Correspondence on “Benchmark performance of laparoscopic left lateral sectionectomy and right hepatectomy in expert centers”

Abstract

Hobeika et al.[1]Hobeika C. Fuks D. Cauchy F F. Goumard C. Gayet B. Laurent A. et al.Benchmark performance of laparoscopic left lateral sectionectomy and right hepatectomy in expert centers.J Hepatol. 2020; 73: 1100-1108Abstract Full Text Full Text PDF PubMed Scopus (11) Google Scholar aimed to establish benchmark values after laparoscopic left lateral sectionectomy (LLLS) and laparoscopic right hepatectomy (LRH). This is a helpful study on an interesting topic. The authors defined the expert centers using the achievement of textbook outcome (TO) as an indicator. A cut-off of 35 laparoscopic liver resections (LLR)/year and 25 LLR/year were independently associated with completion of TO after LLLS and LRH, respectively. The benchmark values were set at the 75th percentile of median outcomes among the expert centers. After LLLS, benchmark values of conversion, severe complication, mortality and TO completion were <7.2%, <5.3%, <1.2% and >46.6%. After LRH, benchmark values of conversion, severe complication, mortality and TO completion were <29.8%, >20.4%, <2.8% and >24.2%. Per definition, the benchmarking represents the best results achievable after a surgical procedure.[2]Berkey T. Benchmarking in health care: turning challenges into success.Jt Comm J Qual Improv. 1994; 20: 277-284PubMed Google Scholar As reported by Prof. Brian K.P. Goh[3]Goh Brian KP. Letter regarding "Benchmark performance of laparoscopic left lateral sectionectomy and right hepatectomy in expert centers".J Hepatol. 2020; 17 (S0168-8278): 30443-30448Google Scholar the benchmark conversion rate after LRH seems to be too high. Moreover, benchmark values of overall and major morbidity are higher than expected. A possible explanation is the methodology used to obtain the benchmark values. There are several approaches for calculating benchmarks in healthcare. The choice of the best method largely depends on the analyzed cohort. The 75th percentile of the median results across centers (meaning that 75% of centers had a median performance that is on par or better than the benchmark) represents a realistic benchmark value if analyzing the “best patient” (lower-risk population) treated in the “best centers”, as reported by the authors who suggested this definition.[4]Rössler Fabian Gonzalo Sapisochin Song GiWon Lin Yu-Hung Simpson Mary Ann Hasegawa Kiyoshi et al.Defining benchmarks for major liver surgery: a multicentre analysis of 5202 living liver donors.Ann Surg. 2016; 264: 492-500Crossref PubMed Scopus (0) Google Scholar By contrast, in the study by Hobeika et al. data from unselected patients treated in medium-high volume centers were analyzed.5Viganò L. Cimino M. Aldrighetti L. Ferrero A. Cillo U. Guglielmi A. et al.Multicentre evaluation of case volume in minimally invasive hepatectomy.Br J Surg. 2020; 107: 443-451Crossref PubMed Scopus (8) Google Scholar, 6Gordon T.A. Bowman H.M. Bass E.B. Lillemoe K.D. Yeo C.J. Heitmiller R.F. et al.Complex gastrointestinal surgery: impact of provider experience on clinical and economic outcomes.J Am Coll Surg. 1999; 189: 46-56Abstract Full Text Full Text PDF PubMed Scopus (164) Google Scholar, 7Lin Herng-Ching Xirasagar Sudha Lee Hsin-Chien Chai Chiah-Yang Hospital volume and inpatient mortality after cancer-related gastrointestinal resections: the experience of an Asian country.Ann Surg Oncol. 2006; 13: 1182-1188Crossref PubMed Scopus (69) Google Scholar Is the 75th percentile the ‘‘best possible’’ result for this setting? Probably the 75th percentile is too generous and consequently the benchmark values are worse than they should be. Recently, we analyzed the benchmark outcomes in laparoscopic liver surgery using data from the Italian Group of Minimally Invasive Liver Surgery (I Go MILS) registry.[8]Russolillo N. Aldrighetti L. Cillo U. Guglielmi A. Ettorre G.M. Giuliante F. et al.Risk-adjusted benchmarks in laparoscopic liver surgery in a national cohort.Br J Surg. 2020; 107: 845-853Crossref PubMed Scopus (12) Google Scholar The benchmark value was defined as the performance achieved by the top 10% of providers after adjusting each center rate based on sample size (Achievable Benchmark of Care (ABC™) method[9]Weissman N. Allison J. Kiefe C. Farmer R.M. Weaver M.T. Williams O.D. et al.Achievable benchmarks of care: the ABCs of benchmarking.J Eval Clin Pract. 1999; 5: 269-281Crossref PubMed Scopus (106) Google Scholar). Using the same definition of TO as Hobeika et al.