A Nationwide Analysis of Adverse Events and Cost between Inpatient Versus Outpatient Alveolar Bone Grafting

Alveolar bone grafting (ABG) has been the preferred treatment modality for children with alveolar clefts. Historically, patients who undergo ABG are kept inpatient for close postoperative monitoring primarily to control postoperative pain secondary to open iliac crest harvest.1 Given the reduction of postoperative pain due to the transition of utilization of the trephine technique for bone harvesting, a reduction in the requirement for postoperative inpatient admission has been observed.2 The purpose of this study was to compare postoperative outcomes between inpatient and outpatient ABG. A retrospective review of the National Surgical Quality Improvement Program-Pediatric database was conducted on patients who underwent ABG from 2012 to 2020. Patient demographics, perioperative factors, length of stay (LOS), surgical site infection (SSI) rates, and 30-day outcomes (ie, readmission, reoperation, postoperative complications) were collected. Entropy balancing was performed to optimally match inpatient and outpatient cohorts based on demographics and comorbidities in a 1:1 ratio. Pearson’s chi-squared, independent t-tests, and multivariate logistic regressions were used to analyze 30-day outcomes. Costs were derived from Medicaid reimbursement codes. Probabilities were based on outcomes reported by the NSQIP database comparing the 2 hospital settings. One-way and probabilistic sensitivity analyses tested the robustness of results to model parameters. The associated costs for inpatient and outpatient procedures were calculated and adjusted to 2022 US dollars. Upon review, 4,924 patients underwent ABG, with 2,467 in each matched hospital setting cohort. Overall, 30-day readmission, reoperation, and complication rates were 0.6%. 0.4%, and 1.2%, respectively, with the inpatient cohort presenting with more postoperative complications (1.6% vs 0.7%; P = .004). The inpatient cohort had higher rates of superficial incisional SSI (0.5% vs 0.1%; P = .007) and organ/space SSI (0.3% vs 0.0%; P = .005) compared to outpatient. Upon multivariate analysis, longer LOS following operation (Odds Ratio [OR]: 1.230; P = .013) and the inpatient setting (OR: 7.248; P = .011) independently predicted superficial incisional SSI. Based on these clinical outcomes, the total cost of outpatient ABG was estimated to be $11,433 vs $19,668 for inpatient ABG, resulting in $8,325 cost savings per patient. ABG is an overall safe procedure for alveolar cleft repair with reported low complication, readmission, and reoperation rates. However, we found that the inpatient setting and extended postoperative stay independently contribute to slightly increased superficial incisional SSI rates. Based on these findings, we recommend shifting towards outpatient ABG procedures as they may confer a lower risk of hospital-acquired infectious complications and cost.