**5. Follow up**

Post-operative follow-up is an indispensable component of any type of surgical care. It is especially critical in cleft care as speech therapy is a necessary adjunct to realizing the full benefits of palatoplasty. Additionally, longitudinal patient evaluation is important when analyzing outcomes and quality improvement interventions. Unfortunately, follow-up is also one of the most challenging aspects of patient care in LMICs due to the time and financial burden placed on patients, as well as limited access to transportation. In the early stages of operation at GCCCC, significant barriers were noted to follow-up, necessitating a rethinking of the way follow-ups were performed.

The District Outreach Follow-up and Speech Therapy (DOFAST) program was started by GCCCC with the goal of bringing the follow-up to patients instead of having them travel to the center. Small multi-disciplinary teams of providers

**43**

*Optimizing Outcomes in Cleft Surgery*

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

lodging had to be covered by the center.

**6. Esthetic outcomes**

were sent to outreach camps near patients living more than 200 km away if there were at least 20 patients to be seen. When patients were evaluated at GCCCC, the direct cost of transportation is covered by the center, but patients must still deal with the indirect costs of travel such as time off from work. These indirect costs are decreased with the DOFAST program, but the costs of staff travel, meals, and

A prospective study was launched to measure changes in follow-up rates and costs after the launch of the DOFAST program [14]. Questionnaires were also completed by 195 patients (122 at GCCCC and 73 at DOFAST camps) to evaluate expenses, time lost, and other patient-related variables. Patients who attended local follow up had fewer accompanying family members, fewer days off work, less lost income (Rs 143 vs. 367; p < 0.05) and lower direct costs (Rs 299 vs. 911; p < 0.05) compared to patients seen at GCCCC. Post-operative follow-up visits increased from 139 monthly visits (follow-up to surgery ratio of 0.722) to 363 monthly visits (ratio of 1.57). Additionally, the average cost to the center per patient was lower for

local follow-up compared to follow-up at the center (Rs. 303 vs. 1100).

post-operative results after cleft lip repair using validated instruments.

a few surgeons and many non-medical personnel.

While complications following cleft lip repairs are widely reported in the literature, esthetic outcomes are rarely assessed. Furthermore, esthetic outcomes after cleft lip repair in LMICs are rarely, if ever, reported. The goals of any quality improvement initiative are not only to reduce complication rates, but also to help patients achieve the best possible esthetic result from their surgery. To that end, OS started the Surgical Outcomes Program (SOP) which aims to critically evaluate

The Unilateral Cleft Lip Severity Index was developed as a tool for analyzing and categorizing unilateral cleft lip deformities according to the amount of lip involved and the degree of nasal asymmetry (**Figure 5**) [31]. The severity index was validated in a study measuring the inter-rater reliability of the tool when used by both surgeon and laypersons. Twenty-five participants (10 surgeons and 15 laypeople) evaluated 25 sets of pre-surgical photographs of unilateral cleft lip patients. Inter-rater reliabilities for both groups were categorized as very good (ICC > 0.8). The severity index is used in conjunction with the Surgical Outcomes Evaluation Scale, which grades the esthetic outcome of a unilateral cleft lip repair based on the symmetry of the nose, cupid's bow, lateral lip, and free vermilion (**Figure 6**) [32]. A similar validation study was performed for the outcomes evaluation scale in which 20 participants (9 surgeons and 12 laypeople) evaluated 25 sets of post-operative photographs. Inter-rater reliabilities were 0.71 for surgeons and 0.82 for laypeople. The validation of these tools for use by non-medical personnel is important as they were designed to be used in resource-limited settings by mission teams composed of

The Unilateral Cleft Lip Severity Index and Surgical Outcomes Evaluation Scale are now utilized globally and provide feedback regarding outcomes to volunteer surgeons as well as OS administrators with a relatively short turn-around time. In order to aid in the interpretation of results, a retrospective study was performed applying the severity index and outcomes evaluation scale to 1823 patients who had undergone unilateral cleft lip repair by OS during missions in various countries and at GCCCC [33]. The results of this study established a normative bell curve of outcomes for each severity of unilateral cleft lip deformity (**Figure 7**). Based on these normative values, a surgeon can see where his or her results fall in the range of results for a given severity of cleft. Surgeons who fall on the upper end of the spectrum can

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

*Current Treatment of Cleft Lip and Palate*

patient understanding and compliance.

