Evaluation of Textbook Outcome as a Composite Quality Measure of Elective Laparoscopic Cholecystectomy

Abstract

ImportanceA textbook outcome (TO) is a composite quality measure that incorporates multiple perioperative events to reflect the most desirable outcome. The use of TO increases the event rate, captures more outcomes to reflect patient experience, and can be used as a benchmark for quality improvement.ObjectivesTo introduce the concept of TO to elective laparoscopic cholecystectomy (LC), propose the TO criteria, and identify characteristics associated with TO failure.Design, Setting, and ParticipantsThis retrospective cohort study was performed at 3 surgical units in a single health board in the United Kingdom. Participants included all patients undergoing elective LC between January 1, 2015, and January 1, 2020. Data were analyzed from January 1, 2015, to January 1, 2020.Main Outcomes and MeasuresThe TO criteria were defined based on review of existing TO metrics in the literature for other surgical procedures. A TO was defined as an unremarkable elective LC without conversion to open cholecystectomy, subtotal cholecystectomy, intraoperative complication, postoperative complications (Clavien-Dindo classification ≥2), postoperative imaging, postoperative intervention, prolonged length of stay (>2 days), readmission within 100 days, or mortality. The rate of TOs was reported. Reasons for TO failure were reported, and preoperative characteristics were compared between TO and TO failure groups using both univariate analysis and multivariable logistic regressions.ResultsA total of 2166 patients underwent elective LC (median age, 54 [range, 13-92] years; 1579 [72.9%] female). One thousand eight hundred fifty-one patients (85.5%) achieved a TO with an unremarkable perioperative course. Reasons for TO failure (315 patients [14.5%]) included conversion to open procedure (25 [7.9%]), subtotal cholecystectomy (59 [18.7%]), intraoperative complications (40 [12.7%]), postoperative complications (Clavien-Dindo classification ≥2; 92 [29.2%]), postoperative imaging (182 [57.8%]), postoperative intervention (57 [18.1%]), prolonged length of stay (>2 days; 142 [45.1%]), readmission (130 [41.3%]), and mortality (1 [0.3%]). Variables associated with TO failure included increasing American Society of Anesthesiologists score (odds ratio [OR], 2.55 [95 CI, 1.69-3.85]; P < .001), increasing number of prior biliary-related admissions (OR, 2.68 [95% CI, 1.36-5.27]; P = .004), acute cholecystitis (OR, 1.42 [95% CI, 1.08-1.85]; P = .01), preoperative endoscopic retrograde cholangiopancreatography (OR, 2.07 [95% CI, 1.46-2.92]; P < .001), and preoperative cholecystostomy (OR, 3.22 [95% CI, 1.54-6.76]; P = .002).Conclusions and RelevanceThese findings suggest that applying the concept of TO to elective LC provides a benchmark to identify suboptimal patterns of care and enables institutions to identify strategies for quality improvement.

Textbook outcome in the laparoscopic cholecystectomy of acute cholecystitis

“…12 This concept has been applied to various diseases. 4,[13][14][15] In the present article, to our knowledge, we reported the first TO assessment for acute cholecystitis.…”

“…Lucocq et al reported that the TO criteria for elective cholecystectomy were conversion to open cholecystectomy, subtotal cholecystectomy, intraoperative complications, postoperative complications (Clavien-Dindo classification ≥2), postoperative imaging or intervention, prolonged postoperative LOS (>2 days), readmission, or mortality. 4 We determined the TO factors in this study by referring and modifying the findings of Lucocq et al We did not include postoperative imaging as a TO factor because some hospitals routinely perform postoperative imaging. In this study, 15% of patients were hospitalized for more than 10 days after surgery (data not shown).…”

“…3 TO has been reported for elective laparoscopic cholecystectomy. 4 We considered that it was valuable to adapt TO to acute cholecystitis, which is associated with a wide variety of patient backgrounds. The purpose of this study was to evaluate TO for acute cholecystitis and to improve the quality of future medical care by examining the factors related to TO failure.…”

Textbook outcome in the surgical treatment of acute cholecystitis

“…TO offered a simpli ed performance measure that might be easier for stakeholders to interpret when evaluating the frequency of overall delivery of the desired clinical result (12). This concept has been applied to various diseases (4,13,14,15). In the present article, to our knowledge, we reported the rst TO assessment for acute cholecystitis.…”

“…The concept of textbook outcome (TO) has emerged as a new tool to provide an overall measure of successful outcome, considering multiple measures of quality after surgical intervention (3). TO has been reported for elective laparoscopic cholecystectomy (4). We considered that it was valuable to adapt TO to acute cholecystitis, which is associated with a wide variety of patient backgrounds.…”