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Multicenter Study
. 2019 Jun 1;154(6):e190571.
doi: 10.1001/jamasurg.2019.0571. Epub 2019 Jun 19.

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

Katiuscha Merath  1 , Qinyu Chen  1 , Fabio Bagante  1   2 , Sorin Alexandrescu  3 , Hugo P Marques  4 , Luca Aldrighetti  5 , Shishir K Maithel  6 , Carlo Pulitano  7 , Matthew J Weiss  8 , Todd W Bauer  9 , Feng Shen  10 , George A Poultsides  11 , Olivier Soubrane  12 , Guillaume Martel  13 , B Groot Koerkamp  14 , Alfredo Guglielmi  2 , Endo Itaru  15 , Jordan M Cloyd  1 , Timothy M Pawlik  1
Affiliations
Multicenter Study

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

Katiuscha Merath et al. JAMA Surg. .

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 participants: This 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 measures: Hospital 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, 1.77-8.54]; P = .001), and no bile duct resection (OR, 2.46 [95% CI, 1.25-4.84]; 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 relevance: In 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.

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Figures

Figure 1.
Figure 1.. Textbook Outcomes by Year and by Hospital
A, Trends in rates of textbook outcome across years. Black dots indicate individual institutions; B, Hospital variation in risk-adjusted percentages of a textbook outcome. In A and B, black dots indicate individual institutions, and solid lines indicate the mean value per year. In B, the dotted lines indicate the 95% CIs.
Figure 2.
Figure 2.. Textbook Outcome Distribution by Its Definition
A, Total patients. Values are 584 (85.0%) for negative margins, 487 (70.9%) for absence of perioperative transfusion, 398 (57.9%) for absence of complications, 356 (51.8%) for no prolonged hospital stay, 644 (93.7%) for no 30-day readmission, and 657 (95.6%) for no 30-day mortality. The solid line indicates the mean. B, Patients categorized by Eastern and Western geographic regions; values for Eastern and Western hospitals, respectively, are 234 (94.0%) and 350 (79.9%) for negative margins, 176 (70.7%) and 311 (71.0%) for absence of perioperative transfusion, 170 (68.3%) and 228 (52.1%) for absence of complications, 64 (25.7%) and 292 (66.7%) for no prolonged hospital stay, 244 (98.0%) and 400 (91.3%) for no 30-day readmission, and 246 (98.8%) and 410 (93.8%) for no 30-day mortality. The solid line indicates the mean for Eastern hospitals and the dotted line, the mean for Western hospitals.
Figure 3.
Figure 3.. Nomogram for the Chances of Achieving a Textbook Outcome After Curative-Intent Resection of Intrahepatic Cholangiocarcinoma
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Comment in

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