Defining Textbook Outcome in liver surgery and an assessment of hospital variation: a nationwide population-based study.

Abstract

Introduction Textbook outcome (TO) is a composite outcome measure covering the surgical care process in a single outcome measure. TO has an advantage over single outcome parameters with low event rates, which have less discriminating impact to detect differences between hospitals. This study aimed to define TO for liver surgery, assess factors associated with TO, and address hospital and network variation after case-mix correction. Methods This was a population-based retrospective study of all patients who underwent liver resection for malignancy in the Netherlands in 2019 and 2020. TO was defined as absence of severe postoperative complications, mortality, prolonged length of stay, and readmission, and obtaining a tumour-free pathological margin. Multivariable logistic regression was used for case-mix adjustment. Results 2377 patients were included. TO was accomplished in 1380 (80%) patients with colorectal liver metastases, in 192 (76%) patients with other liver metastases, in 183 (74%) patients with hepatocellular carcinoma and 86 (51%) patients with biliary cancers. Factors associated with lower TO rates for CRLM included ASA score ≥3 (aOR 0.70, CI 0.51 – 0.95 p=0.02), extra-hepatic disease (aOR 0.64, CI 0.44 – 0.95, p=0.02), tumour size >55mm on preoperative imaging (aOR 0.56, CI 0.34 – 0.94, p=0.02), Charlson Comorbidity Index ≥2 (aOR 0.73, CI 0.54 – 0.98, p=0.04), and major liver resection (aOR 0.50, CI 0.36 – 0.69, p<0.001). After case-mix correction, no significant hospital or oncological network variation was observed. Conclusion TO differs between indications for liver resection and can be used to evaluate hospital and network performances.