The Ohio State University Wexner Medical Center, Columbus.
University of Verona, Verona, Italy.
JAMA Surg. 2019 Jun 1;154(6):e190571. doi: 10.1001/jamasurg.2019.0571. Epub 2019 Jun 19.
Composite measures may be superior to individual measures for the analysis of hospital performance and quality of surgical care.
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.
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.
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).
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.
对于分析医院绩效和外科护理质量，综合指标可能优于单个指标。
确定接受肝内胆管癌根治性切除术的患者中所谓的教科书结果（外科护理质量的综合指标）的发生率。
设计、地点和参与者：本队列研究分析了来自北美、欧洲、澳大利亚和亚洲 15 个主要肝胆中心的多国家、多机构队列的患者，这些患者在 1993 年至 2015 年间接受了肝内胆管癌的根治性切除术。数据分析于 2018 年 4 月至 5 月进行。
复合终点的医院变异教科书结果，定义为阴性边缘、无围手术期输血、无术后手术并发症、无延长住院时间、无 30 天再入院和无 30 天死亡率。次要终点是与实现教科书结果相关的因素。
在 687 例（其中 370 例[53.9%]为男性；中位患者年龄 61[范围 18-86]岁）接受肝内胆管癌根治性切除术的患者中，175 例（25.5%）达到了教科书结果。年龄在 60 岁或以下（优势比[OR]，1.61[95%CI，1.04-2.49]；P=0.03）、术前无黄疸（OR，4.40[95%CI，1.28-15.15]；P=0.02）、无新辅助化疗（OR，2.57[95%CI，1.05-6.29]；P=0.04）、T1a/T1b 期疾病（OR，1.58[95%CI，1.01-2.49]；P=0.049）、N0 状态（OR，3.89[95%CI，1.77-8.54]；P=0.001）和无胆管切除术（OR，2.46[95%CI，1.25-4.84]；P=0.009）与切除后达到教科书结果独立相关。延长住院时间与达到教科书结果的可能性呈最大负相关。开发了一种用于评估教科书结果概率的列线图，在训练数据集（曲线下面积，0.755）和验证数据集（曲线下面积，0.763）中均具有良好的准确性。
在这项研究中，尽管在专门中心进行肝切除术的死亡率低于 5%，但只有约 26%的患者达到了教科书结果。教科书结果可能有助于报告患者层面的医院绩效和医院变异，从而在切除肝内胆管癌后进行质量改进。
