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Nelson G, Fotopoulou C, Taylor J, Glaser G, Bakkum-Gamez J, Meyer LA, Stone R, Mena G, Elias KM, Altman AD, Bisch SP, Ramirez PT, Dowdy SC. Enhanced recovery after surgery (ERAS®) society guidelines for gynecologic oncology: Addressing implementation challenges - 2023 update. Gynecol Oncol 2023; 173:58-67. [PMID: 37086524 DOI: 10.1016/j.ygyno.2023.04.009] [Citation(s) in RCA: 30] [Impact Index Per Article: 30.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2023] [Revised: 04/11/2023] [Accepted: 04/13/2023] [Indexed: 04/24/2023]
Abstract
BACKGROUND Despite evidence supporting its use, many Enhanced Recovery After Surgery (ERAS) recommendations remain poorly adhered to and barriers to ERAS implementation persist. In this second updated ERAS® Society guideline, a consensus for optimal perioperative care in gynecologic oncology surgery is presented, with a specific emphasis on implementation challenges. METHODS Based on the gaps identified by clinician stakeholder groups, nine implementation challenge topics were prioritized for review. A database search of publications using Embase and PubMed was performed (2018-2023). Studies on each topic were selected with emphasis on meta-analyses, randomized controlled trials, and large prospective cohort studies. These studies were then reviewed and graded by an international panel according to the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) system. RESULTS All recommendations on ERAS implementation challenge topics are based on best available evidence. The level of evidence for each item is presented accordingly. CONCLUSIONS The updated evidence base and recommendations for stakeholder derived ERAS implementation challenges in gynecologic oncology are presented by the ERAS® Society in this consensus review.
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Affiliation(s)
- G Nelson
- Department of Obstetrics & Gynecology, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada.
| | - C Fotopoulou
- Department of Surgery and Cancer, Faculty of Medicine, Imperial College London, London, UK
| | - J Taylor
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - G Glaser
- Division of Gynecologic Oncology, Mayo Clinic College of Medicine, Rochester, MN, USA
| | - J Bakkum-Gamez
- Division of Gynecologic Oncology, Mayo Clinic College of Medicine, Rochester, MN, USA
| | - L A Meyer
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - R Stone
- Department of Gynecology and Obstetrics, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - G Mena
- Department of Anesthesiology, Critical Care and Pain Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - K M Elias
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology and Reproductive Biology, Brigham and Women's Hospital, Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA, USA
| | - A D Altman
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | - S P Bisch
- Department of Obstetrics & Gynecology, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - P T Ramirez
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA; Department of Obstetrics and Gynecology, Houston Methodist Hospital, Houston, TX, USA
| | - S C Dowdy
- Division of Gynecologic Oncology, Mayo Clinic College of Medicine, Rochester, MN, USA
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Montgomery C, Stelfox H, Norris C, Rolfson D, Meyer S, Zibdawi M, Bagshaw S. Association between preoperative frailty and outcomes among adults undergoing cardiac surgery: a prospective cohort study. CMAJ Open 2021; 9:E777-E787. [PMID: 34285057 PMCID: PMC8313095 DOI: 10.9778/cmajo.20200034] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND The identification of frailty before complex and invasive procedures may have relevance for prognostic and recovery purposes, to optimally inform patients, caregivers and clinicians about perioperative risk and postoperative care needs. The aim of this study was to estimate the prevalence of frailty and describe the associated clinical course and outcomes of patients referred for nonemergent cardiac surgery. METHODS A prospective cohort of patients aged 50 years and older referred for nonemergent cardiac surgery in Alberta, Canada, from November 2011 to March 2014 were screened preoperatively for frailty, defined as a Clinical Frailty Scale (CFS) score of 5 or greater. Postoperatively, patients were followed by telephone to assess CFS score, health services use and vital status. The primary outcome was all-cause hospital mortality. Secondary outcomes included health services use, hospital discharge disposition, 1-year health-related quality of life and all-cause 5-year mortality. RESULTS The cohort (n = 529) had a mean age of 67 (standard deviation [SD] 9) years; 25.9% were female, and the prevalence of frailty was 9.6% (n = 51; 95% confidence interval [CI] 7.3%-12.5%). Frail patients were older (median age 75, interquartile range [IQR] 65-80 v. 67, IQR 60-73, yr; p < 0.001), were more likely to be female (51.0% v. 23.2%; p < 0.001), had a higher mean EuroSCORE II (8, SD 3 v. 5, SD 3; p < 0.001) and received combined coronary artery bypass grafting and valve procedures more frequently (29.4% v. 15.9%; p = 0.02) than nonfrail patients. Postoperatively, frail patients had a longer median duration of stay in the cardiovascular intensive care unit (median difference 2.2, 95% CI 1.60-2.79) and hospital (median difference 9.3, 95% CI 8.2-10.3). Hospital mortality was 9.8% among frail patients and 1.0% among nonfrail patients (adjusted hazard ratio 3.84, 95% CI 0.90-16.34). INTERPRETATION Preoperative frailty was present in 10% of patients and was associated with a higher risk of morbidity and greater health services use. Preoperative frailty has important implications for the postoperative clinical course and resource utilization of patients undergoing cardiac surgery.
