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Definition and Analysis of Textbook Outcome: A Novel Quality Measure in Kidney Transplantation

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Abstract

Background

“Textbook outcome” (TO) is a novel composite quality measure that encompasses multiple postoperative endpoints, representing the ideal “textbook” hospitalization for complex surgical procedures. We defined TO for kidney transplantation using a cohort from a high-volume institution.

Methods

Adult patients who underwent isolated kidney transplantation at our institution between 2016 and 2019 were included. TO was defined by clinician consensus at our institution to include freedom from intraoperative complication, postoperative reintervention, 30-day intensive care unit or hospital readmission, length of stay > 75th percentile of kidney transplant patients, 90-day mortality, 30-day acute rejection, delayed graft function, and discharge with a Foley catheter. Recipient, operative, financial characteristics, and post-transplant patient, graft, and rejection-free survival were compared between patients who achieved and failed to achieve TO.

Results

A total of 557 kidney transplant patients were included. Of those, 245 (44%) achieved TO. The most common reasons for TO failure were delayed graft function (N = 157, 50%) and hospital readmission within 30 days (N = 155, 50%); the least common was mortality within 90 days (N = 6, 2%). Patient, graft, and rejection-free survival were significantly improved among patients who achieved TO. On average, patients who achieved TO incurred approximately $50,000 less in total inpatient charges compared to those who failed TO.

Conclusions

TO in kidney transplantation was associated with favorable post-transplant outcomes and significant cost-savings. TO may offer transplant centers a detailed performance breakdown to identify aspects of perioperative care in need of process improvement.

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Abbreviations

ANOVA:

Analysis of variance

CI:

Confidence interval

DBD:

Donation after brain death

DCD:

Donation after circulatory death

DDKT:

Deceased donor kidney transplant

DGF:

Delayed graft function

HLA:

Human leukocyte antigen

KDPI:

Kidney donor profile index

KTx:

Kidney transplantation

LDKT:

Living donor kidney transplant

LOS:

Length of stay

NSQIP:

National Surgical Quality Improvement Project

OR:

Odds ratio

TO:

Textbook outcome

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Funding

SEH is supported by the National Center for Advancing Translational Sciences of the National Institutes of Health under award number TL1TR002555. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.

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Authors and Affiliations

  1. Department of Surgery, Duke University Medical Center, Box 3512, Durham, NC, 27710, USA

    Samantha E. Halpern, Dimitrios Moris, Brian I. Shaw, Samuel J. Kesseli, Mariya L. Samoylova, Miriam Manook, Robin Schmitz, Bradley H. Collins, Kadiyala V. Ravindra, Debra L. Sudan, Stuart J. Knechtle, Matthew J. Ellis, Lisa M. McElroy & Andrew S. Barbas

  2. Division of Nephrology, Department of Medicine, Duke University Medical Center, Durham, NC, USA

    Scott L. Sanoff & Matthew J. Ellis

Authors
  1. Samantha E. Halpern
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  2. Dimitrios Moris
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Correspondence to Andrew S. Barbas.

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Halpern, S.E., Moris, D., Shaw, B.I. et al. Definition and Analysis of Textbook Outcome: A Novel Quality Measure in Kidney Transplantation. World J Surg 45, 1504–1513 (2021). https://doi.org/10.1007/s00268-020-05943-y

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