The Textbook Outcome For Norwood Reconstruction
Neel K. Prabhu, BSE, Joseph R. Nellis, MD, MBA, Mary Moya-Mendez, Anna C. Hoover, Cathlyn Medina, James M. Meza, MD, MSc, Nicholas D. Andersen, MD, Joseph W. Turek, MD, PhD, MBA.
Duke University Medical Center, Durham, NC, USA.
Objective(s): To develop a more holistic measure of center performance than mortality, we created a composite "textbook outcome" (TO) for Norwood operations using several endpoints. We hypothesized that meeting TO would have a positive prognostic and financial impact. Methods: This was a single-center retrospective study of primary Norwoods from 2005-2021. Through interdisciplinary clinician consensus, TO was defined as freedom from: mortality, reintervention, 30-day readmission, ECMO, cardiac arrest, reintubation, length of stay >75%ile from STS data report (66d), and mechanical ventilation duration >75%ile (10d) during the index hospitalization. Multivariable logistic regression and Cox proportional hazards modeling were used. Results: 30% (59/196) of patients met TO. Common reasons for failure to attain TO were ventilation duration (68/137,50%) and reintubation (63/137,46%)(Fig.1A). In multivariable analysis, higher weight (OR 2.30(95% CI 1.29-4.29),p=.006) was a positive predictor of meeting TO while pre-operative shock (OR 0.39(0.14-0.96),p=.05) and longer bypass time (OR 0.58(0.38-0.85),p=.009) were negative predictors. Patients that met TO incurred less hospital costs ($153,337(143,931-164,761) vs. $269,241(214,079-365,630),p<.001), and after adjusting for patient factors, meeting TO was independently associated with decreased risk of death (HR 0.50(0.26-0.96),p=.038, Fig.1B). Conclusions: Outcomes continue to improve within congenital heart surgery, making mortality a less sensitive metric of center-specific performance. TO analysis may represent a more sensitive and balanced measure of what makes an operation successful. In addition, our cost data suggest that TO analysis may identify high-value care. 
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