Textbook Outcome Research Articles

Assessment of hospital quality and safety standards among Medicare beneficiaries undergoing surgery for cancer

BackgroundWe sought to assess the relationship between Leapfrog minimum volume standards, Hospital Safety Grades, and Magnet recognition with outcomes among patients undergoing rectal, lung, esophageal, and pancreatic resection for cancer. MethodsStandard Analytical Files linked with the Leapfrog Hospital Survey and the Leapfrog Safety Scores Denominator Files were used to identify Medicare patients who underwent surgery for cancer from 2016 to 2017. Multivariable logistic regression analysis was used to examine textbook outcomes relative to Leapfrog volume, safety grades, and Magnet recognition. ResultsAmong 26,268 Medicare beneficiaries, 7,491 (28.5%) were treated at hospitals meeting the quality trifactor (Leapfrog, safety grade A, and Magnet recognition) vs 18,777 (71.5%) at hospitals not meeting ≥1 designation. Patients at trifactor hospitals had lower odds of complications (odds ratio = 0.83, 95% confidence interval: 0.76–0.89), prolonged duration of stay (odds ratio = 0.89, 95% confidence interval: 0.82–0.97), and higher odds of experiencing textbook outcome (odds ratio = 1.12, 95% confidence interval: 1.06–1.19). Patients undergoing surgery for lung (odds ratio = 1.19, 95% confidence interval: 1.10–1.30) and pancreatic cancer (odds ratio = 1.37, 95% confidence interval: 1.21–1.55) at trifactor hospitals had higher odds of textbook outcome, whereas this effect was not noted after esophageal (odds ratio = 1.16, 95% confidence interval: 0.90–1.48) or rectal cancer (odds ratio = 1.11, 95% confidence interval: 0.98–1.27) surgery. Leapfrog minimum volume standards mediated the effect of the quality trifactor on patient outcomes. ConclusionQuality trifactor hospitals had better short-term outcomes after lung and pancreatic cancer surgery compared with nontrifactor hospitals.

183P Textbook outcome as a measure of surgical quality assessment and prognosis in gastric neuroendocrine carcinoma: A large multicenter sample analysis

183P Textbook outcome as a measure of surgical quality assessment and prognosis in gastric neuroendocrine carcinoma: A large multicenter sample analysis

Implementation of ERAS principles for pancreatoduodenectomy increases the proportion of patients achieving textbook outcome: a retrospective cohort study

Implementation of ERAS principles for pancreatoduodenectomy increases the proportion of patients achieving textbook outcome: a retrospective cohort study

Liver resection for hepatocellular carcinoma in patients with clinically significant portal hypertension.

Background & AimsLiver resection (LR) in patients with hepatocellular carcinoma (HCC) and clinically significant portal hypertension (CSPH) defined as a hepatic venous pressure gradient (HVPG) ≥10 mmHg is not encouraged. Here, we reappraised the outcomes of patients with cirrhosis and CSPH who underwent LR for HCC in highly specialised liver centres.MethodsThis was a retrospective multicentre study from 1999 to 2019. Predictors for postoperative liver decompensation and textbook outcomes were identified.ResultsIn total, 79 patients with a median age of 65 years were included. The Child-Pugh grade was A in 99% of patients, and the median model for end-stage liver disease (MELD) score was 8. The median HVPG was 12 mmHg. Major hepatectomies and laparoscopies were performed in 28% and 34% of patients, respectively. Ninety-day mortality and severe morbidity rates were 6% and 27%, respectively. Postoperative and persistent liver decompensation occurred in 35% and 10% of patients at 3 months. Predictors of liver decompensation included increased preoperative HVPG (p = 0.004), increased serum total bilirubin (p = 0.02), and open approach (p = 0.03). Of the patients, 34% achieved a textbook outcome, of which the laparoscopic approach was the sole predictor (p = 0.004). The 5-year overall survival and recurrence-free survival rates were 55% and 43%, respectively.ConclusionsPatients with cirrhosis, HCC and HVPG ≥10 mmHg can undergo LR with acceptable mortality, morbidity, and liver decompensation rates. The laparoscopic approach was the sole predictor of a textbook outcome.Lay summaryPatients with cirrhosis, hepatocellular carcinoma, and clinically significant portal hypertension (defined as a hepatic venous pressure gradient ≥10 mmHg) can undergo resection with acceptable mortality, morbidity, liver decompensation rates, and a textbook outcome. These results can be achieved in selected patients with preserved liver function, good general status, and sufficient remnant liver volume.

