Textbook outcomes in heart transplantation: A quality metric for the modern era

Traditional quality metrics like one-year survival do not fully encapsulate the multifaceted nature of solid organ transplantation in contemporary practice. Therefore, investigators have proposed using a more comprehensive measure, the textbook outcome. However, the textbook outcome remains ill-defined in the setting of heart transplantation. Within the Organ Procurement and Transplantation Network database, the textbook outcome was defined as having: (1) No postoperative stroke, pacemaker insertion, or dialysis, (2) no extracorporeal membrane oxygenation requirement within 72 hours of transplantation, (3) index length of stay 50% at one year. Of 26,885 heart transplantation recipients between 2011 to 2022, 9,841 (37%) achieved a textbook outcome. Following adjustment, textbook outcome patients demonstrated significantly reduced hazard of mortality at 5- (hazard ratio 0.71, 95% CI 0.65–0.78; P < .001) and 10-years (hazard ratio 0.73, CI 0.68–0.79; P < .001), and significantly greater likelihood of graft survival at 5- (hazard ratio 0.69, CI 0.63–0.75; P < .001) and 10-years (hazard ratio 0.72, CI 0.67–0.77; P < .001). Following estimation of random effects, hospital-specific, risk-adjusted rates of textbook outcome ranged from 39% to 91%, compared to a range of 97% to 99% for one-year patient survival. Multi-level modeling of post-transplantation rates of textbook outcomes revealed that 9% of the variation between transplant programs was attributable to inter-hospital differences. Textbook outcomes offer a nuanced, composite alternative to using one-year survival when evaluating heart transplantation outcomes and comparing transplant program performance.