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

Main Article Content

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.

Article Details

How to Cite
NUMAN, Rachel Christy et al. How to evaluate quality for Thoracic Lung Cancer Surgery: A ‘’textbook outcome’’. Medical Research Archives, [S.l.], n. 3, june 2015. ISSN 2375-1924. Available at: <>. Date accessed: 24 feb. 2024.
Quality of Care; lung cancer; surgery; textbook outcome; outcome indicator; quality improvement
Research Articles


1. Akcali Y, Demir H, Tezcan B. The effect of standard posterolateral versus
muscle-sparing thoracotomy on multiple parameters. Ann Thorac Surg.

2. Birkmeyer JD, Dimick JB and NJO Birkmeyer. Measuring the Quality of Surgical
Care: Structure, process, or Outcome? J Am Coll Surg. 2004;198:626-32.

3. Brunelli A, Berrisford RG, Rocco G et al. The European Thoracic Database
project: composite performance score to measure quality of care after major lung
resection. Eur J Cardiothorac Surg. 2009;35:769-74

4. Brunelli A, Refai M, Salati M, Pompili C, Sabbatini A. Standardized Combined
Outcome Index as an Instrument for Monitoring Performance After Pulmonary
Resection. Ann Thorac Surg. 2011;92:272-77

5. Cao C, Zhu ZH, Yan TD. Video-assisted thoracic surgery versus open thoracotomy
for non-small-cell lung cancer: a propensity score analysis based on a multi-
institutional registry. Eur J Cardiothorac Surg. 2013;44:849-54

6. Chen FF, Zhang D, Wang YL et al. Video-assisted thoracoscopic surgery
lobectomy versus open lobectomy in patients with clinical stage non-small cell lung
cancer: a meta-analysis. Eur J Surg Oncol. 2013;39:957-63

7. Dimick JB, Welch HG and Birkmeyer JD. Surgical Mortality as an Indicator of
Hospital Quality. JAMA. 2004;294:847-51

8. Dimick JB, Staiger DO, Osborne NH et al. Composite measures for rating
hospital quality with major surgery. Health Serv Res. 2012;47:1861-79

9. Dijs-Elsinga J, Otten W, Versluijs MM et al. Choosing a hospital for surgery: the
importance of information on quality of care. Med Decis Making. 2010;30:544-55

10. Fischer B, Lassen U, Mortensen J et al. Preoperative staging of lung cancer with
combined PET-CT. N Engl J Med. 2009;361:32-39

11. Khan IH, McManus KG, McCraith A, McGuigan JA. Muscle sparing thoracotomy:
a biomechanical analysis confirms preservation of muscle strength but no
improvement in wound discomfort. Eur J Cardiothorac Surg. 2000;18:656-61

12. Kolfschoten NE, Kievit J, Gooiker GA et al. Focusing on desired outcomes of care
after colon cancer resections; hospital variations in 'textbook outcome'. Eur J Surg
Oncol. 2013;39:156-63

13. Kozower BD, Stukenborg GJ. Lung cancer resection volume: is procedure
volume really an indicator of quality? Semin Thorac Cardiovasc Surg. 2012;24:93-98

14. Kozower BD, Stukenborg GJ. The relationship between hospital lung cancer
resection volume and patient mortality risk. Ann Surg. 2011;254:1032-37

15. McHorney CA, Ware JE Jr, Lu JF et al. The MOS 36-item Short-Form Health
Survey (SF-36): III. Tests of data quality, scaling assumptions, and reliability across
diverse patient groups. Med Care. 1994;32:40-66

16. Numan RC, Klomp HM, Li W et al. A clinical audit in a multidisciplinary care path
for thoracic surgery: an instrument for continuous quality improvement. Lung Cancer.

17. Staiger DO, Dimick JB, Baser O et al. Empirically derived composite measures of
surgical performance. Med Care. 2009;47:226-33

18. Von Meyenfeldt EM, Gooiker GA, van Gijn W et al. The relationship between
volume or surgeon specialty and outcome in the surgical treatment of lung cancer: a
systematic review and meta-analysis. J Thorac Oncol. 2012;7:1170-78

19. Website of the Integraal Kankercentrum Nederland.

20. Website of the Integraal Kankercentrum Nederland.

21. Website of DICA, jaarraportage 2012.

22. Website of the European Society of thoracic surgeons.