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Can the Concept of Textbook Outcomes Be Applicable to Organ Transplantation?

Dear Editor:

Organ transplantation is a lifesaving and cost-effective treatment for end-stage organ failure. Short-and long-term outcomes after transplant, including patient and graft survival rates, are closely monitored and publicly reported from all US transplant centers.1 The goal of regulatory reviews is to ensure that nationwide outcomes of transplant programs meet current standards after adjustment for recipient and donor risk.2 Furthermore, the Centers for Medicare and Medicaid Services and private insurance companies can also use these data to determine in-network eligibility and transplant center certification.1

Current transplant program performance metrics are thought to be inadequate due to the advances in the field over the past few decades.3 One-year patient and graft survival outcomes are metrics by which transplant programs have lived and died for years; however, because the average 1-year survival for solid-organ transplant now exceeds 90% nationwide, centers might be identified as underperforming based on very modest differences in patient survival.3 This issue has led to a unique situation in which transplant centers have a broad understanding of their patient and graft outcomes but have very limited data about the comparative level of perioperative quality of care that they are providing.

Textbook outcome (TO) is a newly introduced composite metric that captures multiple domains of patient perioperative care. The idea behind this concept is to define the “ideal,” “optimal,” or “textbook” hospitalization, using variables such as perioperative mortality, early postoperative morbidity, readmissions, and operation-specific variables, that can reflect the quality of the surgical treatment.4 Previously, the concept of TO has been applied to several complex procedures, primarily in the domain of surgical oncology. Recently, our group put forth initial definitions of TO in transplantation.3,5 Advocates of this metric have suggested that TO provides a more comprehensive estimate of the quality of perioperative care.6 However, a primary criticism of TO is that there is no consensus in the literature on what should be considered an “optimal” outcome after a specific operation. Moreover, patient risk factors strongly influence outcomes and require comprehensive risk adjustment in order to make valid comparisons. The application of TO is particularly complex in organ transplantation, since both donor and recipient risk factors need to be accounted for in risk adjustment strategies. Furthermore, a possible unintended consequence of such a metric in transplantation is an increase in risk-averse behavior by transplant programs, potentially leading to avoidance of high-risk patients and high-risk donor organs.7

However, thoughtful implementation of composite quality metrics in transplantation does not necessarily need to increase risk-averse behavior. By defining and tracking rates of TO for organ transplant, centers will gain a detailed understanding of their perioperative processes of care and develop insights on how to improve these. Improved understanding of these gaps through the use of TO can allow programs to identify patients who are at high risk of failure to achieve optimal short- and long-term outcomes after transplant and redirect resources accordingly.

Since emerging as a field in the 1980s, organ transplantation has progressed rapidly, due to advances in immunosuppression, surgical techniques, and perioperative care. Its positive social and economic impacts have helped patients to improve their functional status and live longer. However, with patient and graft survival outcomes now at high levels, the time has come to improve efficiency and cost-effectiveness in the field. It is crucial to identify ways to improve processes of care and to develop modern metrics that will capture the quality of care provided. Thus, TO provides a novel quality metric that has the potential to impact transplantation in such a way. Fundamentally, the concept of TO aligns with the patient’s best interest, which is an ideal outcome after transplant. There is a compelling need for consensus among transplant societies on the definition of TO after transplant.


  1. Kasiske BL, McBride MA, Cornell DL, et al. Report of a consensus conference on transplant program quality and surveillance. Am J Transplant. 2012;12(8):1988-1996. doi:10.1111/j.1600-6143.2012.04130.x
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  2. Jay C, Schold JD. Measuring transplant center performance: The goals are not controversial but the methods and consequences can be. Curr Transplant Rep. 2017;4(1):52-58. doi:10.1007/s40472-017-0138-9
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  3. Halpern SE, Moris D, Shaw BI, et al. Definition and Analysis of Textbook Outcome: A Novel Quality Measure in Kidney Transplantation. World J Surg. 2021 Jan 23. doi:10.1007/s00268-020-05943-y
    CrossRef - PubMed
  4. Merath K, Chen Q, Bagante F, et al. A multi-institutional international analysis of textbook outcomes among patients undergoing curative-intent resection of intrahepatic cholangiocarcinoma. JAMA Surg. 2019;154(6):e190571. doi:10.1001/jamasurg.2019.0571
    CrossRef - PubMed
  5. Moris D, Shaw BI, Gloria J, et al. Textbook outcomes in liver transplantation. World J Surg. 2020;44(10):3470-3477. doi:10.1007/s00268-020-05625-9
    CrossRef - PubMed
  6. Fong Y. Textbook outcome nomograms as multivariate clinical tools for building cancer treatment pathways and prognosticating outcomes. JAMA Surg. 2019;154(6):e190572. doi:10.1001/jamasurg.2019.0572
    CrossRef - PubMed
  7. Schold JD, Buccini LD, Poggio ED, Flechner SM, Goldfarb DA. Association of candidate removals from the kidney transplant waiting list and center performance oversight. Am J Transplant. 2016;16(4):1276-1284. doi:10.1111/ajt.13594
    CrossRef - PubMed

DOI : 10.6002/ect.2020.0417


From the Department of Surgery, Duke University Medical Center, Durham, North Carolina, USA
Acknowledgements: The authors have not received any funding or grants in support of the presented research or for the preparation of this work and have no declarations of potential conflicts of interest.
Corresponding author: Dimitrios Moris, Department of Surgery, Duke University Medical Center, 2301 Erwin Rd, 27710, Durham, NC, USA
Phone: +2165716615