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Bariatric outcomes and hospital variation

Dutch researchers develop Textbook Outcomes identifying variation

Age, procedure type, T2DM, hypertension, dyslipidaemia, GERD and OSAS were factors associated with achieving Textbook Outcome in univariate logistic regression

Researchers from the Netherlands have developed an ordered Textbook Outcome for bariatric surgery that captured more hospital variation and enabled individual hospitals to identify which outcomes and specific groups required improvement, thereby increasing the ongoing effort to improve the quality of the outcome of bariatric surgery.

The paper, ‘Textbook Outcome: an Ordered Composite Measure for Quality of Bariatric Surgery’, published in Obesity Surgery, notes that previous Textbook Outcome studies have provided additional information on the overall quality of surgical care. However, these studies/methodologies were limited as they did not give individual hospitals the necessary information on how to improve its performance.

But, by combining multiple outcome parameters, the researchers claim that “this provides more power to detect hospital differences and outcomes will be less likely different due to chance alone,” and subsequently focuses on all outcomes - and not only on single surgical outcome indicators – for the patient.

Therefore, the researchers sought to establish an ordered Textbook Outcome - with Textbook Outcome defined as none of these outcomes occurring - consisting of multiple outcome parameters for bariatric surgery to assess the extent of hospital variation including:

  • Mortality
  • Severe post-operative complications
  • Readmission
  • Mild complications; and
  • Prolonged length of stay (LOS) within 30 days after primary surgery

Data were obtained from the Dutch national bariatric registry, a specific nationwide audit in which all 18 Dutch bariatric centres participate (27,360 unique patient records regarding primary bariatric surgery were entered by 18 Dutch hospitals (27,273 (99.7%) of these records contained complete data and were used for detailed analyses.

A total of 24,201 patients (88.7%) reached Textbook Outcome after primary bariatric surgery. Mild postoperative complications (2.6%; n=720) and prolonged LOS (4.4%; n=1,182) had the greatest effect on achieving TO for the individual patient.

To gain insight into the variation between hospitals, each patient was assigned to one category of the ordered TO group. The last group, the most favourable group, was defined as a Textbook Outcome. On average, 4.3% (range 0.2%–17.1% between hospitals) of the patients had only a mild postoperative complication and 2.6% (range 0.6%–4.5%) had severe postoperative complications. It should be noted that the average for mild postoperative complications was heavily influenced by one hospital that scored 17.1%.

For example, Figure 1 shows the distribution of parameters for not achieving Textbook Outcome. The figure is a detailed representation of all ordered Textbook Outcome groups of patients who have not achieved Textbook Outcome. The outlier of mild postoperative complications in Figure 1 (hospital B) is visible. Another significant outlier is hospital G with 57.6% of the postoperative patients with a prolonged LOS. The national average was 4.2% (range 1.0%–57.6%). In addition, Figure 1 shows the added value of the ordered Textbook Outcome groups above only having the binomial Textbook Outcome, thereby showing hospitals for which exact combination of outcomes they perform not as good as other hospitals do.

Figure 2: Detailed view of ordered non-textbook outcome groups in bariatric surgery

“For instance, patients with only a mild complication or readmission but with a normal LOS might be patients discharged too early and require a different type of intervention comparing to patients with also a prolonged LOS which might represent more complex patients.”

Age, procedure type, T2DM, hypertension, dyslipidaemia, GERD and OSAS were factors associated with achieving Textbook Outcome in univariate logistic regression. All factors remained significant in multivariate logistic regression, except for dyslipidaemia. Factors associated with a significantly effect on achieving Textbook Outcome were included in the case-mix model.

“The variation between hospitals for the individual indicators again shows the outlier hospitals B (on mild complications) and G (on prolonged LOS),” the authors write. “It also shows that for each individual indicator, other hospitals scored significantly worse compared to the national average. A total of 12 out of 18 hospitals performed significantly worse on one or more single outcome parameters after case-mix correction, suggesting integration of these indicators in the ordered Textbook Outcome.”

“An ordered textbook outcome for bariatric surgery is suggested as a composite measure for short-term postoperative outcome after bariatric surgery,” the researchers concluded. “Most importantly, individual hospitals can identify differences in outcome indicators using this ordered Textbook Outcome, whereas these may remain hidden in the previously developed binomial Textbook Outcome. This between-hospital variation may initiate an improvement cycle that will result in hospital and surgical quality improvements and therefore improve the clinical outcome of bariatric surgery.”

To access this paper, please click here

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