Access and Timeliness in a Centralized Surgical Care Pathway for Craniosynostosis: A Stage-Specific Analysis

Background: Access to specialist care and timely completion of surgery are related but distinct health-services outcomes. This study examined stage-specific delay in a centralized surgical care pathway for craniosynostosis by distinguishing late specialist presentation from post-referral surgical delay. Methods: This retrospective multicenter observational study included 420 children with nonsyndromic craniosynostosis who underwent definitive surgery at two tertiary craniofacial referral centers in Tehran, Iran, between 2016 and 2024. The primary outcome was post-referral surgical delay, defined as more than 90 days from the first craniofacial specialist visit to surgery. The main secondary outcome was late specialist presentation, defined as the first specialist visit after 6 months of age. Multivariable logistic regression was used to estimate adjusted odds ratios. Results: Referral-hub residence was associated with higher odds of post-referral surgical delay (adjusted OR 2.62, 95% CI 1.27-5.42; p=0.009). Low socioeconomic position, low parental education, prior misdiagnosis or observation, and pre-referral imaging were associated with late specialist presentation. Surgery after 12 months of age reflected different combinations of late specialist presentation and post-referral delay. Conclusions: Determinants of delay differed by pathway stage. Socioeconomic and diagnostic pathway variables were more closely related to late specialist presentation, whereas referral-hub residence was associated with post-referral surgical delay. Stage-specific monitoring may better identify where delays arise than age-at-surgery endpoints alone. Preprint notice: This manuscript is a preprint and has not completed peer review. It is currently under consideration at BMC Health Services Research. The content may change following editorial and peer-review evaluation.