Textbook outcomes for lower extremity bypass: A useful quality metric for care optimization

Textbook outcomes (TOs) represent the ideal postsurgical scenario that can identify at risk subgroups in need of better follow up. Their application in lower extremity bypass (LEB) has been underexplored. Here, the TO for LEB is defined risk factors identified for failure to achieve a TO.

The Vascular Quality Initiative was queried for elective LEB cases between 2010 and 2023. A TO was defined as absence of major complications, major adverse limb events, prolonged length of stay (>75th percentile), 30-day mortality, and nonhome discharge. Exclusions were based on pathology, inflow/outflow, conduit, and concomitant operations. Primary outcomes included 1-year survival and failure to achieve a TO. Time-to-event analyses were conducted using the Kaplan-Meier method. Logistic regression was used to identify risk factors for failure to achieve a TO and calculate observed:expected ratios for each center.

Of 49,744 cases analyzed, TOs were achieved in 60.7% (n = 4422), 66.9% (n = 4587), and 60.9% (n = 21,661) of suprainguinal anatomical bypass (SAB), suprainguinal extra-anatomical bypass (EAB), and infrainguinal bypass (IIB), respectively. Kaplan-Meier estimates of 1-year bypass patency and survival were better for TO patients (patency with TO: SAB 99.1%, EAB 98.0%, IIB 93.9% vs non-TO: SAB 97.6%, EAB 96.7%, IIB 89.6%; all log-rank P < .001; survival with TO: SAB 98.6%, EAB 95.6%, IIB 96.1% vs non-TO SAB 90.6%, EAB 83.2%, IIB 85.5%; all log-rank P < .001). Achieving a TO was the strongest independent factor associated with 1-year mortality (SAB: hazard ratio [HR], 0.23; 95% confidence interval [CI], 0.17-0.30; EAB: HR, 0.42, 95% CI, 0.35-0.51; IIB: HR 0.44, 95% CI, 0.40-0.49; all P < .001). Risk factors for failure to achieve a TO among all procedures included non-White race, congestive heart failure, chronic obstructive pulmonary disease, preoperative hemoglobin of <12 g/dL, estimated blood loss of >350 mL, and indication of tissue loss/necrosis (all P < .05). Funnel plot analysis revealed outlier centers for SAB (n = 5), EAB (n = 3), and IIB (n = 22). Comparing individual TO component measures of these centers with national averages identified potential targets (eg, length of stay targets, surgical complication rates) for future quality improvement efforts. Additionally, example centers were identified that could serve as models for improving TO rates at other centers through dissemination of best practices.

Failure to achieve a TO is associated with worse long-term LEB outcomes, and these patients may require closer monitoring and support after discharge. TOs are a clinically relevant quality measure that provides a comprehensive framework for identifying areas of improvement in patient care and guiding future quality improvement efforts.