Cost effectiveness of enhanced recovery after surgery programme for vaginal hysterectomy: a comparison of pre and post-implementation expenditures

Enhanced recovery after surgery versus conventional postoperative care in patients undergoing hysterectomy: a systematic review and meta-analysis

PURPOSE

Hysterectomy is a common gynecological surgery associated with significant postoperative discomfort and extended hospital stays. Enhanced recovery after surgery (ERAS), a multidisciplinary approach, has emerged as a strategy aimed at improving perioperative outcomes and promoting faster patient recovery and satisfaction. This meta-analysis aimed to evaluate the impact of ERAS protocols on clinical outcomes, such as hospital stay length, readmission rates, and postoperative complications, in patients undergoing gynecological hysterectomy.

METHODS

Following the preferred reporting items for systematic reviews and meta-analyses (PRISMA) guidelines, a systematic review and meta-analysis were conducted. Databases including PubMed, Embase, and Cochrane library were searched for relevant studies published up to January 31, 2023. A total of seventeen studies were selected based on predefined eligibility and exclusion criteria. Meta-analysis was carried out using a random-effects model with the STATA SE 14.0 software, focusing on outcomes like length of hospital stay, postoperative complications, and readmission rates.

RESULTS

ERAS protocols significantly reduced the length of hospital stays and incidence of postoperative complications such as ileus, without increasing readmission rates or the level of patient-reported pain. Notable heterogeneity was observed among included studies, attributed to the variation in patient populations and the specificity of the documented study protocols.

CONCLUSION

The findings underscore the effectiveness of ERAS protocols in enhancing recovery trajectories in gynecological hysterectomy patients. This reinforces the imperative for broader, standardized adoption of ERAS pathways as an evidence-based approach, fostering a safer and more efficient perioperative care paradigm.

Effectiveness of an Educational Intervention with Guidelines from the Total Acceleration of Postoperative Recovery Project (ACERTO) in Gynecology

OBJECTIVE

 To evaluate the effectiveness of an educational intervention among gynecologists about recommendations of the Total Acceleration of Postoperative Recovery (ACERTO, in the Portuguese acronym) project derived from the solid foundations of Enhanced Recovery After Surgery (ERAS) guidelines to optimize hospital care for surgical-gynecological patients.

METHODS

 Educational intervention through monthly 1-hour long meetings (3 months), with the application of an objective questionnaire about specific knowledge of the ACERTO project between before and after educational intervention phases, for gynecologists, after approval by the ethics committee and signature of informed consent by participants, in a federal university hospital.

RESULTS

 Among the 25 gynecologists who agreed to participate, the educational intervention could be effective with a statistically significant difference between the phases before and after the intervention for the main recommendations of the ACERTO project, such as abbreviation of preoperative fasting (p = 0.006), venous thromboembolism prophylaxis (p = 0.024), knowledge and replication of ACERTO (p = 0.034), and multimodal analgesia (p = 0.021).

CONCLUSION

 An educational intervention, through clinical meetings with exposition and discussion of the recommendations of the ACERTO project based on the ERAS protocol can be effective for the knowledge and possibility of practical application of the main measures, such as abbreviation of preoperative fasting, multimodal analgesia, and prophylaxis of thrombosis among gynecologists.

Enhanced Recovery after Pelvic Organ Prolapse Surgery

The objective of this study was to review on the influence of enhanced rehabilitation in pelvic organ prolapse surgery outcomes, specifically focusing on length of hospital stay, hospital costs, pain, morbidity, and patient satisfaction. Following the PRISMA model and using PubMed as a source, eight articles pertaining to prolapse surgery and two articles concerning vaginal hysterectomies were selected, all published between 2014 and 2021. These studies revealed no significant difference in terms of operating time, intra- and post-operative complications, intra-operative blood loss and post-operative pain scores before and after the introduction of the ERAS program. Only one study noted a difference in readmission rates. There was, however, a noticeable decrease in intra-operative and post-operative intravenous intakes, opioid administration, length of stay, and overall hospital costs with the adoption of ERAS. Additionally, with ERAS, patients were able to mobilize more rapidly, and overall patient satisfaction significantly improved.

Can robotic-assisted surgery support enhanced recovery programs?

