TY - JOUR
T1 - Evaluation of Textbook Outcome as a Composite Quality Measure of Elective Laparoscopic Cholecystectomy
AU - Lucocq, James
AU - Scollay, John
AU - Patil, Pradeep
N1 - Copyright Information:
This is an open access article distributed under the terms of the CC-BY License. © 2022 Lucocq J et al. JAMA Network Open.
PY - 2022/9/20
Y1 - 2022/9/20
N2 - Importance: A 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.Objectives: To introduce the concept of TO to elective laparoscopic cholecystectomy (LC), propose the TO criteria, and identify characteristics associated with TO failure.Design, Setting, and Participants: This 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 Measures: The 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.Results: A 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 Relevance: These 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.
AB - Importance: A 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.Objectives: To introduce the concept of TO to elective laparoscopic cholecystectomy (LC), propose the TO criteria, and identify characteristics associated with TO failure.Design, Setting, and Participants: This 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 Measures: The 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.Results: A 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 Relevance: These 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.
KW - Laparoscopic cholecystectomy
KW - elective surgical procedure
KW - treatment outcome
KW - morbidity
KW - informed consent
UR - http://www.scopus.com/inward/record.url?scp=85138184466&partnerID=8YFLogxK
U2 - 10.1001/jamanetworkopen.2022.32171
DO - 10.1001/jamanetworkopen.2022.32171
M3 - Article
C2 - 36125810
SN - 2574-3805
VL - 5
JO - JAMA Network Open
JF - JAMA Network Open
IS - 9
M1 - e2232171
ER -