Textbook outcome as a hospital benchmarking metric in adult cardiac surgery.

Abstract

Textbook outcome, defined as survival to discharge without complications or prolonged hospitalization, has garnered increasing interest as a surgical quality metric. The present study used a national database to evaluate the utility of textbook outcomes for hospital benchmarking in adult cardiac surgery. All elective admissions entailing coronary artery bypass grafting and/or valve operations were identified from the 2016 to 2022 Nationwide Readmissions Database. Textbook outcome was defined as survival to discharge without cardiac arrest, stroke, prolonged ventilation, renal failure, sepsis, pulmonary embolism, reoperation, or length of stay >14 days. Royston-Parmar models were used to evaluate associations between textbook outcome and 180-day mortality and nonelective readmission. Hierarchical logistic regression was used to identify patient and hospital factors associated with the textbook outcome. Centers with risk-adjusted textbook outcome rates in the lowest decile were designated low textbook outcome hospitals. Among 963,775 patients, 86.0% achieved a textbook outcome. Prolonged hospitalization (58.6%) was the most common reason for a non-textbook outcome. After risk adjustment, textbook outcome patients demonstrated significantly reduced 180-day mortality (hazard ratio, 0.37; 95% confidence interval, 0.33-0.41) and nonelective readmission (hazard ratio, 0.66; 95% confidence interval, 0.65-0.68). Approximately 8.5% of the variation in textbook outcome was attributable to interhospital differences. Low textbook outcome hospitals had lower annual operative volume (median, 107 vs 137 cases/year; P < .001) and were less often teaching hospitals (73.6% vs 79.9%; P = .011). This work demonstrates that the textbook outcome quality metric captures clinically meaningful differences in survival and readmissions following elective cardiac surgery. There was substantial center-level variation in textbook outcome rates, suggesting its utility for hospital benchmarking.