Enhanced recovery after surgery (ERAS) protocols comprise a multimodal approach to optimize patient outcome and recovery. ERAS guidelines recommend minimally invasive surgery (MIS) when possible. Key components in MIS include preoperative patient education and optimization; multimodal and narcotic-sparing analgesia; prophylactic measures regarding nausea, infection, and venous thrombosis; maintenance of euvolemia; and promotion of the early activity. ERAS protocols in MIS improve outcome mainly in terms of reduced length of stay and subsequently reduced cost. In addition, ERAS protocols in MIS reduce postoperative pain and nausea, increase patient satisfaction, and might reduce the rate of postoperative complications. Robotic surgery supports ERAS through facilitating MIS in complex procedures where laparotomy is an alternative approach.

Vaginal packing after vaginal hysterectomy: systematic review and recommendations

INTRODUCTION AND HYPOTHESIS

Vaginal packing is often used after vaginal hysterectomy to reduce the risk of haemorrhagic and infectious complications, but the procedure may impair spontaneous bladder emptying and necessitate permanent bladder catheterization, which itself increases the risk of urinary infection, patient bother, delayed discharge, and increased costs. This systematic review was aimed at assessing the complications and outcomes associated with vaginal packing after vaginal hysterectomy.

METHODS

We conducted a systematic review following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) Statement, using the Population, Interventions, Comparators, Outcomes, and Study design (PICOS) framework to define eligibility. Following data synthesis and subgroup analyses, we assessed the certainty of evidence according to GRADE guidance and formulated a clinical recommendation.

RESULTS

The review included four clinical trials (involving 337 participants). These provided no clear evidence that vaginal packing led to clinically meaningful reductions in adverse effects, such as vaginal bleeding, hematoma formation, or postoperative vaginal cuff infection. Overall, the intervention produced no clear benefit regarding the predefined outcomes.

CONCLUSIONS

Routine vaginal packing after vaginal hysterectomy had no clear benefit on outcomes. We therefore advise against this procedure.

Enhanced Recovery Protocols in Urogynecologic and Pelvic Floor Reconstructive Surgery: A Systematic Review and Meta-Analysis

IMPORTANCE

The implementation of Enhanced Recovery After Surgery (ERAS) protocols may optimize the clinical outcome of surgical patients, by reducing the length of hospital stay (LOS) and improving the quality of recovery.

OBJECTIVE

This study aims to evaluate the impact of ERAS protocols in the intraoperative and postoperative course of patients undergoing pelvic floor reconstructive surgery.

METHODS

A systematic search of PubMed/MEDLINE, Embase, and the Cochrane Library was conducted up to January 2022, using the Systematic Reviews and Meta-analyses guidelines. Search terms, such as ERAS, urogynecology, sacrocolpopexy were tailored to each database as necessary. Statistical analysis was performed using the RevMan 5.4 software. Confidence intervals (CI) were set at 95%. Mean difference and risk ratio were used in the analysis, and the results were calculated using the random effect model.

RESULTS

Six studies that reported outcomes of 1,153 women were included. The ERAS protocols were implemented in 553 women, whereas the remaining 600 received standard perioperative care. A significantly shorter LOS (mean difference, -16.17 hours; 95% CI, -24.07 to -8.26 hours; P < 0.0001) and a higher proportion of patients discharged within 24 hours postoperatively was observed in ERAS patients compared with non-ERAS controls (risk ratio, 3.08; 95% CI, 2.00-4.75; P < 0.00001). Operative time, estimated blood loss, complications, and readmission rates did not differ between the 2 groups.

CONCLUSIONS

Our analysis showed that ERAS protocols have a favorable impact on the perioperative course of urogynecologic populations. More research is required to determine those key components of ERAS protocols, specifically applicable and more beneficial to women with pelvic floor disorders.

AUGS-IUGA Joint Clinical Consensus Statement on Enhanced Recovery After Urogynecologic Surgery: Developed by the Joint Writing Group of the International Urogynecological Association and the American Urogynecologic Society. Individual writing group members are noted in the Acknowledgements section

INTRODUCTION AND HYPOTHESIS

Enhanced recovery after surgery (ERAS) evidence-based protocols for perioperative care can lead to improvements in clinical outcomes and cost savings. This article aims to present consensus recommendations for the optimal perioperative management of patients undergoing urogynecological surgery.

METHODS

A review of meta-analyses, randomized clinical trials, large nonrandomized studies, and review articles was conducted via PubMed and other databases for ERAS and urogynecological surgery. ERAS protocol components were established, and then quality of the evidence was both graded and used to form consensus recommendations for each topic. These recommendations were developed and endorsed by the writing group, which is comprised of the American Urogynecologic Society and the International Urogynecological Association members.

