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19.12.2018 | Original Contribution | Ausgabe 4/2019 Open Access

Obesity Surgery 4/2019

Textbook Outcome: an Ordered Composite Measure for Quality of Bariatric Surgery

Obesity Surgery > Ausgabe 4/2019
Youri Q. M. Poelemeijer, Perla J. Marang-van de Mheen, Michel W. J. M. Wouters, Simon W. Nienhuijs, Ronald S. L. Liem
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The online version of this article (https://​doi.​org/​10.​1007/​s11695-018-03642-1) contains supplementary material, which is available to authorized users.

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Textbook outcome (TO) studies have previously shown that a composite measure can provide additional information on the overall quality of surgical care. However, these were binominal outcomes which do not give individual hospitals the required information on how to improve their performance. The aim of this study is to create an ordered TO consisting of multiple outcome parameters for bariatric surgery to assess the extent of hospital variation.


Patients who underwent a primary bariatric procedure in the Netherlands were included for analyses. The outcomes were ordered as mortality, severe postoperative complications, readmission, mild complications and prolonged length of stay (LOS) within 30 days after primary surgery with TO defined as none of these outcomes occurring. Hospitals were identified with a significantly higher or lower observed/expected ratio than expected based on case-mix and the extent of hospital variation was expressed as the median and interquartile range (IQR).


From a total of 27,360 patients on average, 88.7% reached TO (range 35.5–96.9%). Two hospitals had less than expected TO due to more prolonged LOS (57.6%) in one hospital and more mild complications in another (17.1%). Hospital variation was much smaller for TO (median OR 0.91 IQR [0.62–1.06]) than for an ordered TO (median POR 0.66 IQR [0.55–0.96]).


Using the ordered TO for bariatric surgery, more hospital variation was captured thereby enabling individual hospitals to identify which outcomes and specific groups need improvement. This could attribute to the ongoing effort to improve the quality of the outcome of bariatric surgery.

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