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Textbook Outcome: Definition and Analysis of a Novel Quality Measure in Lung Transplantation.

OBJECTIVE
To define textbook outcome (TO) for lung transplantation (LTx) using a contemporary cohort from a high-volume institution.


SUMMARY BACKGROUND DATA
TO is a standardized, composite quality measure based on multiple postoperative endpoints representing the ideal "textbook" hospitalization.


METHODS
Adult patients who underwent LTx at our institution between 2016-2019 were included. TO was defined as freedom from intraoperative complication, postoperative reintervention, 30-day ICU or hospital readmission, length of stay >75th percentile of LTx patients, 90-day mortality, 30-day acute rejection, grade 3 primary graft dysfunction at 48 or 72 hours, postoperative extracorporeal membrane oxygenation, tracheostomy within 7 days, inpatient dialysis, reintubation, and extubation >48 hours post-transplant. Recipient, operative, financial characteristics and post-transplant outcomes were recorded from institutional data and compared between TO and non-TO groups.


RESULTS
Of 401 LTx recipients, 97 (24.2%) achieved TO. The most common reason for TO failure was extubation >48 hours post-transplant (N=119, 39.1%); the least common was mortality (N=15, 4.9%). Patient and graft survival were improved among patients who achieved versus failed TO (patient survival: log-rank p<0.01; graft survival: log-rank p<0.01). Rejection-free and chronic lung allograft dysfunction (CLAD)-free survival were similar between TO and non-TO groups (rejection-free survival: log-rank p=0.07; CLAD-free survival: log-rank p=0.3). On average, patients who achieved TO incurred approximately $638,000 less in total inpatient charges compared to those who failed TO.


CONCLUSIONS
TO in LTx was associated with favorable post-transplant outcomes and significant cost-savings. TO may offer providers and patients new insight into transplant center quality of care and highlight areas for improvement.