RESULTS

All recommendations on ERAS protocol items are based on best available evidence. The level of evidence for each item is presented accordingly. The components of ERAS with a high level of evidence to support their use include fasting for 6 h and taking clear fluids up to 2 h preoperatively, euvolemia, normothermia, surgical site preparation, antibiotic and antithrombotic prophylaxis, strong antiemetics and dexamethasone to reduce postoperative nausea and vomiting, multimodal analgesia and restrictive use of opiates, use of chewing gum to reduce ileus, removal of catheter as soon as feasible after surgery and avoiding systematic use of drains/vaginal packs.

CONCLUSIONS

The evidence base and recommendations for a urogynecology-relevant ERAS perioperative care pathway are presented in this consensus review. There are several elements of ERAS with strong evidence of benefit in urogynecological surgery.

Evaluation of the impact of an enhanced recovery after surgery (ERAS) programme on the quality of recovery in patients undergoing a scheduled hysterectomy: a prospective single-centre before-after study protocol (RAACHYS study)

INTRODUCTION

The enhanced recovery after surgery (ERAS) programmes following hysterectomies have been studied since 2010, and their positive effects on clinical or economic criteria are now well established. However, the benefits on health outcomes, especially rapid recovery after surgery from patients' perspective is lacking in literature, leading to develop scores supporting person-centred and value-based care such as patient-reported outcome measures. The aim of this study is to assess the impact of an ERAS programme on patients' well-being after undergoing hysterectomy.

METHODS AND ANALYSIS

This is an observational, prospective single-centre before-after clinical trial. 148 patients are recruited and allocated into two groups, before and after ERAS programme implementation, respectively. The ERAS programme consists in optimising factors dealing with early rehabilitation, such as preoperative patient education, multimodal pain management, early postoperative fluid taken and mobilisation. A self-questionnaire quality of recovery-15 (QoR-15) on the preoperative day 1 (D-1), postoperative day 0 evening (D0) and the postoperative day 1 (D+1) is completed by patients. Patients scheduled to undergo hysterectomy, aged 18 years and above, whose physical status are classified as American Society of Anesthesiologists score 1-3 and who are able to return home after being discharged from hospital and contact their physician or the medical department if necessary are recruited for this study. The total duration of inclusion is 36 months. The primary outcome is the difference in QoR-15 scores measured on D+1 which will be compared between the 'before' and the 'after' group, using multiple linear regression model.

ETHICS AND DISSEMINATION

Approval was obtained from the Ethical Committee (Paris, France). Subjects are actually being recruited after giving their oral agreement or non-objection to participate in this clinical trial and following the oral and written information given by the anaesthesiologist practitioner.Trial registration number: ClinicalTrials.gov: NCT04268576 (Pre-result).

Medico-economic impact of enhanced rehabilitation after surgery: an exhaustive, nation-wide claims study

Background

Study of the medico economic impact of enhanced rehabilitation after surgery (ERAS), by comparing the cost of patient care with or without ERAS, both from the point of view of the hospitals and the Social Security Health Insurance Program.

Methods

Retrospective longitudinal study on matched data from March 1, 2019 to December 31, 2019. The data are extracted from the French prospective payment system. We studied 12 of the most commonly performed in ERAS business segments. The primary outcome was the reduction of the average length of hospital stay and its implications on production costs and excess capacity. We also studied the impact on hospital incomes and Social Security Insurance Program expenses. The potential gain in hospital days was computed by comparing the length of stay of ERAS and non-ERAS cases. The cost reduction was estimated using the mean number of avoidable days of hospitalization, and the mean cost of the stays obtained from the national cost study. Finally, we studied an approximation of the additional expense for the Social Security Health Insurance Program on costs standardized by applying public sector rates.

Results

The average length of stay reduction attributed to ERAS is 1.45 (CI 95% 1.42 to 1.48) day per stay, translating to a cost reduction for the hospitals of € 1060 (CI 95% 995 to 1125) per patient and a total of €65 million (CI 95% 61 to 69). At the same time, the additional expenses for the Social Security Insurance Program can conservatively be approximated to € 1.6 million, breaking into a € 2.2 million increase partially compensated by cost savings of € 0.6 million over subsequent stays for complications. Overall, for each percent of additional ERAS activity over the scope of the study, the marginal cost reduction for the hospitals can be estimated to € 1.8 million (CI 95% 1.7 million to 2.0 million).