The association between the composite quality measure “textbook outcome” and long term survival in operated colon cancer

The aim of this study was to investigate the relationship between textbook outcome and survival in patients with surgically treated colon cancer. A total of 804 surgical cases were enrolled between June 1, 2010 and December 31, 2014. Textbook outcome was defined as patients who had colon cancer surgery and met the six healthcare parameters of surgery within 6 weeks, radical resection, lymph node (LN) yield ≥12, no ostomy, no adverse outcome and colonoscopy before/after surgery within 6 months. The effect of textbook outcome on 5-year disease-specific survival (DSS) was calculated using the Kaplan-Meier method. A Cox regression model was used to find significant independent variables and stratified analysis used to determine whether text-book outcome had a survival benefit. A textbook outcome was achieved in 59.5% of patients undergoing colon cancer surgery. Important obstacles to achieving textbook outcome were no stomy, no adverse outcome and LN yield ≥12. Patients with text-book outcome had statistically significant better 5-year DSS compared to those with-out (80.1% vs. 58.3%). Multivariate analyses indicated that colon cancer patients with textbook outcome had better 5-year DSS after adjusting for various confounders ([aHR], 0.44; 95% CI, 0.34-0.57). Thus, besides being an index of short-term quality of care, textbook outcomes could be used as a prognosticator of long-term outcomes, such as 5-year survival rates.

Textbook Outcomes in Autologous Breast Reconstruction with Tram, Latissimus Dorsi Flap, and Free Composite Tissue Flap: Defining a Composite Metric for Quality

Bunn, Corinne MD; Kulshrestha, Sujay MD; Laub, Peter MD; Patel, Parth MD; Vandevender, Darl MD; Slade Baker, Marshall MD, FACS; Agnew, Sonya MD Author Information

From Multiple Quality Indicators of Breast Cancer Care Toward Hospital Variation of a Summary Measure

To improve quality in breast cancer care, large numbers of quality indicators are collected per hospital, but benchmarking remains complex. We aimed to assess the validity of indicators, develop a textbook outcome summary measure, and compare case-mix adjusted hospital performance. From a nationwide population-based registry, all 79 690 nonmetastatic breast cancer patients surgically treated between 2011 and 2016 in 91 hospitals in The Netherlands were included. Twenty-one indicators were calculated and their construct validity tested by Spearman's rho. Between-hospital variation was expressed by interquartile range (IQR), and all valid indicators were included in the summary measure. Standardized scores (observed/expected based on case mix) were calculated as above (>100) or below (<100) expected. The textbook outcome was presented as a continuous and all-or-none score. The size of between-hospital variation varied between indicators. Sixteen (76%) of 21 quality indicators showed construct validity, and 13 were included in the summary measure after excluding redundant indicators that showed collinearity with others owing to strong construct validity. The median all-or-none textbook outcome score was 49% (IQR 42%-54%) before and 49% (IQR 48%-51%) after case-mix adjustment. From the total of 91 hospitals, 3 hospitals were positive (3%) and 9 (10%) were negative outliers. The textbook outcome summary measure showed discriminative ability when hospital performance was presented as an all-or-none score. Although indicator scores and outlier hospitals should always be interpreted cautiously, the summary measure presented here has the potential to improve Dutch breast cancer quality indicator efforts and could be implemented to further test its validity, feasibility, and usefulness.

The association of neighborhood social vulnerability with surgical textbook outcomes among patients undergoing hepatopancreatic surgery

