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Original Investigation
April 24, 2019

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

Author Affiliations
  • 1The Ohio State University Wexner Medical Center, Columbus
  • 2University of Verona, Verona, Italy
  • 3Fundeni Clinical Institute, Bucharest, Romania
  • 4Curry Cabral Hospital, Lisbon, Portugal
  • 5Ospedale San Raffaele, Milan, Italy
  • 6Emory University, Atlanta, Georgia
  • 7University of Sydney, Sydney, Australia
  • 8Johns Hopkins Hospital, Baltimore, Maryland
  • 9University of Virginia, Charlottesville, Virginia
  • 10Eastern Hepatobiliary Surgery Hospital, Shanghai, China
  • 11Stanford University, Stanford, California
  • 12Beaujon Hospital, Clichy, France
  • 13University of Ottawa, Ontario, Canada
  • 14Erasmus University Medical Center, Rotterdam, the Netherlands
  • 15Yokohama City University, Yokohama, Japan
JAMA Surg. Published online April 24, 2019. doi:10.1001/jamasurg.2019.0571
Key Points

Question  To determine the incidence of so-called textbook outcomes, a composite measure of the quality of surgical care, among patients undergoing curative-intent resection of intrahepatic cholangiocarcinoma.

Findings  In this cohort study of 687 patients undergoing the reference procedure, a textbook outcome was achieved in 175 patients (25.5%). 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).

Meaning  While hepatic resection for intrahepatic cholangiocarcinoma was performed with less than 5% mortality in specialized centers, a textbook outcome appears to have been achieved in only one-quarter of patients.

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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