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

Abstract

Intro: Textbook surgical outcome (TO) is a novel composite quality measure in lung transplantation (LTx). Compared to 1-year survival metrics, TO may better differentiate center performance, and motivate improvements in care. To understand the feasibility of implementing this metric, we defined TO in LTx using US national data, and evaluated its ability to predict post-transplant outcomes and differentiate center performance.Methods: Adult patients who underwent isolated LTx between 2016 and 2019 were included. TO was defined as freedom from post-transplant length of stay > 30 days, 90-day mortality, intubation or extracorporeal membrane oxygenation at 72 h posttransplant, post-transplant ventilator support lasting ≥5 days, postoperative airway dehiscence, inpatient dialysis, pre-discharge acute rejection, and grade 3 primary graft dysfunction at 72 h. Recipient and donor characteristics and post-transplant outcomes were compared between patients who achieved and failed TO.Results: Of 8959 lung transplant recipients, 4664 (52.1%) achieved TO. Patient and graft survival were improved among patients who achieved TO (both log-rank P < .0001). Among 62 centers, adjusted rates of TO ranged from 27.0% to 72.4% reflecting a wide variability in center-level performance. Conclusion:TO defined using national data may represent a novel composite metric to guide quality improvement in LTx across US transplant centers. Summary:In this study we defined textbook outcome (TO) for lung transplantation (LTx) using US national data. We found that achievement of TO was associated with improved post-transplant survival, and wide variability in center-level LTx performance. These findings suggest that TO could be readily implemented to compare quality of care among US LTx centers.

Textbook Outcome for Superior Cavopulmonary Connection: A Metric for Single Ventricle Heart Surgery

“…This methodology can be performed at the center level, for quality improvement purposes, as well as at the national level with case-mix adjustment to understand variations in quality of care. 8,9,20 For instance, at our center, we show that the Glenn TO rate has increased with time. Internal benchmarking of performance can be done by performing similar analyses for different operations.…”

Assessing Textbook Outcome After Implementation of Transversus Abdominis Release in a Regional Hospital

“…While comparison of complication rates between hernia studies is biased by registration and interpretation issues, Textbook Outcome enables a comprehensive summary of simple and unambiguous clinical care parameters. Textbook Outcome is used in other surgical specialties for both internal quality improvement and comparison with other studies ( 37 , 38 ). The number of patients with a Textbook Outcome compared to the total number of consecutively performed TARs is depicted as the institutional learning curve.…”

Textbook outcome for the Norwood operation—an informative quality metric in congenital heart surgery

“…In multi-institutional analyses, case-mix–adjusted textbook outcome rates varied significantly between centers, which highlights its discriminative power. 2 , 5 , 6 , 19 Second, careful review of composite outcome rates by center leadership can drive targeted quality improvement efforts, motivated by the fact that textbook outcome achievement independently predicts long-term survival. Third, predictive analyses of textbook outcomes with nomograms can provide patient-level prognostication.…”

“…An example is the textbook outcome, which is a composite measure based on multiple postoperative end points that, when achieved, represents the ideal “textbook” hospitalization after a certain operation. 2 , 3 , 4 , 5 , 6 In complex operations such as lung transplantation, achievement of the textbook outcome has been shown to predict longer survival as well as decreased costs. 3 However, composite quality measures in congenital heart surgery are still early in development.…”