Weidler, Erica M

Objective To identify barriers and facilitators to changing provider's current approaches to evaluation and treatment decision-making for velopharyngeal insufficiency (VPI). Design Cross-sectional qualitative study. Setting Medium and large multidisciplinary cleft teams in the USA and Canada engaged in clinical research. Participants Twenty-eight surgeons and 16 speech-language pathologists from 12 cleft teams. Interventions Semi-structured interviews were conducted exploring perceived barriers and facilitators to changing VPI evaluation and treatment decision-making. Interviews were analyzed using a thematic approach guided by the Consolidated Framework for Implementation Research. Results Providers indicated that adoption of new approaches to VPI evaluation and decision-making would require evidence demonstrating improved speech outcomes or reduced risk of obstructive sleep apnea. Characteristics of persuasive evidence included prospective study design, comparable patient groups, standardized speech evaluations, and long-term follow-up. Providers favored applying new approaches to complex cases or defined subgroups, rather than broad adoption. Providers raised concerns about additional preoperative testing, perceiving it could increase treatment burden. When reflecting on prior changes in care delivery, providers indicated they started by discussing the potential change informally with team members to share information, gather input, and build consensus; in larger teams, discussions also occurred in formal meetings or through administrative hierarchies. Implementation decisions were consensus-based, although the pace of implementation varied among providers. Conclusions Providers have processes for implementing changes in their VPI evaluation and treatment decision-making, and criteria by which they make the decision to implement. These findings can inform the design of implementation strategies to accelerate clinical uptake of research findings.

Objective To explore current approaches to evaluation and treatment decision-making for velopharyngeal insufficiency (VPI) following cleft palate repair. Design Cross-sectional, qualitative study. Setting/participants Participants included 28 surgeons and 17 speech-language pathologists (SLPs) from 12 cleft teams in the United States and Canada. Interventions Semi-structured, qualitative interviews were conducted exploring participants’ current approaches to VPI evaluation and treatment decision-making. Data were analyzed using thematic analysis. Results Participants viewed VPI evaluation as a joint effort of surgeons and SLPs. SLPs were entrusted to conduct formal speech evaluations. All teams completed a perceptual evaluation of speech resonance that included spontaneous speech and phrase repetition. Teams varied in their use of patient questionnaires and nasometry. Most teams performed nasoendoscopy as part of their evaluation, although providers noted limited cooperation in younger children and those with developmental delay. Treatment decision-making occurred either as a joint effort between the evaluating surgeon and SLP or exclusively by the surgeon. Most surgeons employed a personalized approach to treatment decision-making, with 19 distinct approaches described. Elements frequently considered in surgical procedure selection included velopharyngeal gap size and closure pattern as seen on nasoendoscopy. Providers were satisfied with their current approach, although most identified opportunities for improvement. Conclusions Cleft teams have individualized approaches to VPI evaluation and treatment decision-making, with the only common element being completion of a perceptual speech evaluation by an SLP. These findings suggest that efforts to implement new approaches will need to be customized to each team's current process.

Background: Palate re-repair has been proposed as an effective treatment for velopharyngeal insufficiency (VPI) with a low risk of obstructive sleep apnea (OSA). The authors conducted a systematic review and meta-analysis to determine the proportion of patients achieving normal speech resonance following palate re-repair for VPI, the proportion developing OSA, and the criteria for patient selection that are associated with increased effectiveness. Methods: PubMed, Embase, and Scopus were searched from inception through April 2018 for English language articles evaluating palate re-repair for the treatment of VPI in patients with a repaired cleft palate. Inclusion criteria included reporting of hypernasality, nasal air emission, nasometry, additional VPI surgery, and/or OSA outcomes. Meta-analysis was conducted using random effects models. Risk of bias was assessed regarding criteria for patient selection, blinding of outcome assessors, and validity of speech assessment scale. Results: Eighteen studies met inclusion criteria. The incidence of achieving no consistent hypernasality follow palate re-repair was 61% (95% confidence interval [CI]: 44%-75%). The incidence of additional surgery for persistent VPI symptoms was 21% (95% CI: 12%-33%). The incidence of OSA was 28% (95% CI: 13%-49%). Criteria for selecting patients to undergo re-repair varied, with anterior/sagittal position of palatal muscles (33%) and small velopharyngeal gap (22%) being the most common. No specific patient selection criteria led to superior speech outcomes ( P = .6572). Conclusions: Palate re-repair achieves normal speech resonance in many but not all patients with VPI. Further research is needed to identify the specific examination and imaging findings that predict successful correction of VPI with re-repair.