Stijn van Roessel1, Tara M Mackay1, Susan van Dieren1, George P van der Schelling2, Vincent B Nieuwenhuijs3, Koop Bosscha4, Edwin van der Harst5, Ronald M van Dam6, Mike S L Liem7, Sebastiaan Festen8, Martijn W J Stommel9, Daphne Roos10, Fennie Wit11, I Quintus Molenaar12, Vincent E de Meijer13, Geert Kazemier14, Ignace H J T de Hingh15, Hjalmar C van Santvoort16, Bert A Bonsing17, Olivier R Busch1, Bas Groot Koerkamp18, Marc G Besselink1. 1. Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands. 2. Department of Surgery, Amphia Hospital, Breda, The Netherlands. 3. Department of Surgery, Isala Clinics, Zwolle, The Netherlands. 4. Department of Surgery, Jeroen Bosch Hospital, 's Hertogenbosch, The Netherlands. 5. Department of Surgery, Maasstad Hospital, Rotterdam, The Netherlands. 6. Department of Surgery, Maastricht University Medical Center, Maastricht, The Netherlands. 7. Department of Surgery, Medisch Spectrum Twente, Enschede, The Netherlands. 8. Department of Surgery, OLVG, Amsterdam, The Netherlands. 9. Department of Surgery, Radboud University Medical Center, Nijmegen, The Netherlands. 10. Department of Surgery, Reinier de Graaf ziekenhuis, Delft, The Netherlands. 11. Department of Surgery, Tjongerschans, Heerenveen, The Netherlands. 12. Department of Surgery, University Medical Center Utrecht, Utrecht, The Netherlands. 13. Department of Surgery, University Medical Center Groningen, Groningen, The Netherlands. 14. Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands. 15. Department of Surgery, Catharina Hospital, Eindhoven, The Netherlands. 16. Department of Surgery, St. Antonius Hospital, Nieuwegein, The Netherlands. 17. Department of Surgery, Leiden University Medical Center, Leiden, The Netherlands. 18. Department of Surgery, Erasmus MC University Medical Center, Rotterdam, The Netherlands.
Abstract
BACKGROUND: Textbook outcome (TO) is a multidimensional measure for quality assurance, reflecting the "ideal" surgical outcome. METHODS: Post-hoc analysis of patients who underwent pancreatoduodenectomy (PD) or distal pancreatectomy (DP) for all indications between 2014 and 2017, queried from the nationwide prospective Dutch Pancreatic Cancer Audit. An international survey was conducted among 24 experts from 10 countries to reach consensus on the requirements for TO in pancreatic surgery. Univariable and multivariable logistic regression was performed to identify TO predictors. Between-hospital variation in TO rates was compared using observed-versus-expected rates. RESULTS: Based on the survey (92% response rate), TO was defined by the absence of postoperative pancreatic fistula, bile leak, postpancreatectomy hemorrhage (all ISGPS grade B/C), severe complications (Clavien-Dindo ≥III), readmission, and in-hospital mortality. Overall, 3341 patients were included (2633 (79%) PD and 708 (21%) DP) of whom 60.3% achieved TO; 58.3% for PD and 67.4% for DP. On multivariable analysis, ASA class 3 predicted a worse TO rate after PD (ASA 3 OR 0.59 [0.44-0.80]), whereas a dilated pancreatic duct (>3 mm) and pancreatic ductal adenocarcinoma (PDAC) were associated with a better TO rate (OR 2.22 [2.05-3.57] and OR 1.36 [1.14-1.63], respectively). For DP, female sex and the absence of neoadjuvant therapy predicted better TO rates (OR 1.38 [1.01-1.90] and OR 2.53 [1.20-5.31], respectively). When comparing institutions, the observed-versus-expected rate for achieving TO varied from 0.71 to 1.46 per hospital after casemix-adjustment. CONCLUSIONS: TO is a novel quality measure in pancreatic surgery. TO varies considerably between pancreatic centers, demonstrating the potential benefit of quality assurance programs.
BACKGROUND: Textbook outcome (TO) is a multidimensional measure for quality assurance, reflecting the "ideal" surgical outcome. METHODS: Post-hoc analysis of patients who underwent pancreatoduodenectomy (PD) or distal pancreatectomy (DP) for all indications between 2014 and 2017, queried from the nationwide prospective Dutch Pancreatic Cancer Audit. An international survey was conducted among 24 experts from 10 countries to reach consensus on the requirements for TO in pancreatic surgery. Univariable and multivariable logistic regression was performed to identify TO predictors. Between-hospital variation in TO rates was compared using observed-versus-expected rates. RESULTS: Based on the survey (92% response rate), TO was defined by the absence of postoperative pancreatic fistula, bile leak, postpancreatectomy hemorrhage (all ISGPS grade B/C), severe complications (Clavien-Dindo ≥III), readmission, and in-hospital mortality. Overall, 3341 patients were included (2633 (79%) PD and 708 (21%) DP) of whom 60.3% achieved TO; 58.3% for PD and 67.4% for DP. On multivariable analysis, ASA class 3 predicted a worse TO rate after PD (ASA 3 OR 0.59 [0.44-0.80]), whereas a dilated pancreatic duct (>3 mm) and pancreatic ductal adenocarcinoma (PDAC) were associated with a better TO rate (OR 2.22 [2.05-3.57] and OR 1.36 [1.14-1.63], respectively). For DP, female sex and the absence of neoadjuvant therapy predicted better TO rates (OR 1.38 [1.01-1.90] and OR 2.53 [1.20-5.31], respectively). When comparing institutions, the observed-versus-expected rate for achieving TO varied from 0.71 to 1.46 per hospital after casemix-adjustment. CONCLUSIONS: TO is a novel quality measure in pancreatic surgery. TO varies considerably between pancreatic centers, demonstrating the potential benefit of quality assurance programs.
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