Conclusions

Associated with previously known clinical benefits for the patients, these convincing results in terms of economic gain strongly support expanding the adoption of ERAS.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-021-07379-z.

Evaluate the Effectiveness of Enhanced Recovery After Surgery Versus Conventional Approach in Benign Gynecological Surgeries: A Randomized Controlled Trial

Objective

This study aimed to evaluate the effectiveness of enhanced recovery after surgery (ERAS) model versus conventional approach in benign gynecological surgeries (incorporating various routes of surgery).

Methods

This was a randomized controlled trial wherein patients undergoing gynecological surgery for benign indications from January 2019 to July 2020 were recruited and randomized into ERAS and conventional protocol groups using block randomization. The intended primary outcome was to compare the median length of hospital stay in both groups. “Fit for discharge” criteria were used to assess the length of stay as patients who belonged to hilly terrain with limited transportation facilities stayed for a longer duration.

Results

A total of 180 patients were recruited and 90 each was randomized into ERAS and conventional protocol groups. The difference in length of hospital stay between ERAS (36 hours, range 24-96 hours) and conventional group (72 hours, range: 24-144 hours) was significant (p<0.01). A statistically significant difference was noted in the time for recovery of bowel function and tolerance for diet in the ERAS group. No significant difference in complications and readmission (within 30 days) rate was seen between the two groups. Quality of life as assessed by the World Health Organization Quality of Life Brief Version (WHO-QOL BREF) on the day of discharge and day 30 was higher in the ERAS group in physical and psychological domains, while no difference was seen in environmental and social domains.

Conclusion

This study as an institutional experience strengthens the existing evidence regarding the efficacy of ERAS in reducing hospital stay and improving quality of life compared to the conventional perioperative management protocol.

Outpatient Hysterectomy versus Inpatient Hysterectomy: A Systematic Review and Meta-analysis

OBJECTIVE

The aim was to investigate whether outpatient hysterectomy (OH) has benefits when compared with inpatient hysterectomy (IH) regarding postoperative complications, readmissions, operative outcomes, cost, and patient quality of life.

DATA SOURCES

A systematic search for studies comparing OH with IH was conducted through PubMed, SAGE, and Scopus from January 2010 to March 2020, without limitations regarding language and study design.

METHODS OF STUDY SELECTION

Studies reporting on the differences between same-day discharge and overnight stay after hysterectomy were included. The study outcomes were overall complication rate, type of complication, readmission after discharge, surgery duration, estimated blood loss, payer savings, hospital savings, and health-related quality of life (HrQoL). Median and range are used to describe non-normal data, while mean ± SD and confidence interval are used to descibe data with normal distribution. A meta-analysis with sensitivity analysis and subgroup analyses was performed.

TABULATION, INTEGRATION, AND RESULTS

Eight studies published between 2011 and 2019 with 104,466 patients who underwent hysterectomy were included in this systematic review and meta-analysis. All included studies except 1 were found to have a high risk of bias. OH in comparison with IH had a lower overall complication rate (odds ratio [OR] 0.70; 95% confidence interval [CI], 0.60-0.82) and lower rates of wound infection (OR 0.60; 95% CI, 0.43-0.84), urinary tract infection (OR 0.64; 95% CI, 0.52-0.78), need for transfusion (OR 0.36; 95% CI, 0.22-0.59), sepsis (OR 0.33; 95% CI, 0.17-0.64), uncontrolled pain (OR 0.79; 95% CI, 0.66-0.95), and bleeding requiring medical attention (OR 0.82; 95% CI, 0.73-0.94). In addition, patients who underwent OH had a lower readmission rate (OR 0.81; 95% CI, 0.75-0.87), surgery duration (standardized mean difference -0.35; 95% CI, -0.61 to -0.08), and estimated blood loss (standardized mean difference -0.63; 95% CI, -0.93 to -0.33) than those who underwent IH. A qualitative analysis found that OH had a poorer patient HrQoL and a lower cost for the hospital as well as the payer.

CONCLUSION

OHs present fewer complications and have a lower readmission rate and estimated blood loss as well as a shorter surgery duration than IHs. OHs also have a cost benefit in comparison with IHs. But patients seem to have a worse HrQoL in the first postoperative week after OH. The high risk of bias of the included studies indicates that well-designed clinical trials and standardization of surgical complication reporting are essential to better address this issue.

