A Composite Measure for Quality of Care in Patients with Symptomatic Carotid Stenosis Using Textbook Outcome
Laurien S Kuhrij1, Eleonora G Karthaus2, Anco C Vahl3
1Department of Neurology, Amsterdam University Medical Centre, Academic Medical Centre, Amsterdam, the Netherlands; Dutch Institute for Clinical Auditing, Leiden, the Netherlands.
Insights
Textbook outcome (TO) is a comprehensive measure of quality care. In the Netherlands, most patients undergoing carotid endarterectomy (CEA) achieve TO, but variations between hospitals suggest performance differences.
Area of Science:
- Vascular Surgery
- Health Services Research
- Quality Improvement
Background:
- Individual outcome measures (IOM) may not fully capture hospital performance.
- Textbook outcome (TO) represents an ideal patient outcome with no adverse events.
- Evaluating TO in carotid endarterectomy (CEA) can enhance quality assessment.
Purpose of the Study:
- To assess the utility of Textbook Outcome (TO) as a quality measure in symptomatic patients undergoing Carotid Endarterectomy (CEA).
- To identify factors associated with achieving TO and compare hospital performance using TO.
Main Methods:
- Included symptomatic patients who underwent CEA in 2018 from the Dutch Audit for Carotid Interventions.
- Defined TO as the absence of 30-day mortality, neurological events (stroke/TIA), cranial nerve deficit, hemorrhage, 30-day readmission, prolonged LOS (>5 days), or surgical complications.
- Utilized multivariable logistic regression for casemix adjustment and calculated observed/expected (O/E) ratios for hospital comparison in funnel plots.
Main Results:
- 70.7% of patients achieved TO; prolonged LOS was the most common reason for not achieving it.
- Younger age, no pulmonary comorbidity, higher hemoglobin, and TIA as the index event were associated with achieving TO.
- Hospital O/E ratios ranged from 0.63 to 1.27, with two hospitals showing significantly lower TO rates.
Conclusions:
- Most patients undergoing CEA in the Netherlands achieve TO.
- Observed variations in TO rates between hospitals may indicate performance disparities.
- TO can serve as a valuable additive measure to existing IOMs, particularly for low-risk procedures like CEA.
Objective:
Composite measures may better objectify hospital performance than individual outcome measures (IOM). Textbook outcome (TO) is an outcome measure achieved for an individual patient when all undesirable outcomes are absent. The aim of this study was to assess TO as an additional outcome measure to evaluate quality of care in symptomatic patients treated by carotid endarterectomy (CEA).
Methods:
All symptomatic patients treated by CEA in 2018, registered in the Dutch Audit for Carotid Interventions, were included. TO was defined as a composite of the absence of 30 day mortality, neurological events (any stroke or transient ischaemic attack [TIA]), cranial nerve deficit, haemorrhage, 30 day readmission, prolonged length of stay (LOS; > 5 days) and any other surgical complication. Multivariable logistic regression was used to identify covariables associated with achieving TO, which were used for casemix adjustment for hospital comparison. For each hospital, an observed vs. expected number of events ratio (O/E ratio) was calculated and plotted in a funnel plot with 95% control limits.
Results:
In total, 70.7% of patients had a desired outcome within 30 days after CEA and therefore achieved TO. Prolonged LOS was the most common parameter (85%) and mortality the least common (1.1%) for not achieving TO. Covariates associated with achieving TO were younger age, the absence of pulmonary comorbidity, higher haemoglobin levels, and TIA as index event. In the case mix adjusted funnel plot, the O/E ratios between hospitals ranged between 0.63 and 1.27, with two hospitals revealing a statistically significantly lower rate of TO (with O/E ratios of 0.63 and 0.66).
Conclusion:
In the Netherlands, most patients treated by CEA achieve TO. Variation between hospitals in achieving TO might imply differences in performance. TO may be used as an additive to the pre-existing IOM, especially in surgical care with low baseline risk such as CEA.
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