• No post-operative antibiotics

*Cleft Lip* [27]

*Cleft Palate* [28]

families [26].

• Nothing in mouth

• Older patients

*Cases to be performed by experienced surgeons* • Complete unilateral cleft palate • Complete bilateral cleft palate

1. Implement standardized perioperative protocols for cleft lip and cleft palate.

• 1 dose pre-operative intravenous antibiotic before incision

• Wash wound two times a day with clean water and blot dry • Normal diet with soft foods, breastfeeding okay immediately

• 1 dose pre-operative intravenous antibiotic before incision

instructions and provide handouts in the local language with pictographs. 3. Higher risk patients should be done by the most experienced surgeons [28].

4. Educate surgeons about optimal techniques for successful outcomes [29].

*Evidence-based recommendations for improving outcomes in cleft surgery.*

• No tapes over incisions or other complicated dressings

• No chewing tobacco, pan, etc. for older patients

• 5 days of oral antibiotics post-operatively [30]

Standardizing things means all doctors and nurses are doing the same thing and this translates into improved

• Oral hygiene including washing mouth after eating and brushing teeth twice a day

• May breastfeed immediately; liquid diet by syringe / spoon for 1 week; soft diet for three weeks

• Oral hygiene including washing mouth after eating and brushing teeth twice a day

2. Implement standardized patient education program that is taught to nurses then to patients and

Teaching sessions are held on the ward after surgery before discharge where nurses go through all discharge

**42**

**5. Follow up**

**Table 3.**

were performed.

Post-operative follow-up is an indispensable component of any type of surgical care. It is especially critical in cleft care as speech therapy is a necessary adjunct to realizing the full benefits of palatoplasty. Additionally, longitudinal patient evaluation is important when analyzing outcomes and quality improvement interventions. Unfortunately, follow-up is also one of the most challenging aspects of patient care in LMICs due to the time and financial burden placed on patients, as well as limited access to transportation. In the early stages of operation at GCCCC, significant barriers were noted to follow-up, necessitating a rethinking of the way follow-ups

Complications in cleft palate surgery are very closely linked to technique. Surgeons should be taught to

adequately mobilize all tissues for a tension-free repair. Delicate tissue handling is stressed.

The District Outreach Follow-up and Speech Therapy (DOFAST) program was started by GCCCC with the goal of bringing the follow-up to patients instead of having them travel to the center. Small multi-disciplinary teams of providers

were sent to outreach camps near patients living more than 200 km away if there were at least 20 patients to be seen. When patients were evaluated at GCCCC, the direct cost of transportation is covered by the center, but patients must still deal with the indirect costs of travel such as time off from work. These indirect costs are decreased with the DOFAST program, but the costs of staff travel, meals, and lodging had to be covered by the center.

A prospective study was launched to measure changes in follow-up rates and costs after the launch of the DOFAST program [14]. Questionnaires were also completed by 195 patients (122 at GCCCC and 73 at DOFAST camps) to evaluate expenses, time lost, and other patient-related variables. Patients who attended local follow up had fewer accompanying family members, fewer days off work, less lost income (Rs 143 vs. 367; p < 0.05) and lower direct costs (Rs 299 vs. 911; p < 0.05) compared to patients seen at GCCCC. Post-operative follow-up visits increased from 139 monthly visits (follow-up to surgery ratio of 0.722) to 363 monthly visits (ratio of 1.57). Additionally, the average cost to the center per patient was lower for local follow-up compared to follow-up at the center (Rs. 303 vs. 1100).
