November #PRSJournalClub Recap – Barriers to reconstructive surgery in low- and middle-income countries: a cross-sectional study of 453 cleft lip and cleft palate patients in Vietnam

by Ibrahim Khansa, MD (@IbrahimKhansaMD)

The November edition of the #PRSJournalClub was another phenomenal discussion, this time centered around global cleft care, with authors William P. Magee III, MD DDS (@wpmagee) and Caroline Yao, MD MS (@CarolineYaoMD). The article, “Barriers to reconstructive surgery in low- and middle-income countries: a cross-sectional study of 453 cleft lip and cleft palate patients in Vietnam” can be accessed for free!

In this article, the authors surveyed 453 families of patients presenting to an Operation Smile mission in Vietnam, in order to investigate barriers to cleft care in that country. Their response rate was an impressive 100%. They found the mean age of children presenting for their first cleft surgery to be 3.24 years. Surprisingly, patients with health insurance were less likely to have received prior surgery than patients without health insurance.

The most common barriers to cleft care were the lack of trained medical personnel, treatment cost, travel costs, family opinion, and lack of trust in the medical system.

November PRS Journal Club Podcast:

Getting Started






 Top Q&A

@shujashafqatmd: how do your results affect need for education of foreign surgeons and patients?
@wpmagee: Lots of great local surgeons. Operation Smile has focused on local training for over 25 years
@CarolineYaoMD: Our research established cross cultural partnerships – the backbone to learning from each other. Key is building cross-cultural, international partnerships btwn surgeons, hospitals & universities. Thru education, improve public perception of trustworthiness of hospitals & medical professionals in developing countries. Financial burden of getting cleft care is paramount. They struggle less with cultural/superstition barriers.

@IbrahimKhansaMD: Interesting that patients with insurance were later to get surgery. Any idea why?
@CarolineYaoMD: “Universal health care” & insurance in Vietnam and many other countries do not include cleft care
@wpmagee: Insurance covers very little and families wait for humanitarian org. Ironically these surgeon are their own

@JordanFreyMD: How has your experience been w training local surgeons to create sustainability?
@CarolineYaoMD: Great OR discussions re: different surgical techniques. They and we all want to learn how to be better.

@ChadPurnellMD: How often are local surgeons participating in cleft missions?
@CarolineYaoMD: 100% of the 15 operationsmile missions I attended had 50%+ local surgeons operating. Current missions strive to teach local surgeons to maximize sustainability and create new leaders.
@ChadPurnellMD: My experience same- amazing how committed @operationsmile is to sustainable cleftcare
@CarolineYaoMD: Agree! Thx to technology, social media & cross-cultural friendships, everyone can learn more & better.

@SNiknamBienia: Have u looked at analyzing this data in other countries as well? curious about South America
@CarolineYaoMD: We have plans to expand this project to every continent. Need more residents like u who r committed!
@RizwanUSheikh: Sounds like an excellent idea. Many more patients to benefit

@shujashafqatmd: 100% response rate of 453 households is excellent. What made them more eager to respond?
@Muriu: The 50%+ local surgeons is an excellent way to address the mistrust of medical practitioners barrier (stranger danger) while at the same time improving the communities trust in their own human resource wrt surgeon’s.

@JordanFreyMD: Any advice for residents looking to get involved in global surgery?
@wpmagee: Our door is wide open. We have great team, awesome partnerships and lots of opp!

@Muriu: what barriers to accessing surgery did you encounter that were unique to your study population? #PRSJournalClub
@CarolineYaoMD: In many countries we surveyed, sadly, they trusted the outside surgeons more because of perceived local corruption. Unique was a widespread cultural acceptance of surgical care. Fewer superstitious beliefs regarding cleft
@AmandaKSilvaMD: very sad indeed. What can be done on our end to help instill trust in the local surgeons?
@CarolineYaoMD: showing families the local surgeons working alongside international mission surgeons went a long way!

@shujashafqatmd: are there any unique features of medical insurance in Vietnam vs. the US?
@CarolineYaoMD: Similar: all children get gov’t sponsored healthcare & gov’t sponsored insurance available. Different: gov’t sponsored care in vietnam covers far less & very hard to access vs US
@shujashafqatmd: I assume no private insurance?
@CarolineYaoMD: There is private insurance in Vietnam, often employer based like the US. Most choose to pay out of pocket

@pallabc: Similarly, how difficult was repairing lip with ?Millard in children presenting late with no PSO/NAM?
@CarolineYaoMD: bilat cleft lip esp hard w/o nam. But cleft surgeons in centers & missions are do 100+ clefts/yr so get ok results

@JordanFreyMD: Any mechanism in place to see pts for long term follow up after mission cleft repair? Telemedicine?
@CarolineYaoMD: one of the biggest challenges of mission based care. Comprehensive care cntrs do best @60-80% 1yr f/u

@loveselflessly: Love that local med & dental students involved! Future role for empowering host-initiated research?
@CarolineYaoMD: yes! We trained a team of local students & charity workers in survey admin & proper data collection #PRSJournalClub

@docrfsm: Is there possibility for other organizations to partner in such tremendous research efforts?
@CarolineYaoMD: yes! Pls reach out to us if you or anyone else wants to partner. Lots of opportunity.

@sammysinnoMD: is there any way to create comprehensive centers abroad?
@CarolineYaoMD: Yes @operationsmile has created them in Vietnam, Guwahati, Nicaragua & working on more. Other orgs are too. Much room for more local investment in local comprehensive centers in partnership w/experts

@sammysinnoMD: we need to have mission work seamless integrated as an option in American training-how can we?
@CarolineYaoMD: Need 2lobby4 ACGME approved resident rotations+funding for international trading. See paper here 4 evidence.

@pallabc: Do you offer secondary bone grafting for alveolar clefts in mission setting? Rx expectations must be high.
@CarolineYaoMD: for most @operationsmile missions, no bone grafting 2/2 need for strict f/u. comprehensive cntrs offer grafting.

Congratulations to Dr. Soleil Niknam-Bienia on winning the 1st ever PRS Journal Club T-shirt Raffle!!


Read the articles, listen to the podcast and join us for the December #PRSJournalClub Live Twitter Discussion with @ValLambros:

Sunday & Monday, December 18th & 19th





Barriers to Reconstructive Surgery in Low- and Middle-Income Countries: A Cross-Sectional Study of 453 Cleft Lip and Cleft Palate Patients in Vietnam. Yao, Caroline A. M.D., M.S.; Magee, William P. III M.D., D.D.S. et al.
Plastic & Reconstructive Surgery: November 2016 – Volume 138 – Issue 5 – p 887e–895e. doi: 10.1097/PRS.0000000000002656


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