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Affiliation(s)
- Carmel Montgomery
- Department of Critical Care Medicine (Montgomery, Zibdawi, Bagshaw), Faculty of Medicine & Dentistry, University of Alberta, Edmonton, Alta.; Department of Critical Care Medicine (Stelfox), Cumming School of Medicine, and Department of Community Health Sciences (Stelfox), University of Calgary, Calgary, Alta.; Faculty of Nursing and School of Public Health (Norris, Bagshaw), University of Alberta; Strategic Clinical Networks (Norris, Bagshaw), Alberta Health Services; Division of Geriatric Medicine (Rolfson), Department of Medicine, and Division of Cardiac Surgery, (Meyer) Department of Surgery, Faculty of Medicine & Dentistry, University of Alberta, Edmonton, Alta.
| | - Henry Stelfox
- Department of Critical Care Medicine (Montgomery, Zibdawi, Bagshaw), Faculty of Medicine & Dentistry, University of Alberta, Edmonton, Alta.; Department of Critical Care Medicine (Stelfox), Cumming School of Medicine, and Department of Community Health Sciences (Stelfox), University of Calgary, Calgary, Alta.; Faculty of Nursing and School of Public Health (Norris, Bagshaw), University of Alberta; Strategic Clinical Networks (Norris, Bagshaw), Alberta Health Services; Division of Geriatric Medicine (Rolfson), Department of Medicine, and Division of Cardiac Surgery, (Meyer) Department of Surgery, Faculty of Medicine & Dentistry, University of Alberta, Edmonton, Alta
| | - Colleen Norris
- Department of Critical Care Medicine (Montgomery, Zibdawi, Bagshaw), Faculty of Medicine & Dentistry, University of Alberta, Edmonton, Alta.; Department of Critical Care Medicine (Stelfox), Cumming School of Medicine, and Department of Community Health Sciences (Stelfox), University of Calgary, Calgary, Alta.; Faculty of Nursing and School of Public Health (Norris, Bagshaw), University of Alberta; Strategic Clinical Networks (Norris, Bagshaw), Alberta Health Services; Division of Geriatric Medicine (Rolfson), Department of Medicine, and Division of Cardiac Surgery, (Meyer) Department of Surgery, Faculty of Medicine & Dentistry, University of Alberta, Edmonton, Alta
| | - Darryl Rolfson
- Department of Critical Care Medicine (Montgomery, Zibdawi, Bagshaw), Faculty of Medicine & Dentistry, University of Alberta, Edmonton, Alta.; Department of Critical Care Medicine (Stelfox), Cumming School of Medicine, and Department of Community Health Sciences (Stelfox), University of Calgary, Calgary, Alta.; Faculty of Nursing and School of Public Health (Norris, Bagshaw), University of Alberta; Strategic Clinical Networks (Norris, Bagshaw), Alberta Health Services; Division of Geriatric Medicine (Rolfson), Department of Medicine, and Division of Cardiac Surgery, (Meyer) Department of Surgery, Faculty of Medicine & Dentistry, University of Alberta, Edmonton, Alta
| | - Steven Meyer
- Department of Critical Care Medicine (Montgomery, Zibdawi, Bagshaw), Faculty of Medicine & Dentistry, University of Alberta, Edmonton, Alta.; Department of Critical Care Medicine (Stelfox), Cumming School of Medicine, and Department of Community Health Sciences (Stelfox), University of Calgary, Calgary, Alta.; Faculty of Nursing and School of Public Health (Norris, Bagshaw), University of Alberta; Strategic Clinical Networks (Norris, Bagshaw), Alberta Health Services; Division of Geriatric Medicine (Rolfson), Department of Medicine, and Division of Cardiac Surgery, (Meyer) Department of Surgery, Faculty of Medicine & Dentistry, University of Alberta, Edmonton, Alta
| | - Mohamad Zibdawi
- Department of Critical Care Medicine (Montgomery, Zibdawi, Bagshaw), Faculty of Medicine & Dentistry, University of Alberta, Edmonton, Alta.; Department of Critical Care Medicine (Stelfox), Cumming School of Medicine, and Department of Community Health Sciences (Stelfox), University of Calgary, Calgary, Alta.; Faculty of Nursing and School of Public Health (Norris, Bagshaw), University of Alberta; Strategic Clinical Networks (Norris, Bagshaw), Alberta Health Services; Division of Geriatric Medicine (Rolfson), Department of Medicine, and Division of Cardiac Surgery, (Meyer) Department of Surgery, Faculty of Medicine & Dentistry, University of Alberta, Edmonton, Alta
| | - Sean Bagshaw