Enhanced recovery pathways and patient-reported outcome measures in gynaecological oncology

Comprehensive peri-operative care for women with gynaecological malignancy is essential to ensure optimal clinical outcomes and maximise patient experience through the continuum of care. Implementation of peri-operative enhanced recovery pathways in gynaecological oncology have been repeatedly shown to improve postoperative recovery, decrease complications and reduce healthcare costs. With increasing emphasis being placed on patient-centred care in the current healthcare environment, incorporation of patient-reported outcome data collection and analysis within the enhanced recovery pathway as part of quality measurement is not only useful, but necessary. Inclusion of patient-reported outcome enhanced recovery pathway evaluation enables clinicians to capture authentic patient-reported parameters such as subtle symptoms, changes in function and multiple dimensions of well-being, directly from the source. These data guide the treatment course by encouraging shared decision-making between the patient and clinicians and provide the necessary foundation for ongoing peri-operative quality improvement efforts. Elements of the gynaecological oncology enhanced recovery pathway are divided into five phases of care: pre-admission; pre-operative; intra-operative; postoperative; and post-discharge. The development process starts with detailing each step of the patient's journey in all five phases, then identifying stakeholder groups responsible for care at each of these phases and assembling a multidisciplinary team including: gynaecologists; anaesthetists; nurses; nutritionists; physical therapists; and others, to provide input into the institutional pathway. To practically integrate patient-reported outcomes into an enhanced recovery pathway, a validated measurement tool should be incorporated into the peri-operative workflow. The ideal tool should be concise to facilitate longitudinal assessments by the clinical staff.

The impact of implementation of a hysterectomy enhanced recovery pathway on anesthetic medication costs

Aim: To evaluate the effect of implementation of a hysterectomy Enhanced Recovery After Surgery (ERAS) protocol on perioperative anesthetic medication costs. Patients & methods: Historical cohort study of 84 adult patients who underwent a hysterectomy. Forty-two patients who underwent surgery before protocol implementation comprised the pre-ERAS group. Forty-two patients who underwent surgery after protocol implementation comprised the post-ERAS group. Data on anesthetic medication costs and outcomes were analyzed. Results: Compared with the pre-ERAS group, the post-ERAS group's total medication cost was significantly lower (median: 325.20 USD; interquartile range [IQR]: 256.12-430.65 USD vs median: 273.10 USD; IQR: 220.63-370.59 USD, median difference: -40.76, 95% CI: -130.39, 16.99, p = 0.047). Length of stay was significantly longer in pre-ERAS when compared with post-ERAS groups (median: 5.0 days; IQR: 4.0-7.0 days vs median: 3.0 days; IQR: 3.0-4.0 days, median difference: -2.0 days, 95% CI: -2.5581, -1.4419, p < 0.0001). Conclusion: ERAS protocols may reduce perioperative medication costs.

Pre-emptive Non-narcotic Pain Medication before Minimally Invasive Surgery in Gynecologic Oncology

STUDY OBJECTIVE

To review the impact of enhanced recovery after surgery (ERAS) after minimally invasive surgery (MIS) with respect to perioperative narcotics, time in the recovery room, and total time in hospital.

DESIGN

Retrospective cohort.

SETTING

Teaching hospital.

PATIENTS

All patients having MIS in the division of gynecologic oncology during a 20-month period.

INTERVENTION

MIS cases were compared before and after the implementation of an ERAS protocol that incorporated orally administered acetaminophen, gabapentin, and celecoxib.

MEASUREMENT AND MAIN RESULTS

A total of 800 MIS cases were performed during the period (77% laparoscopy, 18% robotic, 5% mini-lap). Of these, 449 cases were treated without and 351 with the ERAS protocol. There were no significant differences between the groups with respect to age, BMI, surgery type, smoking, surgical indication, blood loss, or diagnosis. Total narcotic use in milligram intravenous equivalents of morphine (mg IV Eq) was significantly less in the ERAS patients (28.5-mg IV Eq vs 23.6-mg IV Eq; p <.001). There was a trend toward less narcotics in recovery (4.8-mg IV Eq vs 4.1-mg IV Eq; p = .08). Postoperative recovery room time was not different between the groups (129 minutes vs 131 minutes; p = .66). ERAS was associated with a higher rate of same day discharge (38.5% vs 49.0%; p = .003) and a shorter length of hospital stay (22.9 hours vs 18.5 hours; p = .008), with a hazard ratio for discharge of 0.82 (0.71-0.94). However, the same day discharge rate varied widely between treating physicians (20% to 56%).

