**2. Models of cleft care delivery**

Charitable foundations have supported cleft missions to LMICs since the late 1960s. Early efforts followed a vertical model of care delivery in which teams are sent to underserved regions for short-periods of time to provide surgical care. This model has often been criticized for its emphasis on patient volume over quality, and for its inherently limited provision for post-surgical follow up [8]. Other criticisms include the marginalization of local providers whose welfare may be threatened by foreign aid, and the use of missions as a training ground for surgeons with little experience in cleft lip and palate repair [17]. Despite these criticisms, cleft missions have been an impactful mean to serve a large number of untreated patients and are essential in parts of the world where cleft care is otherwise nonexistent.

A horizontal model of care delivery focuses solely on building local capacity by partnering with area institutions and equipping them to become autonomous centers for comprehensive cleft care. This is accomplished through long-term financial commitments and by providing training to local surgeons, with the goal of ultimately making foundational support obsolete. The horizontal model has been effective in many LMICs, with substantial disability-adjusted life years (DALYs) averted in a cost-effective manner [18, 19]. However, the success of this model hinges on extended periods of investment from charitable organizations, as well as from individual providers, and this limits the scope of this strategy. Additionally, a horizontal program can only be initiated in regions where a care system already exists. Thus, in the most remote areas of the world, surgical missions are still a necessity.

A broadly applicable yet effective strategy for cleft care in LMICs should mobilize surgical missions while simultaneously working to increase the capacity of the local healthcare system, and this has been termed the diagonal model of healthcare delivery (**Figure 1**) [20]. In the state of Assam, India, this model has been utilized to develop a sustainable, high-volume cleft care center that emphasizes empowerment of local providers and continuous quality improvement.

**37**

**Table 1.**

*based care to center-based care.*

ogy, and nutrition.

**Figure 1.**

*surgeons.*

*Optimizing Outcomes in Cleft Surgery*

*DOI: http://dx.doi.org/10.5772/intechopen.89882*

In 2009, OS began missions to Guwahati, a large city in the state of Assam in India. After seeing the outsized burden of untreated clefts in this region, OS partnered with the state government of Assam and with Indian charitable foundations to establish the Guwahati Comprehensive Cleft Care Center (GCCCC) [21]. GCCCC is a surgical specialty hospital dedicated to providing the full spectrum of cleft care to patients who otherwise would not have access to it [22]. Since its opening in 2011, GCCCC has treated over 16,000 patients, while providing a center of operations for follow up and outcomes evaluation [23]. One of the initial goals of GCCCC was to provide training to local providers, and the center is now led entirely by local staff representing plastic surgery, oral surgery, orthodontics, speech pathology, psychol-

*In the diagonal model of cleft care delivery, surgical missions are mobilized while simultaneously initiating efforts to increase local capacity. Missions serve as a bridge to the ultimate goal of transitioning care to local* 

Two large missions were held in Guwahati prior to the opening of GCCCC, and this period of transition provides a unique opportunity to compare outcomes between a mission-based model of care delivery and a center-based model. In order to evaluate differences in complications, we performed a retrospective review of 3419 consecutive patients who underwent cleft lip repair and 1728 consecutive patients who underwent cleft palate repair with OS over a 4-year period

(2010–2014) [13]. Our results show that early complication rates decreased for both cleft lip and cleft palate repairs with the transition to center-based care at GCCCC (p < 0.05) (**Table 1**). For cleft lip repairs, complication rates (infection, wound dehiscence) decreased three-fold from the initial mission, and for cleft palate repairs, complication rates (bleeding, flap necrosis, dehiscence, fistula formation)

No. cleft lip repairs 298 356 2765

No. cleft palate repairs 120 116 1491

Cleft lip complications 13.2% 6.7% 4% <0.05

Cleft palate complications 28% 30% 15.8% <0.05

*Early complication rates after cleft lip and cleft palate repair in Guwahati during the transition from mission-*

**Dec 2010 mission Jan 2011 mission GCCCC** *p*

*Optimizing Outcomes in Cleft Surgery DOI: http://dx.doi.org/10.5772/intechopen.89882*

#### **Figure 1.**

*Current Treatment of Cleft Lip and Palate*

access to cleft care in LMICs.

