(10) Neighborhood-Level Socioeconomic Disparities and Their Influence on Cleft Surgery Timing and Long-Term Outcomes: A Three-Decade Experience

Abstract:

Background: Delayed access to cleft surgery can result in considerable morbidity, including nutritional deficiencies, reduced social and educational participation, and speech challenges. The influence of geographical areas of deprivation on the timing of cleft repair surgery has yet to be thoroughly examined. This study investigates the relationship between neighborhood-level socioeconomic deprivation in a major US city and the timing of cleft lip (CL) and palate (CP) repairs over the past three decades.

Methods: A retrospective review of patients who underwent cleft lip and/or palate repair at a major children’s hospital from 1995 to 2024 was conducted. Area Deprivation Index (ADI), a composite measure designed to quantify the geographic distribution of socioeconomic deprivation on a 10-point scale was used to classify patients. Higher scores indicated more disadvantaged neighborhoods (Figure 1). Patients were grouped into low (ADI 1-3), medium (ADI 4-6), and high (ADI 7-10) deprivation cohorts based on their household zip code. The study included patients with both cleft lip and palate, categorized by race and insurance status. Outcome measures were age at surgery, readmission, operative time, and hospitalization duration, with delays defined as cleft lip repair after 6 months and cleft palate repair after 12 months. Statistical analysis was performed using the Kruskal-Wallis test, chi-square, and multivariate logistic regression.

Results: Of 2591 patients a total of 702 of them met the inclusion criteria. Mean ages at cleft lip repair differed across deprivation groups (Low: 3.2 ± 1.6 months; Medium: 5.7 ± 9.8 months; High: 5.5 ± 6.8 months, P = .011). Mean ages at cleft palate repair also differed across deprivation groups (Low: 1.05 ± 0.4 years; Medium: 1.7 ± 2.9 years; High: 1.9 ± 3.1 years, P = .024) (Figure 1). The high and medium deprivation cohorts were significantly 8.5 times more likely to have delayed cleft lip repair (P = .015) and 4.9 times more likely to have cleft palate repair (P = .035) than the low deprivation cohort. White patients were most common in the low deprivation group (36.9%), while Hispanic/Latino patients predominated in the medium (65.5%) and high (71.8%) deprivation groups (P < .001). Logistic regression identified high ADI and female sex as independent predictors of CL delay (P < .001), while public insurance, race, greater hospital distance, and prior CL delay contributed to CP repair delays (P < .001). Readmission rates, operative times, and hospitalization duration did not significantly differ across deprivation groups.

Conclusion: Children from neighborhoods with higher levels of socioeconomic deprivation underwent cleft repairs at older ages and faced greater delays in receiving timely surgical care compared to those from less disadvantaged areas. These findings underscore the impact of socioeconomic factors on timely surgical intervention and suggest a need for targeted strategies to address these disparities and improve outcomes for patients in higher deprivation cohorts.
Figure 1. Distribution of age at surgical repair and ADI by ZIP code.