BackgroundPrevious studies have largely examined social determinants of health relative to individual surgery quality metrics. We sought to characterize possible differences in “textbook outcome,” a composite measure of quality, relative to social vulnerability index. MethodsThe Medicare Standard Analytical Files from 2013 to 2017 were used to identify beneficiaries who underwent hepatopancreatic surgery. Individuals were stratified into 3 groups dependent on their social vulnerability (low, average, high). Textbook outcome was defined as absence of postoperative surgical complications, prolonged length of stay, 90-day readmission, and 90-day mortality. ResultsAmong 32,142 patients who underwent hepatopancreatic surgery, 18,841 (58.6%) patients underwent a pancreatectomy, whereas 13,301 (41.4%) underwent a hepatectomy. The overall incidence of textbook outcome after hepatopancreatic surgery was 51.2% (n = 16,445). Patients with a low social vulnerability index who underwent pancreatic resection more often achieved a textbook outcome versus patients who had an average or high social vulnerability index (low social vulnerability index: 48.3% vs average social vulnerability index: 46.5% vs high social vulnerability index: 44.9%; P = .004). The odds of obtaining a textbook outcome after pancreatic surgery was inversely associated with degree of vulnerability (low social vulnerability index, referent: average social vulnerability index: odds ratio 0.94, 95% confidence interval 0.87–1.00 vs high social vulnerability index: odds ratio 0.89, 95% confidence interval 0.82–0.97). Similarly, social vulnerability index was independently associated with textbook outcome after hepatic resection. Likewise, there were increased risks and incidence of various postoperative surgical outcomes, including 90-day mortality and complications as the social vulnerability index increased. ConclusionOnly one-half (51.2%) of Medicare beneficiaries achieved the composite quality textbook outcome metric. Social vulnerability was associated with lower attainment of textbook outcome and an increased risk of adverse postoperative surgical outcomes after hepatopancreatic surgery.

Textbook outcome as a composite outcome measure in non-small-cell lung cancer surgery.

OBJECTIVES Quality assessment is an important element in providing surgical cancer care. The main objective of this study was to develop a new composite measure ‘textbook outcome’, to evaluate and improve quality of surgical care for patients undergoing a resection for non-small-cell lung cancer (NSCLC).METHODSAll patients undergoing an anatomical resection for NSCLC from 2012 to 2016 registered in the nationwide Dutch Lung Cancer Audit were included in an analysis to assess usefulness of a composite measure as a quality indicator. Based on expert opinion, textbook outcome was defined as having a complete resection (negative resection margins and sufficient lymph node dissection), plus no 30-day or in-hospital mortality, no reintervention in 30 days, no readmission to the intensive care unit, no prolonged hospital stay (<14 days), no hospital readmission after discharge and no major complications. The percentage of patients with a textbook outcome was calculated per hospital. Between-hospital variation in textbook outcome was analysed using case-mix adjustment models.RESULTSIn total, 5513 patients were included in this study. Textbook outcome was achieved in 26.4% of patients. Insufficient lymph node dissection had the most substantial effect on not realizing textbook outcome. If ‘sufficient lymph node dissection’ was not included as a criterion, textbook outcome would be 60.7%. Case-mix adjusted textbook outcome proportions per hospitals varied between 13.2% and 37.7%.CONCLUSIONSIn contrast to focusing on a single aspect, the composite measure textbook outcome provides insight into comprehensive performance in NSCLC surgery. It can be used to evaluate both individual hospitals and national performance and provides the opportunity to give benchmarked feedback to thoracic surgeons.

Influence of surgical approach and quality of resection on the probability of cure for early-stage HCC occurring in cirrhosis.

Background & AimsThe quality of surgical care of patients with HCC is associated with improved long-term prognosis and may also be influenced by the type of surgical approach. The present study aimed at evaluating the role of the laparoscopic approach on quality of surgical care and long-term prognosis in optimal HCC surgical candidates.MethodsAll consecutive patients undergoing open (OLR) or laparoscopic liver resection (LLR) for early-stage HCC in cirrhosis (METAVIR F4) at 5 French expert hepato-pancreatico-biliary centres between 2010 and 2018 were enrolled. Quality of surgical care was defined by textbook outcome (TO), a combination of 6 criteria representing ideal hospitalisation. Factors associated with TO were determined on multivariate analysis. Comparison between LLR and OLR was performed after propensity score matching (PSM). The primary endpoint was disease-free survival (DFS). Statistical cure was modelled using a non-mixture model.ResultsOverall, 425 patients were included. Median follow-up was 42.0 months. LLR was performed in 267 (62.8%) patients. TO was achieved in 140 (32.9%) patients. LLR was independently associated with TO (odds ratio [OR] 2.81; 95% CI 1.29–6.12; p = 0.009). After PSM, LLR patients cumulated higher number of TO criteria than OLR patients (5 vs. 4; p = 0.012). The 1-, 3-, and 5-year DFS of LLR patients with and without TO were 82.3%, 64.4%, and 62.5%, and 76.9%, 51.4%, and 30.2%, respectively (p = 0.003). On multivariable Cox regression, TO was independently associated with improved DFS (hazard ratio 0.34; p = 0.001). The cure fraction of the whole population was 24.4%. Patients achieving TO had increased cure fraction than patients not achieving TO (32.6% vs. 18.1%).ConclusionsQuality of surgical care improves the prognosis of patients with early-stage HCC and is promoted by the laparoscopic approach.Lay summaryThe overall quality of surgical care, as measured by TO, plays a pivotal role in the prognosis and, in particular, on the probability of statistical cure of patients with resectable early-stage HCC occurring in cirrhosis. By influencing TO, laparoscopy has an indirect impact on the probability of cure and long-term management of these patients. This study strongly supports the promising curative role of mini-invasive treatments for early-stage HCC, such as low-difficulty LLR.