**2. Models of cleft care delivery**

locating former patients, varying degrees of patient compliance, and coordinating

In this chapter, we discuss Operation Smile's quality improvement efforts in global cleft care during the past decade and review their impact on measured outcomes. Operation Smile (OS) is an international not-for-profit organization that has provided hundreds of thousands of free cleft lip and palate surgeries to patients in LMICs since 1982. The organization has placed an emphasis on optimizing patient care through research and maintains electronic medical records and photo documentation for all treated patients. By analyzing data collected from missions and cleft centers, OS has been able to implement standardized protocols and quality control mechanisms that have resulted in decreased complications and increased

Charitable foundations have supported cleft missions to LMICs since the late 1960s. Early efforts followed a vertical model of care delivery in which teams are sent to underserved regions for short-periods of time to provide surgical care. This model has often been criticized for its emphasis on patient volume over quality, and for its inherently limited provision for post-surgical follow up [8]. Other criticisms include the marginalization of local providers whose welfare may be threatened by foreign aid, and the use of missions as a training ground for surgeons with little experience in cleft lip and palate repair [17]. Despite these criticisms, cleft missions have been an impactful mean to serve a large number of untreated patients and are

A horizontal model of care delivery focuses solely on building local capacity by partnering with area institutions and equipping them to become autonomous centers for comprehensive cleft care. This is accomplished through long-term financial commitments and by providing training to local surgeons, with the goal of ultimately making foundational support obsolete. The horizontal model has been effective in many LMICs, with substantial disability-adjusted life years (DALYs) averted in a cost-effective manner [18, 19]. However, the success of this model hinges on extended periods of investment from charitable organizations, as well as from individual providers, and this limits the scope of this strategy. Additionally, a horizontal program can only be initiated in regions where a care system already exists. Thus, in the most remote areas of the world, surgical missions are still a

A broadly applicable yet effective strategy for cleft care in LMICs should mobilize surgical missions while simultaneously working to increase the capacity of the local healthcare system, and this has been termed the diagonal model of healthcare delivery (**Figure 1**) [20]. In the state of Assam, India, this model has been utilized to develop a sustainable, high-volume cleft care center that emphasizes empowerment

of local providers and continuous quality improvement.

essential in parts of the world where cleft care is otherwise nonexistent.

What little data that exists indicates that cleft mission work in low and middleincome countries (LMICs) has at times been associated with poor outcomes [8]. Complication rates following cleft palate repair in these settings often approach 30% and follow up rates are understandably much lower than at tertiary care centers in developed nations [13, 14]. In order to bridge this gap, thoughtfully designed quality improvement measures must be implemented, and outcomes must be tracked over time to prove the efficacy of these interventions. Recently, various groups have contributed to a growing body of literature related to such efforts, and

follow-up with local providers have also been noted as barriers [11, 12].

some substantial improvements have been reported [13, 15, 16].

**36**

necessity.

*In the diagonal model of cleft care delivery, surgical missions are mobilized while simultaneously initiating efforts to increase local capacity. Missions serve as a bridge to the ultimate goal of transitioning care to local surgeons.*

In 2009, OS began missions to Guwahati, a large city in the state of Assam in India. After seeing the outsized burden of untreated clefts in this region, OS partnered with the state government of Assam and with Indian charitable foundations to establish the Guwahati Comprehensive Cleft Care Center (GCCCC) [21]. GCCCC is a surgical specialty hospital dedicated to providing the full spectrum of cleft care to patients who otherwise would not have access to it [22]. Since its opening in 2011, GCCCC has treated over 16,000 patients, while providing a center of operations for follow up and outcomes evaluation [23]. One of the initial goals of GCCCC was to provide training to local providers, and the center is now led entirely by local staff representing plastic surgery, oral surgery, orthodontics, speech pathology, psychology, and nutrition.

Two large missions were held in Guwahati prior to the opening of GCCCC, and this period of transition provides a unique opportunity to compare outcomes between a mission-based model of care delivery and a center-based model. In order to evaluate differences in complications, we performed a retrospective review of 3419 consecutive patients who underwent cleft lip repair and 1728 consecutive patients who underwent cleft palate repair with OS over a 4-year period (2010–2014) [13]. Our results show that early complication rates decreased for both cleft lip and cleft palate repairs with the transition to center-based care at GCCCC (p < 0.05) (**Table 1**). For cleft lip repairs, complication rates (infection, wound dehiscence) decreased three-fold from the initial mission, and for cleft palate repairs, complication rates (bleeding, flap necrosis, dehiscence, fistula formation)


#### **Table 1.**

*Early complication rates after cleft lip and cleft palate repair in Guwahati during the transition from missionbased care to center-based care.*

were halved. These changes are attributable to multiple factors, including the presence of a permanent facility to provide systemized and chronological care, standardized protocols, training of permanent staff in all disciplines, and evolution of techniques over high volumes of cases.

GCCCC was designed from the outset to provide the highest level of care to the people it would serve while integrating the local community into its operations. As the center evolved, various quality metrics began to improve, and this is discussed below. The success in Guwahati highlights the effectiveness of the diagonal model of cleft care delivery, in which surgical missions are initiated with a concomitant effort to build local capacity.
