Monday, February 13, 2017

From The Bench: Minority and Public Insurance Status: Delay to Treatment

By Francis Smith

Minority and Public Insurance Status: Is There a Delay to Alveolar Bone Grafting Surgery?

from The Cleft Palate-Craniofacial Journal, Volume 54, Issue 1, January 2017.

A new article in The Cleft Palate-Craniofacial Journal illustrates the inequality of access of children to critical cleft lip/palate surgery due to minority status.

There are certain ages or life stages at which repair of cleft lip and palate and subsequent follow-up procedures need to be done to ensure good oral and dental function and health, according to published guidelines . Primary cleft repair takes place within the first 12-18 months of life, and follow-up surgeries should be performed according to the stages of development of the palate and other oral structures. A cleft in the lip and/or palate can result in a gap in the alveolus, or bony structure that forms the upper dental arch. One critical surgery is alveolar bone grafting (ABG) surgery, in which bone is taken from the pelvis (specifically, from the iliac crest) and put into the alveolar gap resulting from the cleft, to close the gap. ABG surgery is typically performed at age 8 or 9, during transition from the deciduous dentition ("baby teeth") to permanent dentition ("adult teeth"). This surgery is necessary in order to stabilize the dental arch, provide bony support for permanent teeth and allow for complete oral rehabilitation going forth. Without this surgery, or if it is delayed, complete repair of the cleft is impossible, the dental arch is unstable and cannot support permanent teeth, and oral rehabilitation is compromised.

Unfortunately, children in minority racial groups (particularly black and Hispanic) and who are on public medical insurance (such as Medicaid and state Title V plans) have less access to health care than those in non-minority groups and insured privately. This includes children with cleft lip and/or palate. Prior research has found such a delay in cleft palate repair and follow-up surgeries in children in minority groups and who are on public insurance plans. 

Researchers at the Children's Hospital of Philadelphia (CHOP) did a 13-year retrospective chart study of 233 patients who underwent ABG surgery at CHOP to determine when the children had the surgery. The researchers included only children with nonsyndromic clefts (not part of any syndrome) who had prior preliminary cleft palate repair at CHOP and stayed on with the same team over the years for the ABG surgery; those who left the team before ABG were excluded. Also, this study is the experience of one institution, and not necessary reflective of the general experience among other hospitals. On average, the age at which ABG was done was 8 years. However, Caucasian and Asian children underwent ABG approximately one year earlier than their African-American and Hispanic peers. Further, the researchers found that most of the patients examined in the study who had ABG surgery were white males as well as on Asian children who were adopted into white families and got timely cleft care once they entered the healthcare system. In this study, insurance status played no significant role--the type of insurance did not affect the timing of surgery, and less than 20% of patients were on public insurance.

From their results, the team concluded that there are significant delays and disparities in timely ABG surgery among black and Hispanic children compared to their white and Asian peers. This demonstrates a need to increase minority access to good healthcare and treatment for cleft lip and palate in a timely fashion.

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