CONCLUSIONS

Implementation of an ERAS protocol for MIS appears to reduce total perioperative narcotic use but does not reduce recovery room time. There was a reduction in total hospital time, but this may be dependent on practice patterns of individual physicians.

Adoption of enhanced recovery after laparotomy in gynecologic oncology

Introduction

Enhanced recovery after surgery (ERAS) pathways combine a comprehensive set of peri-operative practices that have been demonstrated to hasten patient post-operative recovery. We aimed to evaluate the adoption of ERAS components and assess attitudes towards ERAS among gynecologic oncologists.

Methods

We developed and administered a cross-sectional survey of attending, fellow, and resident physicians who were members of the Society of Gynecologic Oncology in January 2018. The χ2 test was used to compare adherence to individual components of ERAS.

Results

There was a 23% survey response rate and we analyzed 289 responses: 79% were attending physicians, 57% were from academic institutions, and 64% were from institutions with an established ERAS pathway. Respondents from ERAS institutions were significantly more likely to adhere to recommendations regarding pre-operative fasting for liquids (ERAS 51%, non-ERAS 28%; p<0.001), carbohydrate loading (63% vs 16%; p<0.001), intra-operative fluid management (78% vs 32%; p<0.001), and extended duration of deep vein thrombosis prophylaxis for malignancy (69% vs 55%; p=0.003). We found no difference in the use of mechanical bowel preparation, use of peritoneal drainage, or use of nasogastric tubes between ERAS and non-ERAS institutions. Nearly all respondents (92%) felt that ERAS pathways were safe.

Discussion

Practicing at an institution with an ERAS pathway increased adoption of many ERAS elements; however, adherence to certain guidelines remains highly variable. Use of bowel preparation, nasogastric tubes, and peritoneal drainage catheters remain common. Future work should identify barriers to the implementation of ERAS and its components.

Fast-track pathway for elective caesarean section: a quality improvement initiative to promote day 1 discharge

Enhanced recovery after surgery (ERAS) aims to improve perioperative care, hasten recovery to the normal physiological state and shorten length of stay (LoS). There is evidence that ERAS programmes following elective caesarean section (ELCS) confer benefit through faster return to physiological state and reduced LoS for mother and baby. Baseline audit of ELCS in 2013 revealed a mean LoS of 3 days. We piloted an ERAS discharge pathway promoting day 2 discharge, which rose from 5.0% to 40.2%. 19.2% of women went home on day 1. Many women fed back that they would prefer day 1 discharge. We hypothesised that a day 1 discharge pathway for low-risk women could benefit both women and services at our maternity unit. From October 2015, we developed a 'fast-track pathway' (FTP) using a Plan-Do-Study-Act approach. Between October 2015 and April 2016, we prospectively audited clinical outcomes, LoS and maternal satisfaction from all women placed on the FTP. We held regular multidisciplinary team meetings to allow contemporaneous analysis. Satisfaction was analysed by Likert scale at postoperative surveys. Women were identified in antenatal clinic after meeting predefined low-risk criteria. 27.3% of women (n=131/479) delivering by ELCS entered the FTP. 76.2% of women on the FTP were discharged on day 1. Mean LoS fell to 1.31 days. 94.2% of women who established breast feeding at day 1 were still breast feeding at 7 days. Overall satisfaction at day 7 was 4.71 on a 5-point Likert scale. 73.1% of women reported good pain control. Additional financial savings are estimated at £99 886 annually. There were no related cases of readmission. Day 1 discharge after ELCS is safe and acceptable in carefully selected, low-risk women and has high satisfaction. There may be resultant financial savings and improved flow through a maternity unit with no detected adverse effect on breast feeding, maternal morbidity or postnatal readmissions.

Improved Outcomes of Enhanced Recovery After Surgery (ERAS) Protocol for Radical Cystectomy with Addition of a Multidisciplinary Care Process in a US Comprehensive Cancer Care Center

INTRODUCTION

Although enhanced recovery after surgery (ERAS) components include both anesthesia and surgical care processes, it is unclear whether a multidisciplinary approach to implementing ERAS care processes improves clinical outcomes. The addition of multidisciplinary care with anesthesiology-related components to an existing ERAS protocol for radical cystectomy at a US comprehensive cancer center provided an opportunity to compare short- and long-term outcomes.

METHODS

We retrospectively compared the outcomes of 116 consecutive patients who underwent cystectomy after implementation of a multidisciplinary ERAS protocol with those of a historical control group of 143 consecutive patients who had been treated with a surgical ERAS protocol. Length of stay, return of bowel function, rate of blood transfusion, nausea, pain, and readmission rates were examined.

