTS AND METHODS: From 2008 to 2013, a retrospective study was performed on infants and neonates who underwent primary distraction for craniofacial abnormalities. Midface or mandibular distraction was performed because of respiratory impairment and/or globe exposure. The apparatus used included Steinmann pins, stainless steel wires, attachment bolts, orthopaedic pulleys, string and intravenous bags for weights. For midface distraction, a transzygomatic pin was inserted, and a transmandibular pin or a cerclage wire was inserted into the mandible through the symphysis or body of the mandible and connected to the pulley system. RESULTS: Distraction osteogenesis was performed on five patients - three mandibular distractions (Pierre Robin sequence) and two transfacial distractions (Apert syndrome/Pfeiffer syndrome type III). The mean age, duration of distraction and duration of consolidation at the time of distraction was 60.5 days, 18.6 days and 16.4 days, respectively. The mean length of distraction achieved was 12 mm. Common complications observed were pin loosening, pressure necrosis of the skin and uneven pull. A major disadvantage was the longer hospital stay required. CONCLUSION: The African method of distraction is effective, easy and cost effective and could be used in third-world hospitals where surgical expertise or expensive distraction sets are not freely available.

Study of Treatment Expense of Patients with Congenital Malformations of Craniofacial in Srinagarind Hospital between 2010 and 2014.

Objectives: To report the treatment expenses of the congenital malformations of craniofacial of in-patients of Srinagarind Hospital between 2010 and 2014 Material and Method: The expenses of congenital malformations of craniofacial in-patients of Srinagarind Hospital were studied by analyzing the actual amount charged and the reimbursement of treatment expenses. Results: One thousand eight hundred forty five in-patients were treated 2,144 times. The average treatment was about once or twice per person. Male patients were 54.1% and female were 45.9%. About 84% of the patients were under the universal coverage, with an average Relative Weight (RW) between 2010 and 2014 of 1.6988, 1.7059, 1.4847, 1.4165, and 1.5096, respectively. The average of the RW and the treatment expenses differentiated by the patients' eligible medical expenses for self-paid, Government or State Enterprise Officer (OFC), Social Security Scheme (SSS), and universal coverage (UC) were 1.0398, 1.1596, 1.2759, 1.3477, respectively. The average RW calculated under diagnosis-related group (DRG) for each patient was 1.3148. The estimated RW of OFC at 13,378 and UC at 9,600 baht per RW were 18,081, 14,535, 14,259, and 17,118 baht, for an average of 16,842 baht. The average of the treatment expenses charged by the hospital to the OFC was 14,535 baht and to the UC was 17,118 baht for each treatment. The treatment expense under DRG was lower than the cost under the hospital charge by 2,051,072 baht. Conclusion: The present study analyzed the treatment expense by patients' eligible medical expenses between 2010 and 2014. The universal coverage and government or state enterprise officer's charges were reimbursed to the hospital under DRG system for 32,257,000 baht while the hospitals actual charges were 34,308,072 baht. This indicated that Srinagarind Hospital must set up the fund to support congenital malformations of craniofacial patients for a minimum sum of 410,214 baht per year. This is likely to increase in the future.

Scalable, sustainable cost-effective surgical care: a model for safety and quality in the developing world, part I: challenge and commitment.

BACKGROUND: With an estimated backlog of 4,000,000 patients worldwide, cleft lip and cleft palate remain a stark example of the global burden of surgical disease. The need for a new paradigm in global surgery has been increasingly recognized by governments, funding agencies, and professionals to exponentially expand care while emphasizing safety and quality. This three-part article examines the evolution of the Operation Smile Guwahati Comprehensive Cleft Care Center (GCCCC) as an innovative model for sustainable cleft care in the developing world. METHODS: The GCCCC is the result of a unique public-private partnership between government, charity, and private enterprise. In 2009, Operation Smile, the Government of Assam, the National Rural Health Mission, and the Tata Group joined together to work towards the common goal of creating a center of excellence in cleft care for the region. RESULTS: This partnership combined expertise in medical care and training, organizational structure and management, local health care infrastructure, and finance. A state-of-the-art surgical facility was constructed in Guwahati, Assam which includes a modern integrated operating suite with an open layout, advanced surgical equipment, sophisticated anesthesia and monitoring capabilities, central medical gases, and sterilization facilities. CONCLUSION: The combination of established leaders and dreamers from different arenas combined to create a synergy of ambitions, resources, and compassion that became the backbone of success in Guwahati.

