How to evaluate quality for Thoracic Lung Cancer Surgery: A ‘’textbook outcome’’

Rachel Christy Numan, Paul Baas, Jacobus A Burgers, Vincent van der Noort, Harm van Tinteren, Johanna W. van Sandick, Houke M. Klomp, Michel W Wouters



Measuring surgical quality gives rise to an ongoing debate on which quality of care indicators should be used. Individual measures such as postoperative mortality, do not fully reflect quality of care. Instead, a summarizing measure (i.e. a “textbook outcome”) can be used. The objectives of this study were to investigate the proportion of patients with a ‘’textbook outcome’’ and to identify variables reducing the chance for a ‘’textbook outcome’’.


Materials and Methods

From January 2003 to December 2011, 152 patients operated for non-small cell lung carcinoma (NSCLC) were identified using both a prospective database (N=93) which was incorporated in a multidisciplinary care path for thoracic surgery in the Netherlands Cancer Institute, and a retrospective database (N=59). Patient-, tumour-, treatment- and outcome characteristics were collected.  A ‘’textbook outcome’’ was defined as a postoperative course without in-hospital death, without complications within 30 days, without re-intervention within 30 days, and without re-admission within 30 days after discharge, in combination with a radical tumour resection, a hospital stay < 16 days and an Intensive Care stay < 3 days.



In 96 of 152 patients (63%), a ‘’textbook outcome’’ was realized.  A logistic regression analysis including stage of disease, pulmonary co-morbidity, smoking status, lung function and type of resection showed that stage of disease was an independent risk factor that reduced the chance of a ‘’textbook outcome’’(OR 0.56 , 95% CI 0.33-0.92, p=0.024).



A “textbook outcome” is a comprehensive, summarizing measure that has the potential to overcome limitations of individual measures describing postoperative outcome. This is the first study exploring the use of a ‘’textbook outcome’’ for lung cancer surgery. We showed, in two thirds of the patients, a ‘’textbook outcome’’ was realized, where only the stage of disease was identified as an independent negative risk factor.


Quality of Care; lung cancer; surgery; textbook outcome; outcome indicator; quality improvement

Full Text:


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DOI: http://dx.doi.org/10.18103/mra.v0i3.250


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