RESULTS

Implementation of a multidisciplinary ERAS protocol was associated with better postsurgical symptom control, as indicated by lower rates of patient-reported nausea (P < .05). Multivariate Poisson regression analysis showed a decrease in estimated intraoperative transfusions (P ≤ .001) after adjusting for the effects of potential confounding variables. There were no statistically significant differences noted in length of stay, return of bowel function, 30- and 90-day complications, or readmissions.

CONCLUSION

This is the first study to investigate the effects of adding anesthesia ERAS components to an existing surgical ERAS protocol for radical cystectomy. We found that with the addition of anesthesia-related interventions, there was a decrease in transfusions and nausea.

Reporting and Analysis of Trial-Based Cost-Effectiveness Evaluations in Obstetrics and Gynaecology

BACKGROUND AND OBJECTIVES

The aim was to systematically review whether the reporting and analysis of trial-based cost-effectiveness evaluations in the field of obstetrics and gynaecology comply with guidelines and recommendations, and whether this has improved over time.

DATA SOURCES AND SELECTION CRITERIA

A literature search was performed in MEDLINE, the NHS Economic Evaluation Database (NHS EED) and the Health Technology Assessment (HTA) database to identify trial-based cost-effectiveness evaluations in obstetrics and gynaecology published between January 1, 2000 and May 16, 2017. Studies performed in middle- and low-income countries and studies related to prevention, midwifery, and reproduction were excluded.

DATA COLLECTION AND ANALYSIS

Reporting quality was assessed using the Consolidated Health Economic Evaluation Reporting Standard (CHEERS) statement (a modified version with 21 items, as we focused on trial-based cost-effectiveness evaluations) and the statistical quality was assessed using a literature-based list of criteria (8 items). Exploratory regression analyses were performed to assess the association between reporting and statistical quality scores and publication year.

RESULTS

The electronic search resulted in 5482 potentially eligible studies. Forty-five studies fulfilled the inclusion criteria, 22 in obstetrics and 23 in gynaecology. Twenty-seven (60%) studies did not adhere to 50% (n = 10) or more of the reporting quality items and 32 studies (71%) did not meet 50% (n = 4) or more of the statistical quality items. As for the statistical quality, no study used the appropriate method to assess cost differences, no advanced methods were used to deal with missing data, and clustering of data was ignored in all studies. No significant improvements over time were found in reporting or statistical quality in gynaecology, whereas in obstetrics a significant improvement in reporting and statistical quality was found over time.

LIMITATIONS

The focus of this review was on trial-based cost-effectiveness evaluations in obstetrics and gynaecology, so further research is needed to explore whether results from this review are generalizable to other medical disciplines.

CONCLUSIONS AND IMPLICATIONS OF KEY FINDINGS

The reporting and analysis of trial-based cost-effectiveness evaluations in gynaecology and obstetrics is generally poor. Since this can result in biased results, incorrect conclusions, and inappropriate healthcare decisions, there is an urgent need for improvement in the methods of cost-effectiveness evaluations in this field.

The Development of Enhanced Recovery After Surgery Across Surgical Specialties

BACKGROUND

Enhanced recovery after surgery (ERAS^®) principles have gained traction in variety of surgical disciplines. The promise of a reduced length of stay without compromising patient safety or increasing readmission rates has produced a body of literature examining the implementation of ERAS in the care of general, thoracic, urologic, and gynecologic surgery patients.

METHODS

We performed a review of the literature pertaining to studies of ERAS implementation across colorectal surgery, general surgery, thoracic surgery, urology, and gynecology. The extent of ERAS implementation and reported outcomes across key studies as well as systematic reviews and meta-analyses in each field were summarized.

RESULTS

The implementation of ERAS protocols has not been uniform across surgical specialties. Despite this, ERAS has produced improvements in patient outcomes. The most commonly described benefit of ERAS application has been reduced length of stay; complication and readmission rates are most consistently decreased in the colorectal literature. Studies have started to measure more nuanced measures of postoperative patient well-being. Efforts are growing to standardize ERAS protocols across diverse fields and call attention to the need for quality control.

CONCLUSIONS

Challenges remain in the study and execution of ERAS. Controlling for adherence to ERAS components and implementing uniform ERAS protocols across studies are burgeoning topics that have significant implications for study design. The practice of ERAS and its benefits to patients are expected to evolve. Assessing improvements in postdischarge quality of life, timing of return to work and independent living, and adherence to scheduled delivery of adjuvant treatments will strengthen future ERAS investigations.