A Composite Measure for Quality of Care in Patients with Symptomatic Carotid Stenosis Using Textbook Outcome

Composite measures may better objectify hospital performance than individual outcome measures (IOM). Textbook outcome (TO) is an outcome measure achieved for an individual patient when all undesirable outcomes are absent. The aim of this study was to assess TO as an additional outcome measure to evaluate quality of care in symptomatic patients treated by carotid endarterectomy (CEA). All symptomatic patients treated by CEA in 2018, registered in the Dutch Audit for Carotid Interventions, were included. TO was defined as a composite of the absence of 30 day mortality, neurological events (any stroke or transient ischaemic attack [TIA]), cranial nerve deficit, haemorrhage, 30 day readmission, prolonged length of stay (LOS; > 5 days) and any other surgical complication. Multivariable logistic regression was used to identify covariables associated with achieving TO, which were used for casemix adjustment for hospital comparison. For each hospital, an observed vs. expected number of events ratio (O/E ratio) was calculated and plotted in a funnel plot with 95% control limits. In total, 70.7% of patients had a desired outcome within 30 days after CEA and therefore achieved TO. Prolonged LOS was the most common parameter (85%) and mortality the least common (1.1%) for not achieving TO. Covariates associated with achieving TO were younger age, the absence of pulmonary comorbidity, higher haemoglobin levels, and TIA as index event. In the case mix adjusted funnel plot, the O/E ratios between hospitals ranged between 0.63 and 1.27, with two hospitals revealing a statistically significantly lower rate of TO (with O/E ratios of 0.63 and 0.66). In the Netherlands, most patients treated by CEA achieve TO. Variation between hospitals in achieving TO might imply differences in performance. TO may be used as an additive to the pre-existing IOM, especially in surgical care with low baseline risk such as CEA.

Analysis of textbook outcomes among patients undergoing resection of retroperitoneal sarcoma: A multi-institutional analysis of the US Sarcoma Collaborative.

The novel composite metric textbook outcome (TO) has increasingly been used as a quality indicator but has not been reported among patients undergoing surgical resection for retroperitoneal sarcoma (RPS) using multi-institutional collaborative data. All patients who underwent resection for RPS between 2000 to 2016 from eight academic institutions were included. TO was defined as a patient with R0/R1 resection that discharged to home and was without transfusion, reoperation, grade ≥2 complications, hospital-stay >50th percentile, or 90-day readmission or mortality. Univariate and multivariable analyses were performed. Among 627 patients, 56.1% were female and the median age was 59 years. A minority of patients achieved a TO (34.9%). Factors associated with achieving a TO were tumor size <20 cm and low tumor grade, while ASA class ≥3, history of a prior cardiac event, resection of left colon/rectum, distal pancreatic resection, major venous resection and drain placement were associated with not achieving a TO (all P < .05). Achievement of a TO was associated with improved survival (median:12.7 vs 5.9 years, P < .01). Among patients undergoing resection for RPS, failure to achieve TO is common and associated with significantly worse survival. The use of TO may inform patient expectations and serve as a measure for patient-level hospital performance.

Is Patient Satisfaction Dictated by Quality of Care Among Patients Undergoing Complex Surgical Procedures for a Malignant Indication?

