Analysis of a modified surgical desirability of outcome ranking (mDOOR) among patients undergoing surgery for Hepatocellular carcinoma.

BACKGROUND

Composite measures represent a validated method for evaluating surgical care quality. We defined a modified Desirability Of Outcome Ranking (mDOOR) and compared it with textbook outcome (TO).

METHODS

In this cohort study, patients undergoing curative-intent surgery for HCC were identified from an international cohort. The performance and agreement of mDOOR, TO, and other measures of postoperative course with respect to overall survival (OS) were compared using Harrell's Concordance-index (C-index) and Cohen's kappa.

RESULTS

Among 2181 patients, 77.6 % (n = 1692) achieved the most desirable outcome (i.e., DOOR1), whereas roughly one-half of patients achieved TO (n = 1,171, 53.7 %). Patients with lower mDOOR had a better 5-year OS compared with patients with higher mDOOR (64.7 % vs. 51.9 %; p < 0.001). On multivariable analysis, higher mDOOR was associated with worse OS (HR 1.35, 95%CI 1.28-1.44; p < 0.001). The mDOOR demonstrated improved performance compared with the comprehensive complication index (C-index: 0.696 vs. 0.649; p < 0.001) and the Accordion score (C-index: 0.696 vs. 0.653; p = 0.002).

CONCLUSION

Roughly 4 out of 5 patients achieved the most desirable outcome. Higher mDOOR was associated with worse long-term outcomes. A composite outcome ranking may provide more insight on surgical outcomes, complementing traditional metrics.