Scalable, sustainable cost-effective surgical care: a model for safety and quality in the developing world, part II: program development and quality care.

BACKGROUND: The Guwahati Comprehensive Cleft Care Center (GCCCC) is committed to free medical and surgical care to patients afflicted with facial deformities in Assam, India. A needs-based approach was utilized to assemble numerous teams, processes of care, and systems aimed at providing world-class care to the most needy of patients, and to assist them with breaking through the barriers that prohibit them from obtaining services. METHODS: A team of international professionals from various disciplines served in Guwahati full time to implement and oversee patient care and training of local counterparts. Recruitment of local professionals in all disciplines began early in the scheme of the program and led to gradual expansion of all medical teams. Emphasis was placed on achieving optimal outcome for each patient treated, as opposed to treating the maximum number of patients. RESULTS: The center is open year round to offer full-time services and follow-up care. Along with surgery, GCCCC provides speech therapy, child life counseling, dental care, otolaryngology, orthodontics, and nutrition services for the cleft patients under one roof. Local medical providers participated in a model of graded responsibility commiserate with individualized skill and progress, and gradually assumed all leadership positions and now account for 92% of the workforce. Institutional infrastructure improvements positioned and empowered teams of skilled local providers while implementing systemized perioperative processes. CONCLUSION: This needs-based approach to program development in Guwahati was successful in optimization of quality and safety in all clinical divisions.

Scalable, sustainable cost-effective surgical care: a model for safety and quality in the developing world, part III: impact and sustainability.

BACKGROUND: The Guwahati Comprehensive Cleft Care Center (GCCCC) utilizes a high-volume, subspecialized institution to provide safe, quality, and comprehensive and cost-effective surgical care to a highly vulnerable patient population. METHODS: The GCCCC utilized a diagonal model of surgical care delivery, with vertical inputs of mission-based care transitioning to investments in infrastructure and human capital to create a sustainable, local care delivery system. Over the first 2.5 years of service (May 2011-November 2013), the GCCCC made significant advances in numerous areas. Progress was meticulously documented to evaluate performance and provide transparency to stakeholders including donors, government officials, medical oversight bodies, employees, and patients. RESULTS: During this time period, the GCCCC provided free operations to 7,034 patients, with improved safety, outcomes, and multidisciplinary services while dramatically decreasing costs and increasing investments in the local community. The center has become a regional referral cleft center, and governments of surrounding states have contracted the GCCCC to provide care for their citizens with cleft lip and cleft palate. Additional regional and global impact is anticipated through continued investments into education and training, comprehensive services, and research and outcomes. CONCLUSION: The success of this public private partnership demonstrates the value of this model of surgical care in the developing world, and offers a blueprint for reproduction. The GCCCC experience has been consistent with previous studies demonstrating a positive volume-outcomes relationship, and provides evidence for the value of the specialty hospital model for surgical delivery in the developing world.

Critical issues in craniofacial care: quality of life, costs of care, and implications of prenatal diagnosis.

