PMY Tang, NSY Chao

Dear Editor,

I read with great interest regarding the original article "Are there regionalisation of high complexity surgeries and decentralisation of outpatient treatment services for cleft lip and/or palate in the state of Sao Paulo, Brazil?" (HK J Paediatr (new series) 2018; Vol 23. No. 3).¹ The authors mentioned that the regionalisation of surgeries for craniofacial treatment involved only centres of excellence is likely to be associated with better surgical results, reduction of operative and postsurgical mortality and greater access to provide more comprehensive care, especially in view of the multi-disciplinary and inter-disciplinary character of the management of patients with cleft lip and/or palate anomalies. I cannot agree more with the authors.

In fact, it had been shown by the Clinical Standards Advisory Group (CSAG) in the United Kingdom that concentration of these highly complex operations into a few specialised centers are associated with better surgical outcomes and improved patients' satisfaction, as published in the renowned Cleft Care UK Study (CCUK) (CSAG2).² Furthermore, the importance of longitudinal audit on a medical condition such as cleft lip and/or palate is of special significance as the prevalence of cleft anomaly is relatively low in the general population.

In Hong Kong, about 120 new patients with cleft lip and/or palate are born annually,³ with data collected by the questionnaire survey and a review of the care provided by the Hospital Authority (HA) hospitals by Liu et al in 1998. Since then, numerous collaborative researches on cleft care have been conducted over the years in HA hospitals; ranging from antenatal counselling for fetal cleft anomalies,⁴ to 16-year review of the surgical technique in palatoplasty;⁵ and most studies had already published in various local and international journals. However, as there is currently no central registry for congenital structural anomaly such as cleft lip and/or palate, we could only rely on the Clinical Data and Reporting System (CDARS) database, which recorded all operations done in HA hospitals, to conduct large scale, long term audits on cleft care.

In the current era, outcome assessment had become a core component of clinical practice.⁶ The minimum requirements for accreditation established by the American Cleft Palate Association (ACPA)⁷ states that the "cleft team should have mechanisms to monitor its short and long term treatment outcomes by documenting its treatment outcomes, including baseline performance and changes over time". With robust evidence pointing the advantages of having a dedicated specialised team of healthcare professionals in the comprehensive management of cleft patients, we believe now is the appropriate time for us to establish a cross-cluster, cross-sector, national data-base registry for cleft anomaly in Hong Kong. Ideally, a task force should be set up in developing systems for comprehensive appraisal of cleft care ?for accountability, quality improvement and health system design. With visionary planning, and to ensure the sustainability of cleft care in the future, apart from well-established clinical pathway protocols, a continuous successive training program for practitioners is also essential.

We are optimistic that with the re-organisation of paediatric healthcare services at the Hong Kong Children Hospital, our patients would continue to benefit from the continual dedication of the committed multidisciplinary team in the future.

Declaration of Interest

None

References

1. Tovani-Palone MR, Formenton A, BertolinSR. Are there regionalisation of high complexity surgeries and decentralisation of outpatient treatment services for cleft lip and/or palate in the State of Sao Paulo, Brazil? HK J Paediatr (new series) 2018;23:211-9.

2. Ness AR Wills AK, Waylen A, et al. Centralization of cleft care in the UK. Part 1-6: a tale of two studies. Orthod Craniofac Res. 2015;18 Suppl 2:56-62.

3. Liu KKW, Chow TK, Paterson EH, Kwok SPY. Changing trends in the management of cleft lip and palate in Hong Kong - the evolution of multidisciplinary care. Ann Coll Surg HK 1998;2:118-21.

4. Tang PMY, Chung KLY, Leung YCL, et al. Multidisciplinary antenatal counselling of fetal cleft lip/palate deformity in a single center: A review of 62 pregnant women in Hong Kong. Hong Kong J Paediatr (new series) 2016;21:152-5.

5. Chan EKW, Lee KH, Tsui BSY, et al. From von Langenbeck to Furlow palatoplasty: A 16-year review of cleft palate repair. Surgical Practice 2014;18:67-71.

6. Sitzman TJ, Allori AC, Thorburn G. Measuring outcomes in cleft lip and palate treatment. Clin Plastic Surg 2014;41:311-9.

7. American Cleft Palate ?Craniofacial Association, Standards for Approval of cleft palate and craniofacial teams. ACPA, 2010. http://www.acpa-cpf.org/team_car/standards accessed 25th July 2018.