A Multi-institutional International Analysis of Textbook Outcomes Among Patients Undergoing Curative-Intent Resection of Intrahepatic Cholangiocarcinoma

Abstract

IMPORTANCE Composite measures may be superior to individual measures for the analysis of hospital performance and quality of surgical care.OBJECTIVE To determine the incidence of a so-called textbook outcome, a composite measure of the quality of surgical care, among patients undergoing curative-intent resection of intrahepatic cholangiocarcinoma. DESIGN, SETTING, AND PARTICIPANTSThis cohort study involved an analysis of a multinational, multi-institutional cohort of patient from 15 major hepatobiliary centers in North America, Europe, Australia, and Asia who underwent curative-intent resection of intrahepatic cholangiocarcinoma between 1993 and 2015. Data analysis was conducted from April 2018 to May 2018. MAIN OUTCOMES AND MEASURESHospital variation in the composite end point of textbook outcome, defined as negative margins, no perioperative transfusion, no postoperative surgical complications, no prolonged length of stay, no 30-day readmissions, and no 30-day mortality. Secondary end points were factors associated with achieving textbook outcomes. RESULTS Among 687 patients (of whom 370 [53.9%] were men; median patient age, 61 [range, 18-86] years) undergoing curative-intent resection of intrahepatic cholangiocarcinoma, a textbook outcome was achieved in 175 patients (25.5%). Being 60 years or younger (odds ratio [OR], 1.61 [95% CI, 1.04-2.49]; P = .03), absence of preoperative jaundice (OR, 4.40 [95% CI, 1.28-15.15]; P = .02), no neoadjuvant chemotherapy (OR, 2.57 [95% CI, 1.05-6.29]; P = .04), T1a/T1b-stage disease (OR, 1.58 [95% CI, 1.01-2.49]; P = .049), N0 status (OR, 3.89 [95% CI,]; P = .001), and no bile duct resection (OR, 2.46 [95% CI,; P = .009) were independently associated with achieving a textbook outcome after resection. A prolonged length of stay had the greatest negative association with a textbook outcome. A nomogram to assess the probability of textbook outcome was developed and had good accuracy in both the training data set (area under the curve, 0.755) and validation data set (area under the curve, 0.763). CONCLUSIONS AND RELEVANCEIn this study, while hepatic resection for intrahepatic cholangiocarcinoma was performed with less than 5% mortality in specialized centers, a textbook outcome was achieved in only approximately 26% of patients. A textbook outcome may be useful for the reporting of patient-level hospital performance and hospital variation, leading to quality improvement efforts after resection of intrahepatic cholangiocarcinoma.

Assessment of textbook oncologic outcomes following pancreaticoduodenectomy for pancreatic adenocarcinoma

“…Providing patients data on composite measures such as textbook outcome and TOO may facilitate more “realistic” conversations and help frame expectations around complex surgical procedures. For example, previous studies have reported textbook outcomes range from 25% to 50% among patients undergoing surgery for intrahepatic cholangiocarcinoma, as well as esophageal, gastric, or colon cancers 6,8,10 . In the current study, the ability to achieve TOO was even lower among patients with PDAC as fewer than one in five patients had an “optimal” outcome.…”

“…While the reason for this is undoubtedly multifactorial, the lower odds of TOO among PDAC patients likely relates to the complexity of PD with a higher incidence of anticipated complications, which have been demonstrated to prolong hospitalization, as well as delay administration of adjuvant therapy 21–24 . In addition, the lower incidence of a TOO in the current study may be due, in part, to the use of the NCDB, which included a more generalized sample of hospitals compared with multi‐intuitional studies that contained more select data from high‐volume centers 6,8,10 …”

“…One such application of a composite quality outcomes measure, the “textbook outcome,” has been defined by previous investigators in the setting of surgical treatment of colon cancer, aortic aneurysm, gastroesophageal cancer, morbid obesity, and intrahepatic cholangiocarcinoma 6–10 . By encompassing multiple desirable outcomes, textbook outcome offers a simplified performance measure that may be easier to interpret by stakeholders when evaluating the frequency of overall delivery of the desired clinical result.…”

Comparing textbook outcomes among patients undergoing surgery for cancer at U. S. News & World Report ranked hospitals

“…Van Roessel et al 38 noted that TO can better reflect the quality and may be a powerful parameter to assess quality between different hospitals during regular audits for pancreatic surgery. Similarly, several other investigators reported TO as a useful tool to assess interhospital variations among patients undergoing complex surgery 10,11,37 . As the TO composite measure combines important quality parameters into a single metric, TO may increase the reliability to evaluate overall hospital performance.…”

“…Therefore, evaluating single parameters may not capture the multidimensional aspect of surgical quality as top‐ranked hospitals might perform better on one parameter while not as well on others. To this end, composite outcome measures such as TO might prove to be superior for the analyses of overall patient‐centered hospital performance 37 . Van Roessel et al 38 noted that TO can better reflect the quality and may be a powerful parameter to assess quality between different hospitals during regular audits for pancreatic surgery.…”