Reply: Outpatient versus Inpatient Primary Cleft Lip and Palate Surgery: Analysis of Early Complications.

Abstract

Sir: We thank Torabi et al. for their interest in our recently published study and for offering their perspective regarding its results.1 The American College of Surgeons National Surgical Quality Improvement Program Pediatric database user guide specifies that the database “collects data on approximately 120 variables, including preoperative risk factors, intraoperative variables, and 30-day postoperative mortality and morbidity outcomes for patients undergoing major surgical procedures in both the inpatient and outpatient setting.”2 The admission status variable is not “vaguely defined” as Torabi et al. have alluded to. The admission status variable is clearly defined as “The hospital’s definition of inpatient and outpatient status,” and data are collected by a “site’s trained and certified Surgical Clinical Reviewer (SCR) using a variety of methods including medical chart abstraction,” which seems reasonable when one considers the logistics associated with maintaining a national multi-institutional database including thousands of patients from close to 100 institutions.2 The admission status variable has also been used in previously published studies evaluating outcomes following cleft surgery.3,4 We agree with Torabi et al. and Liau and Lin5 that the American College of Surgeons National Surgical Quality Improvement Program Pediatric database is not the ideal database with which to evaluate outcomes following cleft surgery, and its limitations have been clearly highlighted in our article, most importantly for the purposes of this discussion: the coding of hospital length of stay in days rather than hours and its retrospective nature. Ideal data would include cleft surgery–specific variables and would be prospective in nature to establish causality between exposures and outcomes. Nevertheless, the challenges of generating prospective discipline-specific data are well known, and have resulted in major recent efforts to rely on “real-world data,” prospective or retrospective, to support decision-making in health care.6 This is particularly relevant for clinical questions similar to the one raised in our study, where prospective randomization would be unethical. Until better data are available, retrospective studies such as ours can provide a snapshot of clinical practice patterns among cleft providers to assist with clinical decision-making, while emphasizing that “Surgeon clinical judgement and evaluation of overall patient condition” should remain the cornerstone when making these decisions as our study concludes. We respectfully disagree with Torabi et al. that selecting patients with a hospital length of stay coded as 0 is the ideal method to identify patients undergoing outpatient cleft surgery. As highlighted by the discussants, the length of stay of patients staying in the hospital for a few hours might be coded as 1, for example, based on hospital practices. Nevertheless, these patients were included in the inpatient group in their analysis, but would have really undergone outpatient procedures. This can skew the analysis significantly, given that patients with a hospital length of stay coded as 1 were the largest group of patients in both cleft lip and palate groups. Similarly, patients staying in the hospital for 23 hours and extended observation, which do not really fall under the realm of outpatient surgery, might have their length of stay coded as 0 in the database. With these issues in mind, we analyzed the data based on admission status as defined by the developers of the database, while calculating average hospital length of stay adjusted for statistical outliers for each of the groups. Ideally, a hospital length of stay coded in hours would have allowed us to better delineate admission status as described in our article, but such information and hospital-specific definitions of outpatient procedures are not available in the database. We therefore preferred to adhere to variables as defined by the developers of the database. DISCLOSURE None of the authors has a financial interest to declare in relation to the content of this communication. Rami S. Kantar, M.D.Roberto L. Flores, M.D.Hansjörg Wyss Department of Plastic SurgeryNew York University Langone HealthNew York, N.Y.