Enhanced Recovery Pathways in Gynecology and Gynecologic Oncology

IMPORTANCE

Enhanced recovery programs (ERPs) are considered standard of care across a variety of surgical disciplines, but ERPs have not been widely adopted in gynecology.

OBJECTIVE

The aim of this study was to describe ERP principles and the role of ERPs in gynecology and gynecologic oncology.

EVIDENCE ACQUISITION

Comprehensive literature search was performed using MEDLINE, the Cochrane Collaboration Database, and PubMed.

RESULTS

Meta-analyses of a substantial number of randomized controlled trials have shown that implementation of ERP protocols is associated with decreased length of hospital stay, a decrease in rates of postoperative complication, decreased morbidity, and cost savings while preserving patient satisfaction and quality of life.

CONCLUSIONS AND RELEVANCE

High-quality evidence exists for improved outcomes among patients in ERPs. Enhanced recovery programs save resources and costs across the health care system. As quality metrics and bundled payments increase in health care, ERPs will have increasing prominence.

A call for new standard of care in perioperative gynecologic oncology practice: Impact of enhanced recovery after surgery (ERAS) programs

Enhanced recovery after surgery (ERAS) programs aim to hasten functional recovery and improve postoperative outcomes. However, there is a paucity of data on ERAS programs in gynecologic surgery. We reviewed the published literature on ERAS programs in colorectal surgery, general gynecologic surgery, and gynecologic oncology surgery to evaluate the impact of such programs on outcomes, and to identify key elements in establishing a successful ERAS program. ERAS programs are associated with shorter length of hospital stay, a reduction in overall health care costs, and improvements in patient satisfaction. We suggest an ERAS program for gynecologic oncology practice involving preoperative, intraoperative, and postoperative strategies including; preadmission counseling, avoidance of preoperative bowel preparation, use of opioid-sparing multimodal perioperative analgesia (including loco-regional analgesia), intraoperative goal-directed fluid therapy (GDT), and use of minimally invasive surgical techniques with avoidance of routine use of nasogastric tube, drains and/or catheters. Postoperatively, it is important to encourage early feeding, early mobilization, timely removal of tubes and drains, if present, and function oriented multimodal analgesia regimens. Successful implementation of an ERAS program requires a multidisciplinary team effort and active participation of the patient in their goal-oriented functional recovery program. However, future outcome studies should evaluate the efficacy of an intervention within the pathway, include objective measures of symptom burden and control, study measures of functional recovery, and quantify outcomes of the program in relation to the rates of adherence to the key elements of care in gynecologic oncology such as oncologic outcomes and return to intended oncologic therapy (RIOT).

Demonstrating Value: A Case Study of Enhanced Recovery

An enhanced recovery after surgery strategy will be increasingly adopted in the era of value-based care. The various elements in each enhanced recovery after surgery protocol are likely to add value to the overall patient surgical journey. Although the evidence varies considerably based on type of surgery and patient group, the team-based approach of care should be universally applied to patient care. This article provides an overview of up-to-date techniques and methodology for enhanced recovery, including an overview of value-based care, delivery, and the evidence base supporting enhanced recovery after surgery.

Interruptions and distractions in the gynaecological operating theatre: irritating or dangerous?

Distractions and interference can include visual (e.g. staff obscuring monitors), audio (e.g. noise, irrelevant communication) and equipment problems. Level of distraction is usually defined as I: relatively inconsequential; II: > one member of the surgical team affected; III: the entire surgical team affected. The aim of this study was to observe the frequency and impact of distracting events and interruptions on elective gynaecology cases. Data from 35 cases were collected from 10 consecutive operating sessions. Mean number of interruptions was 26 episodes/case, while mean number of level II/III distractions was 17 episodes/case. Ninety per cent of interruptions occur in the first 30 minutes of the procedure and 80.9% lead to level II/III distraction. Although no complications were directly attributable to the observed distractions, the mean prolongation of operating time was 18.46 minutes/case. Understanding their effects on theatre environment enables appropriate measures to be taken so that theatre productivity and patient safety are optimised.

PRACTITIONER SUMMARY

This observational study of 35 elective cases shows a mean interruption rate of 26 episodes/case with 80.9% affecting > one member of operating team, leading to mean prolongation of 18.46 minutes/case. Theatre staff should be aware of these findings and appropriate measures taken to optimise theatre productivity and patient safety.