Composite Quality Metric Can Help Predict Surgical Outcomes in ICC

Only about 11% of patients received care meeting a composite quality metric, a study found.

For patients with intrahepatic cholangiocarcinoma (ICC), a composite metric may be a better tool to assess care quality vs traditional outcome measures and high-volume surgical centers tend to do a better job of meeting the composite metric, according to a new study published in Journal of Surgical Oncology.

The study authors said although surgery is the cornerstone of ICC care, it rarely results in a long-term cure. Only about 10% of patients are cured long term following surgery, and this low success rate is likely the result of multiple factors, including tumor-specific factors. Clinician performance and surgical quality also play significant roles, but the authors said it is difficult to know exactly how much of a role they play, given that most previous research into perioperative care has used the “very siloed” approach of measuring outcomes like mortality, morbidity, margin status, and 30-day readmission.

“Given the not infrequent suboptimal outcomes following surgery, as well as the increased recognition of patient-centered outcome metrics, there has been growing interest to identify composite quality measures associated with the delivery of care to surgical patients,” they said.

One promising composite approach is “textbook outcomes,” an “all-or-nothing” assessment of whether clinicians meet all of the parameters of optimal care. However, given the particularities of cancer care and the need for cancer-specific parameters like adequate lymph node surgical assessment and receipt of appropriate adjuvant therapy, the authors said a more specific version of textbook outcomes, “textbook oncologic outcomes” (TOO) should be used.

In the new study, the investigators wanted to see how TOO and volume of ICC surgeries performed by a given medical center affected patient outcomes. They noted that the rarity of ICC means that most hepatic resection operations are performed at regional cancer centers, and existing evidence suggests the volume of surgeries performed at a given health care center have a significant impact on the outcomes of such surgeries.

The investigators searched the National Cancer Database to identify patients who underwent hepatic resection for ICC between 2004 and 2018, finding 5359 patients. Next, they assessed whether TOO was achieved in those patients, defining TOO as margin-negative resection, provision of appropriate adjuvant therapy and adequate lymphadenectomy, and the absence of 90-day mortality, prolonged hospitalization, and 30-day readmission. In addition, the authors categorized patients based on the annual hepatectomy volume for ICC at their hospital.

The analysis showed that just 599 patients (11.2%) received care that met the TOO classification.

The most common reason providers failed to reach TOO was lymphadenectomy inadequacy. When the researchers looked at hepatectomy volume, they found that high-volume facilities had a 67% greater chance of achieving TOO for a given patient compared with low-volume facilities (odds ratio [OR] 1.67; 95% CI, 1.24-2.25; P < .001.) That also translated into better outcomes. People treated at high-volume centers who received TOO care had a median overall survival of 71.1 months vs 47.3 months among people treated at low-volume centers (P < .05).

They said TOO is a more holistic approach to assessing patient care, since it incorporates a wider range of factors. They said it is also more helpful for patients; previous research shows TOO can have a significant impact on where a patient chooses to undergo surgery.

The authors conceded that their study has limitations related to its retrospective nature and potential selection bias in the variables used. They also said the relatively long length of the study period means changes in diagnosis and management strategies would have changed over the course of the study period.

Still, they said the study suggests that TOO can play a meaningful role in assessing quality of care and predicting outcomes.

“Both procedural volume, as well as center/provider past performance relative to TOO, should be considered when assessing the best chance for a patient to achieve an optimal outcome following resection of ICC,” they concluded.


Munir MM, Alaimo L, Moazzam Z, et al. Textbook oncologic outcomes and regionalization among patients undergoing hepatic resection for intrahepatic cholangiocarcinoma. J Surg Oncol. Published online September 22, 2022. doi:10.1002/jso.27102

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