The current study aimed to define the relationship between patient satisfaction, hospital-level factors, and clinical outcomes among patients undergoingmajor surgery for cancer. The Medicare Inpatient Standard Analytic Files were used to identify patients undergoing lung, esophageal, colorectal, hepatic, or pancreatic surgery between 2016 and 2017, and Hospital Consumer Assessment of Healthcare Providers and Systems survey data were used to assess performance in terms of patient satisfaction. Among 60,446 patients, half were female (n = 31,244, 52%) with a median age of 73years (interquartile range [IQR] 69-78years). Patients who underwent surgery for esophageal resection (odds ratio [OR] 2.44; 95% confidence interval [CI] 1.10-5.40) and were Caucasian (OR 2.43; 95% CI 2.11-2.81) had optimal patient satisfaction. Hospital level factors such as urban location (OR 3.69; 95% CI 3.16-4.29), 200 + beds (OR 3.58; 95% CI 3.09-4.13), greater inpatient surgical volume (OR 3.03; 95% CI 2.82-3.25), higher nurse-to-bed ratio (OR 4.57; 95% CI 4.25-4.92), non-profit hospital status (OR 1.14; 95% CI 1.01-1.29), and non-teaching hospital status (OR 1.52; 95% CI 1.39-1.65) were related to optimal patient satisfaction. In adjusted analysis, patients undergoing surgery at hospitals reporting poor or average patient satisfaction had 22% higher odds of 90-day mortality than patients undergoing surgery at optimal-satisfaction hospitals (OR 1.22; 95% CI 1.09-1.36). In addition, hospitals with the highest patient satisfaction scores also had the highest proportion of surgical cases that achieved the composite textbook outcome (TO) quality metric (OR 1.12; 95% CI 1.05-1.20). Higher patient satisfaction was strongly associated with hospital structural measures such as bed number, urban location, nurse-to-bed ratio, and "optimal" TO after cancer surgery. These data highlight how high quality of care can directly lead to improved patient satisfaction among surgical patients with cancer.

Textbook Outcomes in Liver Transplantation.

Textbook outcome (TO) is an emerging concept within multiple surgical domains, which represents a novel effort to define a standardized, composite quality benchmark based on multiple postoperative endpoints that represent the ideal "textbook" hospitalization. We sought to define TO for liver transplantation (LT) using a cohort from a high procedural volume center. Patients who underwent LT at our institution between 2014 and 2017 were eligible for the study. The definition of TO was determined by clinician consensus at our institution to include freedom from: mortality within 90days, primary allograft non-function, early allograft dysfunction (EAD), rejection within 30days, readmission with 30days, readmission to the ICU during index hospitalization, hospital length of stay > 75th percentile of all liver transplant patients, red blood cell (RBC) transfusion requirement greater than the 75th percentile for all liver transplant patients, Clavien-Dindo Grade III complication (re-intervention), and major intraoperative complication. Two hundred and thirty-one liver transplants with complete data were performed within the study period. Of those, 71 (31%) achieved a TO. Overall, the most likely event to lead to failure to achieve TO was readmission within 30days (n = 57, 37%) or reoperation (n = 49, 32%). Overall and rejection-free survival did not differ significantly between the 2 groups. Interestingly, patients who achieved TO incurred approximately $60,000 less in total charges than those who did not. When we limit this to charges specifically attributable to the transplant episode, the difference was approximately $50,000 and remained significantly less for those that achieved TO. Here, we present the first definition of TO in LT. Though not associated with long-term outcomes, TO in LT is associated with a significantly lower charges and costs of the initial hospitalization. A multi-institutional study to validate this definition of TO is warranted.

Implementation of enhanced recovery after surgery for pancreatoduodenectomy increases the proportion of patients achieving textbook outcome: A retrospective cohort study

