Textbook Outcomes in Liver Transplantation

Abstract

Background 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. Methods 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 90 days, primary allograft non-function, early allograft dysfunction (EAD), rejection within 30 days, readmission with 30 days, 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.Results 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 30 days (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. Conclusions 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.

Textbook surgical outcome in lung transplantation: Analysis of a US national registry

“…Finally, our definition of TO was defined based on clinician consensus at a single institution. While this procedure is consistent with that reported in the literature, 18,19 we recognize that this approach inherently introduces bias in the selection of variables included in the definition. To limit this bias, future efforts to define TO in LTx may elect a data-driven approach to identify variables to prospectively optimize the definition among LTx programs nationally.…”

“…TO is a novel multidimensional quality measure that may better differentiate performance and quality among US LTx centers than current TO was achieved by 52.1% of LTx recipients nationally, considerably higher than published rates of TO in institutional cohorts of kidney and liver transplant recipients (44.0% and 31.0%, respectively). 17,18 While some discordance in rates of TO achievement between singlecenter and national studies is expected, we observed a roughly twofold increase in our institution's rate of TO achievement when applying the current definition based on national data compared to our definition of TO using institutional data. 19 This stark difference in rates of TO achievement highlights the inherent differences in these TO measures, and likely reflects the variation in available LTx perioperative endpoints.…”

“…Definitions typically include indicators of perioperative quality such as early morbidity, early mortality, early readmissions, and procedure‐specific variables such as margin status in oncology 11–16 . Although originally established in surgical oncology, TOs have recently been introduced in transplantation as a means to evaluate the multidimensional nature of quality of care in the increasingly complex landscape of solid organ transplantation 17–19 . In LTx, a TO metric composed of multiple perioperative endpoints may offer more nuanced understanding of the complex nature of LTx hospitalizations in addition to standard 1‐year survival metrics and provide a means to evaluate center performance and guide quality improvement.…”

Evaluation of the learning curve for totally robotic single-anastomosis duodenal–ileal bypass with sleeve gastrectomy by CUSUM analysis

“…According to a review of existing "Textbook Outcome" metrics in the literature [19][20][21][22][23] , the de nition of surgical failure was subsequently expanded for totally robotic SADI-S-speci c outcomes selected based on clinician consensus among a team of bariatric surgeons at our institution. The nal de nition of surgical failure in totally robotic SADI-S included the following 5 key parameters: operative time > 210 min, length of postoperative stay > 7 days, postoperative morbid event ≥ Clavien grade II, conversion to laparotomy, and rehospitalization or death after totally robotic SADI-S. Surgical failure was recorded when any of the aforementioned parameters were observed.…”

Telemedicine for Follow-up Management of Patients After Liver Transplantation: Cohort Study

“…Although the definition of textbook outcome varies, it frequently includes the evaluation of morbidity, mortality, length of stay, and hospital readmission. Moris et al [15] defined textbook outcome as a metric of an ideal outcome in liver transplantation. The textbook outcome for liver transplantation is based on the exclusion of the following parameters: mortality within 90 days, primary allograft nonfunction, early allograft dysfunction, rejection of the graft within 30 days, readmission with 30 days, readmission to the intensive care unit during hospitalization, hospital length of stay >75th percentile of all liver transplantation, red blood cell transfusion requirement >75th percentile for all liver transplantation complications (reintervention), and major intraoperative complications.…”