[1]Hobeika C. Fuks D. Cauchy F F. Goumard C. Gayet B. Laurent A. et al.Benchmark performance of laparoscopic left lateral sectionectomy and right hepatectomy in expert centers.J Hepatol. 2020; 73: 1100-1108Abstract Full Text Full Text PDF PubMed Scopus (11) Google Scholar (negative margins, no transfusion, no complication, hospital stay <6 days after LLLS and <8 days after LRH, no readmission and no mortality) and the same cut-off values of 25 LLR/year for LLLS and 35 LLR/year for LRH, we identified 341 LLLS (from 15 centers) and 167 LRH (from 9 centers) – performed between January 2014 and September 2020 – in the I Go MILS registry. Next, the benchmark values of postoperative outcomes, conversion and TO rates were calculated with both the definitions: the 75th percentile and the ABC methods. The benchmark values of the I Go MILS registry calculated with the 75th percentile were similar to the French registry results and remarkably higher than the ABC values (Table 1). For example, the ABC value for conversion rate after LRH was 8.3%, as expected by Goh.[2]Berkey T. Benchmarking in health care: turning challenges into success.Jt Comm J Qual Improv. 1994; 20: 277-284PubMed Google Scholar Similarly, according to the ABC method, in the best-case scenario, around 1 patient out of 5 would develop a postoperative complication after LRH, compared to 1 out of 2 reported by Hobeika et al.Table 1Comparison of benchmark values of 2 laparoscopic liver procedures (left lateral sectionectomy and right hepatectomy) between Italian and French registries.I GO MILS registryFrench registryABC (%)75th percentile (%)75th percentile (%)LLLSn = 341n = 516 Overall morbidity4.52519.8 Major morbidity∗Postoperative morbidity grade 3 or 4 according to Dindo classification.0105.3 Textbook outcomenegative margins, no transfusion, no complication, no prolonged hospital stay (<6 days after LLLS and <8 days after LRH), no readmission and no mortality.77.240.546.6 Conversion rate09.57.2LRHn = 167n = 346 Overall morbidity17.343.752.1 Major morbidity∗Postoperative morbidity grade 3 or 4 according to Dindo classification.4.12020.4 Textbook outcomenegative margins, no transfusion, no complication, no prolonged hospital stay (<6 days after LLLS and <8 days after LRH), no readmission and no mortality.55.22424.2 Conversion rate8.318.629.8I GO MILS, Italian Group of Minimally Invasive Liver Surgery; LLLS, laparoscopic left lateral sectionectomy; LRH, laparoscopic right hepatectomy; ABC, Achievable Benchmark of Care value.∗ Postoperative morbidity grade 3 or 4 according to Dindo classification.∗∗ negative margins, no transfusion, no complication, no prolonged hospital stay (<6 days after LLLS and <8 days after LRH), no readmission and no mortality. Open table in a new tab I GO MILS, Italian Group of Minimally Invasive Liver Surgery; LLLS, laparoscopic left lateral sectionectomy; LRH, laparoscopic right hepatectomy; ABC, Achievable Benchmark of Care value. In conclusion, the ABC methods seems to provide more realistic benchmark values when analyzing data from national/international registries. The authors received no financial support to produce this manuscript. Russolillo and Ferrero developed the theory and performed the computations. Aldrighetti, Guglielmi and Giuliante supervised the findings of this work. All authors discussed the results and contributed to the final version. The authors declare no conflicts of interest that pertain to this work. Please refer to the accompanying ICMJE disclosure forms for further details. The following is/are the supplementary data to this article: Download .pdf (.18 MB) Help with pdf files Multimedia component 1 Benchmark performance of laparoscopic left lateral sectionectomy and right hepatectomy in expert centersJournal of HepatologyVol. 73Issue 5PreviewHerein, we aimed to establish benchmark values – based on a composite indicator of healthcare quality – for the performance of laparoscopic left lateral sectionectomy (LLLS) and laparoscopic right hepatectomy (LRH) using data from expert centers. Full-Text PDF Reply to: “Letter regarding Benchmark performance of laparoscopic left lateral sectionectomy and right hepatectomy in expert centers”Journal of HepatologyVol. 74Issue 4PreviewWe thank Dr Russolillo et al.1 for their insightful comments and for validating the methodology used in our study in an Italian cohort of patients who underwent laparoscopic liver resection (LLR). To review, Russolillo et al. questioned the relevance of a benchmark based on the 75th percentile of the median outcome and argued in favor of the ABCTM methodology (The Achievable Benchmark of Care).2,3 Full-Text PDF