- Department of Critical Care Medicine (Montgomery, Zibdawi, Bagshaw), Faculty of Medicine & Dentistry, University of Alberta, Edmonton, Alta.; Department of Critical Care Medicine (Stelfox), Cumming School of Medicine, and Department of Community Health Sciences (Stelfox), University of Calgary, Calgary, Alta.; Faculty of Nursing and School of Public Health (Norris, Bagshaw), University of Alberta; Strategic Clinical Networks (Norris, Bagshaw), Alberta Health Services; Division of Geriatric Medicine (Rolfson), Department of Medicine, and Division of Cardiac Surgery, (Meyer) Department of Surgery, Faculty of Medicine & Dentistry, University of Alberta, Edmonton, Alta
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Siracuse JJ, Farber A, Cheng TW, Levin SR, Kalesan B. Hospital-Level Medicaid Prevalence Is Associated with Increased Length of Stay after Asymptomatic Carotid Endarterectomy and Stenting Despite no Increase in Major Complications. Ann Vasc Surg 2020; 71:65-73. [PMID: 32949743 DOI: 10.1016/j.avsg.2020.09.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2020] [Revised: 09/07/2020] [Accepted: 09/08/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND Length of stay (LOS) after carotid endarterectomy (CEA) and carotid artery stenting (CAS) for asymptomatic disease is used as a quality measure and affects hospital operating margins. Patient-level Medicaid status has traditionally been associated with longer hospital LOS. Our goal was to assess the association between hospital-level Medicaid prevalence and postoperative LOS after CEA and CAS. METHODS The National Inpatient Sample was queried from 2006-2014 for CEA and CAS performed for asymptomatic carotid stenosis. Overall hospital-level Medicaid prevalence was divided into quartiles. The quartiles were further categorized into low Medicaid prevalence (LM) (lowest quartile), medium Medicaid prevalence (MM) (second and third quartiles), and high Medicaid prevalence (HM) (fourth quartile) cohorts. The primary outcome evaluated was postoperative LOS >1 day. The secondary outcomes included perioperative/in-hospital complications and mortality. RESULTS There were 984,283 patients with asymptomatic carotid stenosis who underwent CEA (88%) or CAS (12%). Mean postoperative LOS after CEA at hospitals with LM, MM, and HM prevalence was 1.4 ± 1.5, 2.1 ± 2.5, and 2.2 ± 2.8 days (P = 0.0001), respectively, and after CAS were 1.7 ± 2.6, 1.8 ± 2.1, and 2 ± 2.6 days (P < 0.0001), respectively. After CEA, relative to LM prevalence, MM (OR 1.62, 95% CI 1.17-2.24) and HM (OR 1.66, 95% CI 1.2-2.28) prevalence were associated with a higher likelihood of LOS > 1 day (P = 0.009). After CAS, relative to LM prevalence, HM prevalence was associated with a higher likelihood of LOS >1 day (OR 1.42, 95% CI 1.06-1.91) (P = 0.003). After CEA, neurologic (0.8% vs. 0.9% vs. 0.9%, P = 0.83) and cardiac complications (0.9% vs. 1.2% vs. 1.2%, P = 0.24) were similar among hospitals with LM, MM, and HM prevalence, respectively. After CAS, the prevalence of neurological (1.1% vs. 1% vs. 1.2%, P = 0.42) and cardiac complications (2% vs. 1.3% vs. 1.5%, P = 0.46) were also similar. After both CEA and CAS, mortality was similar among Medicaid prevalence cohorts. CONCLUSIONS Higher hospital-level Medicaid prevalence was associated with longer LOS after CEA and CAS for asymptomatic carotid stenosis. Value-based payment models should adjust for hospital-level Medicaid prevalence to appropriately reimburse providers and hospital with higher Medicaid prevalence as well as investigate care pathways and systems improvement to help reduce LOS.
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Affiliation(s)
- Jeffrey J Siracuse
- Division of Vascular and Endovascular Surgery, Boston Medical Center, Boston University School of Medicine, Boston, MA.
| | - Alik Farber
- Division of Vascular and Endovascular Surgery, Boston Medical Center, Boston University School of Medicine, Boston, MA
| | - Thomas W Cheng
- Division of Vascular and Endovascular Surgery, Boston Medical Center, Boston University School of Medicine, Boston, MA
| | - Scott R Levin
- Division of Vascular and Endovascular Surgery, Boston Medical Center, Boston University School of Medicine, Boston, MA
| | - Bindu Kalesan
- Center for Clinical Translational Epidemiology and Comparative Effectiveness Research, Preventative Medicine & Epidemiology, Department of Medicine, Boston University School of Medicine, Boston, MA
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