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Quality Improvement/Clinical Outcomes

E411: The "Textbook Outcome” Isn’t Textbook: Significant Variation in “Textbook Outcome” Definitions Following a Systemic Review of the Surgical Oncology Literature

    ePoster Abstract Author(s)

  • Corey Hounschell, DO

    Resident Physician
    University of Kansas Medical Center
    Overland Park, Kansas, United States

    • Submitter(s)

  • Corey Hounschell, DO

    Resident Physician
    University of Kansas Medical Center
    Overland Park, Kansas, United States

    • Author(s)

  • Corey Hounschell, DO

    Resident Physician
    University of Kansas Medical Center
    Overland Park, Kansas, United States

  • LC

    Lynn Chollet-Hinton, PhD

    Assistant Professor
    University of Kansas Department of Biostatistics, United States

  • JB

    Julie Broski, n/a

    Medical Writer
    University of Kansas Department of Surgery, United States

  • KL

    Kelsey Lambou, MD

    Resident Physician
    University of Kansas Department of Surgery, United States

  • KS

    Kate Sanner-Dixon, MD

    Resident Physician
    University of Kansas Medical Center Department of Surgery, United States

  • LS

    Luke Selby, MD

    Assistant Professor of Surgery
    University of Kansas Department of Surgery, United States

Introduction: Surgical outcome reporting has traditionally been single outcome focused. The recent composite “textbook outcome” (TO) measure has become popular without an agreed upon definition. Using PRISMA guidelines, we conducted a systematic review of surgical oncology focused TO manuscripts to assess the heterogeneity of the TO definitions.

Methods: Articles focusing on HIPEC or the surgical treatment of breast, esophageal, gastric, liver, pancreas, liver, colon, rectal cancers, retroperitoneal sarcoma were identified in April 2023. Following exclusions, 82/122 initial articles were included in the final descriptive analysis, 24 included multiple disease sites.

Results: Eighty-two papers encompassing 10 unique disease sites or procedure types were included (Breast: 1, colon: 8, esophageal: 17, gastric: 13, HIPEC: 1, liver: 33, multivisceral resection: 1, pancreas: 22, rectal: 8, RP sarcoma: 2). Source data, the number of components of a TO, and component differed greatly within and across disease sites. Data sources included institutional databases (28/82,34%), multi-center collaboratives (13/82, 16%), national (37/82, 45%) and international (4 /82, 5%) databases. The mean number of TO components was 6 (range: 4-13), no component was included in all definitions.  Readmission (77/82, 94%), post-operative mortality (75/82, 92%), and length of stay (72/82, 88%) were most included, least commonly included was receipt of adjuvant chemotherapy (3/82, 4%). Time cutoffs and component definitions varied greatly: readmission cutoff: 30 days (40/77, 52%), 90 days (25/77, 32%), 6 months (1/77, 1%); not reported (11/77, 14%); mortality cutoff: 30 days (29/75, 39%), 90 days: (34/75, 45%), not reported (12/75,16%); LOS cutoff: 50th %tile (8/72, 11%), 75th%tile (33/72, 46%), 90th%tile (1/72, 1%), 3-10 days (3/72, 4%), 14-21 days (26/72, 36%), average LOS (1/72, 1%

Conclusions: TO, a recently adopted composite outcome measure, provides a comprehensive view of perioperative outcomes.  As currently used, however, there is significant heterogeneity within and across disease sites that limits generalizability and interpretation.  Authors should standardize component definitions and disease-specific components inclusion to improve its utility.

Learning Objectives:

  • Describe the concept of a "textbook outcome" as it is used in surgical oncology literature
  • Explain how the heterogeneity by which "textbook outcome" is currently reported limits its use in the practice of quality improvement efforts
  • Describe some ways in which the concept of a "textbook outcome" could become a more useful tool for surgical oncologists