Background: In 1988, Renier and Marchac asserted that children with craniosynostosis who undergo cranial vault remodeling (CVR) after 12 months of age experience delayed neurocognitive development compared to children who undergo CVR before 12 months of age. The purpose of this study was to identify factors potentially confounding this cause-and-effect relationship. The authors hypothesize that children with socioeconomic disadvantages or comorbid conditions are more likely to undergo CVR after 12 months and may represent a selection bias toward delayed neurocognitive development. Methods: Patients with nonsyndromic single-suture craniosynostosis who underwent CVR between 2009 and 2020 at Michigan Medicine were included (n = 227). Sociodemographic and clinical variables were documented. The sample was dichotomized to compare patients who underwent CVR before (early) and after (late) 12 months of age. Statistical analysis was performed at P < 0.05 significance. Results: The early and late groups contained 157 patients and 70 patients, respectively. Compared to the early group, the late group contained a larger proportion of patients who identified as non-White (P = 0.03), qualified for need-based financial assistance (P = 0.03), were born preterm (P < 0.01), or had a comorbid condition (P < 0.01). Based on preoperative testing, the late group contained a larger proportion of patients with baseline cognitive (P < 0.001) and language (P = 0.008) delays relative to the early group. Conclusions: This study demonstrates that socioeconomic disadvantages and comorbid conditions are prevalent among patients who undergo delayed CVR and may represent a selection bias toward delayed neurocognitive development. Future studies evaluating the relationship between surgical timing and neurocognitive development must control for these factors. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, II.

The neurodevelopmental consequences of nonsyndromic single-suture (NSS) craniosynostosis are the subject of continued debate. Although the predictive validity of the Bayley Scales of Infant and Toddler Development (Third Edition) (BSID-III) have been questioned, this neurodevelopmental testing battery continues to be widely utilized among multidisciplinary craniofacial teams. The purpose of this study is to evaluate the neurodevelopmental functioning of patients with NSS craniosynostosis before and after surgical correction and the impact of surgical correction on neurodevelopmental trajectory based on BSID-III testing. All patients with NSS craniosynostosis who underwent cranial vault remodeling between 2009 and 2020 were considered for inclusion. Patients who failed to complete BSID-III testing within 2 months of surgery preoperatively and 2 years of surgery postoperatively were excluded. A total of 66 patients met criteria for the study. On language testing, both the preoperative mean score (P = 0.007) and postoperative mean score (P = 0.003) were significantly lower than the population norm. Furthermore, on motor testing, both the preoperative mean score (P = 0.005) and postoperative mean score (P = 0.001) were significantly lower than the population norm. Bayley Scales of Infant and Toddler Development (Third Edition) testing revealed no significant change between preoperative and postoperative neurodevelopmental functioning. Overall, this study suggests that patients with NSS craniosynostosis experience modest delays in language and motor development, which are present before and after cranial vault remodeling. In addition, this study provides evidence that cranial vault remodeling does not significantly impact the neurodevelopmental trajectory. Multicenter st udies and refined neurodevelopmental testing methods are necessary to definitively establish the neurodevelopmental implications of NSS craniosynostosis.

ImportanceCollaborative quality improvement (CQI) models, often supported by private payers, create hospital networks to improve health care delivery. Recently, these systems have focused on opioid stewardship; however, it is unclear whether reduction in postoperative opioid prescribing occurs uniformly across health insurance payer types.ObjectiveTo evaluate the association between insurance payer type, postoperative opioid prescription size, and patient-reported outcomes in a large statewide CQI model.Design, Setting, and ParticipantsThis retrospective cohort study used data from 70 hospitals within the Michigan Surgical Quality Collaborative clinical registry for adult patients (age ≥18 years) undergoing general, colorectal, vascular, or gynecologic surgical procedures between January 1, 2018, and December 31, 2020.ExposureInsurance type, classified as private, Medicare, or Medicaid.Main Outcomes and MeasuresThe primary outcome was postoperative opioid prescription size in milligrams of oral morphine equivalents (OME). Secondary outcomes were patient-reported opioid consumption, refill rate, satisfaction, pain, quality of life, and regret about undergoing surgery.ResultsA total of 40 149 patients (22 921 [57.1%] female; mean [SD] age, 53 [17] years) underwent surgery during the study period. Within this cohort, 23 097 patients (57.5%) had private insurance, 10 667 (26.6%) had Medicare, and 6385 (15.9%) had Medicaid. Unadjusted opioid prescription size decreased for all 3 groups during the study period from 115 to 61 OME for private insurance patients, from 96 to 53 OME for Medicare patients, and from 132 to 65 OME for Medicaid patients. A total of 22 665 patients received a postoperative opioid prescription and had follow-up data for opioid consumption and refill. The rate of opioid consumption was highest among Medicaid patients throughout the study period (16.82 OME [95% CI, 12.57-21.07 OME] greater than among patients with private insurance) but increased the least over time. The odds of refill significantly decreased over time for patients with Medicaid compared with patients with private insurance (odds ratio, 0.93; 95% CI, 0.89-0.98). Adjusted refill rates for private insurance remained between 3.0% and 3.1% over the study period; adjusted refill rates among Medicare and Medicaid patients decreased from 4.7% to 3.1% and 6.5% to 3.4%, respectively, by the end of the study period.Conclusions and RelevanceIn this retrospective cohort study of surgical patients in Michigan from 2018 to 2020, postoperative opioid prescription size decreased across all payer types, and differences between groups narrowed over time. Although funded by private payers, the CQI model appeared to have benefitted patients with Medicare and Medicaid as well.