BackgroundEnhanced Recovery After Surgery (ERAS) for patients undergoing pancreatoduodenectomy is associated with reduced length of stay (LOS) and morbidity. However, external validating of the impact is difficult due to the multimodal aspects of ERAS. This study aimed to assess implementation of ERAS for pancreatoduodenectomy with a composite measure of multiple ideal outcome indicators defined as ‘textbook outcome’ (TBO). MethodsIn a tertiary referral center, 250 patients undergoing pancreatoduodenectomy were included in ERAS (May 2012–January 2017) and compared to a cohort of 125 patients undergoing traditional perioperative management (November 2009–April 2012). TBO was defined as proportion of patients without prolonged LOS, Clavien-Dindo ≥ III complications, postoperative pancreatic fistula, postpancreatectomy hemorrhage, bile leakage, readmissions or 30-day/in-hospital mortality. Additionally, overall treatment costs were calculated and compared using bootstrap independent t-test. ResultsThe two cohorts were comparable in terms of demographic and surgical details. Implementation of ERAS was associated with reduced median LOS (10 days vs 13 days, p < 0.001) and comparable overall complication rate (62.0% vs 61.6%, p = 0.940) when compared to the traditional management group. In addition, a higher proportion of patients achieved TBO (56.4% vs 44.0%, p = 0.023) when treated according to ERAS principles. Furthermore, ERAS was associated with reduced mean total costs (£18132 vs £19385, p < 0.005). ConclusionImplementation of ERAS for patients undergoing pancreatoduodenectomy is beneficial for both patients and hospitals. ERAS increased the proportion of patients achieving TBO and reduced overall costs. TBO is a potential measure for the evaluation of ERAS.

Benchmark performance of laparoscopic left lateral sectionectomy and right hepatectomy in expert centers

Herein, 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. Data from a nationwide multicenter survey including all patients undergoing LLLS and LRH between 2000 and 2017 were analyzed. Textbook outcome (TO) completion was considered in patients fulfilling all 6 of the following characteristics: negative margins, no transfusion, no complication, no prolonged hospital stay, no readmission and no mortality. For each procedure, a cut-off laparoscopic liver resection (LLR) volume by center was associated with TO on multivariable analysis. These cut-offs defined the expert centers. The benchmark values were set at the 75th percentile of median outcomes among these expert centers. Among 4,400 LLRs performed in 29 centers, 855 patients who underwent LLLS and 488 who underwent LRH were identified. The overall incidences of TO after LLLS and LRH were 43.7% and 23.8%, respectively. LLR volume cut-offs of 25 LLR/year (odds ratio [OR] 2.45; bootstrap 95% CI 1.65-3.69; p= 0.001) and 35 LLR/year (OR 2.55; bootstrap 95% CI 1.34-5.63; p= 0.003) were independently associated with completion of TO after LLLS and LRH, respectively. Eight centers for LLLS and 6 centers for LRH, including 516 and 346 patients undergoing LLLS/LRH respectively, reached these cut-offs and were identified as expert centers. After LLLS, benchmark values of severe complication, mortality and TO completion were defined as ≤5.3%, ≤1.2% and ≥46.6%, respectively. After LRH, benchmark values of severe complication, mortality and TO completion were ≤20.4%, ≤2.8% and ≥24.2%, respectively. This study provides an up-to-date reference on the benchmark performance of LLLS and LRH in expert centers. In a nationwide French survey of laparoscopic liver resection, expert centers were defined according tothe completion of a textbook outcome, which is a composite indicator of healthcare quality. Benchmark values regarding intra-operative details and outcomes were established using data from 516 patients with laparoscopic left lateral sectionectiomy and 346 patients with laparoscopic right hepatectomy from expert centers. These values should be used as a reference point to improve the quality of laparoscopic resections.

Assessing Textbook Outcomes Following Liver Surgery for Primary Liver Cancer Over a 12-Year Time Period at Major Hepatobiliary Centers

The objective of the current study was to comprehensively assess the change of practice in hepatobiliary surgery by determining the rates and the trends of textbook outcomes (TO) among patients undergoing surgery for primary liver cancerover time. Patients undergoing curative-intent resection for primary liver malignancies, including hepatocellular carcinoma (HCC) and intrahepatic cholangiocarcinoma (ICC) between 2005 and 2017 were analyzed using a large, international multi-institutional dataset. Rates of TO were assessed over time. Factors associated with achieving a TO and the impact of TO on long-term survival were examined. Among 1829 patients, 944 (51.6%) and 885 (48.4%) individuals underwent curative-intent resection for HCC and ICC, respectively. Over time, patients were older, more frequently had ASA class> 2, albumin-bilirubin grade 2/3, major vascular invasion and more frequently underwent major liver resection (all p < 0.05). Overall, a total of 1126 (62.0%) patients achieved a TO. No increasing trends in TO rates were noted over the years (ptrend = 0.90). In addition, there was no increasing trend in the TO rates among patients undergoing either major (ptrend = 0.39) or minor liver resection (ptrend = 0.63) over the study period. Achieving a TO was independently associated with 26% and 37% decreased hazards of death among ICC (HR 0.74, 95%CI 0.56-0.97) and HCC patients (HR 0.63, 95%CI 0.46-0.85), respectively. Approximately 6 in 10 patients undergoing surgery for primary liver tumors achieved a TO. While TO rates did not increase over time, TO was associated with better long-term outcomes following liver resection for both HCC and ICC.