Since the 2000 Surgeon General's Report on Oral Health (SGROH), substantial areas of inquiry relative to individuals, especially children and youth, with orofacial clefts and other craniofacial conditions have emerged. These areas include access to and cost of care, stigmatization and quality of life, and social and ethical issues around prenatal diagnosis. This update on the 2000 SGROH examines what we have learned about the cost and ability to access cleft and craniofacial care, prenatal diagnosis, and how quality of life is impacted by these conditions and the burden of care. The development of new research tools to assess quality of life since 2000 will permit further study of the impact of oral and craniofacial conditions on children and families and the effect of treatment on quality of life. Despite a better understanding of the higher use of services and increased costs of care for families of children with craniofacial conditions, major gaps in research must be addressed to assist with program planning and policy development for these groups of children and their families. Further work is also needed to assess the cost-effectiveness of craniofacial team care and to better understand family experience with accessing needed care. Finally, prenatal detection and diagnosis of clefts and craniofacial conditions have advanced dramatically, and the roles of craniofacial professionals and teams have been affected. New understandings of prenatal diagnosis and genomic sciences are redefining genetic counseling, therapy, and future preventive initiatives.

Why do we behave as we do?

It is important for surgeons to have insight into themselves, their life stories, and the rationales they use to convince themselves that their actions are unselfish and well motivated. The battle between Philanthropia and Philotechnica was recognized by Hippocrates and is still a source of internal strife for many surgeons: the need to perform an operation that they are poorly equipped to do offset against the knowledge that it could be better done by someone else. In the treatment or referral for treatment of children with craniosynostosis and craniofacial syndromes, appropriate referrals are often not made or are made only after some problem has occurred as a result of surgical intervention. Several instances of children receiving extensive surgery for wrongly diagnosed craniosynostosis are explored. The thesis is that only by knowing our own internal motivations can we avoid falling into a posture that is good for our own egos and pocketbooks but bad for our patients.

Global strategies to reduce the health care burden of craniofacial anomalies: report of WHO meetings on international collaborative research on craniofacial anomalies.

Although several significant research projects have arisen from international cooperation, especially in the field of genetics, these have been the exception rather than the rule. However, those of us who had the privilege and delight of participating in the World Health Organization meetings were struck by a common realization of the vast potential of systematic international cooperation. It is clear that the global model will be the most effective approach for tackling the big questions in craniofacial anomalies, be they concerned with cause, treatment, or prevention. This report will serve as a road map for making collaboration the rule and not the exception and hopefully be a stimulus for the creation of partnerships between international research teams and funding agencies.

Perceived functional impact of abnormal facial appearance.

Functional facial deformities are usually described as those that impair respiration, eating, hearing, or speech. Yet facial scars and cutaneous deformities have a significant negative effect on social functionality that has been poorly documented in the scientific literature. Insurance companies are declining payments for reconstructive surgical procedures for facial deformities caused by congenital disabilities and after cancer or trauma operations that do not affect mechanical facial activity. The purpose of this study was to establish a large, sample-based evaluation of the perceived social functioning, interpersonal characteristics, and employability indices for a range of facial appearances (normal and abnormal). Adult volunteer evaluators (n = 210) provided their subjective perceptions based on facial physical appearance, and an analysis of the consequences of facial deformity on parameters of preferential treatment was performed. A two-group comparative research design rated the differences among 10 examples of digitally altered facial photographs of actual patients among various age and ethnic groups with "normal" and "abnormal" congenital deformities or posttrauma scars. Photographs of adult patients with observable congenital and posttraumatic deformities (abnormal) were digitally retouched to eliminate the stigmatic defects (normal). The normal and abnormal photographs of identical patients were evaluated by the large sample study group on nine parameters of social functioning, such as honesty, employability, attractiveness, and effectiveness, using a visual analogue rating scale. Patients with abnormal facial characteristics were rated as significantly less honest (p = 0.007), less employable (p = 0.001), less trustworthy (p = 0.01), less optimistic (p = 0.001), less effective (p = 0.02), less capable (p = 0.002), less intelligent (p = 0.03), less popular (p = 0.001), and less attractive (p = 0.001) than were the same patients with normal facial appearances. Facial deformity caused by trauma, congenital disabilities, and postsurgical sequelae present with significant adverse functional consequences. Facial deformities have a significant negative effect on perceptions of social functionality, including employability, honesty, and trustworthiness. Adverse perceptions of patients with facial deformities occur regardless of sex, educational level, and age of evaluator.