Influence of hospital teaching status on the chance to achieve a textbook outcome after hepatopancreatic surgery for cancer among Medicare beneficiaries

BackgroundAssessing composite measures of quality such as textbook outcome may be superior to focusing on individual parameters when evaluating hospital performance. The aim of the current study was to assess the impact of teaching hospital status on the occurrence of a textbook outcome after hepatopancreatic surgery. MethodsThe Medicare Inpatient Standard Analytic Files were used to identify patients undergoing hepatopancreatic surgery from 2013 to 2015 for a malignant indication. Stratified and multivariable regression analyses were performed to determine the relationship between teaching hospital status, hospital surgical volume and textbook outcome. ResultsAmong 8,035 Medicare patients (hepatectomy; 41.8%, pancreatectomy; 58.2%), 6,196 (77.1%) patients underwent surgery at a major teaching hospital, whereas 1,839 (22.9%) patients underwent surgery at a minor teaching hospital. Patients undergoing surgery for pancreatic cancer at a major teaching hospital had a greater likelihood of achieving a textbook outcome compared with patients treated at a minor teaching hospital (minor teaching hospital: 456, 40% versus major teaching hospital: 1,606, 45.4%; P = .002). The likelihood of textbook outcome was also greater among patients undergoing hepatopancreatic surgery at high-volume centers (pancreas, low volume: 875, 40.5% versus high volume: 1,187, 47.1% P < .001; liver, low volume: 608, 41.8% versus high volume: 886, 46.6%; P = .005). When examining only major teaching hospitals, patients undergoing a pancreatectomy at a high-volume center had 29% greater odds of achieving a textbook outcome (odds ratio 1.29, 95% confidence interval 1.12–1.49). In contrast, among patients undergoing pancreatic resection at high-volume centers, the odds of achieving a textbook outcome was comparable among major versus minor teaching hospital (odds ratio 1.17, 95% confidence interval 0.89–1.53). ConclusionThe odds of achieving a textbook outcome after pancreatic and hepatic surgery was greater at major versus minor teaching hospitals; however, this effect was largely mediated by hepatopancreatic procedural volume. Patients and payers should focus on regionalization of pancreatic and liver resection to high-volume centers in an effort to optimize the chances of achieving a textbook outcome.

Textbook Outcomes Among Patients Undergoing Retroperitoneal Sarcoma Resection.

Recently, the concept of textbook outcome (TO) has emerged as a novel effort to develop a benchmark that reflects multiple domains of quality. The aims of the current study were to define TO for retroperitoneal sarcoma (RPS), evaluate the relationship of TO with hospital volume and assess the association of TO with overall survival. Patients who underwent resection for RPS diagnosed between 2004 and 2015 were identified in the National Cancer Database. The primary outcome was TO that was defined as: hospital length of stay<75th percentile, survival>90 days from surgery, no readmission within 30 days and grossly negative margins. Of the 11,032 patients analyzed, 54.0% had a TO. Among patients who had a TO, 57.8% were treated in high-volume hospitals. Undergoing surgery at high-volume centers was associated with a higher probability of a TO (p=0.009). TO were associated with significantly longer overall survival (p<0.001). In a subgroup analysis with grossly negative margins and no 90-day mortality, the association of TO with improved survival persisted (p<0.001). The concept of TO is a promising tool for measuring patient-level hospital performance and may be useful for identifying important variations in care for patients with RPS.

ASO Author Reflections: Chance of Textbook Outcome following Hepatopancreatic Surgery Varies Based on Cancer Center Designation.

ASO Author Reflections: Chance of Textbook Outcome following Hepatopancreatic Surgery Varies Based on Cancer Center Designation.