1
|
Leaman EE, Ludbrook GL. The Cost-Effectiveness of Early High-Acuity Postoperative Care for Medium-Risk Surgical Patients. Anesth Analg 2024; 139:323-331. [PMID: 38009844 DOI: 10.1213/ane.0000000000006743] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2023]
Abstract
BACKGROUND Initiatives in perioperative care warrant robust cost-effectiveness analysis in a cost-constrained era when high-value care is a priority. A model of anesthesia-led early high-acuity postoperative care, advanced recovery room care (ARRC), has shown benefit in terms of hospital and patient outcomes, but its cost-effectiveness has not yet been formally determined. METHODS Data from a previously published single-center prospective cohort study of ARRC in medium-risk patients were used to generate a Markov model, which described patient transition between care locations, each with different characteristics and costs. The incremental cost-effectiveness ratio (ICER), using days at home (DAH) and hospital costs, was calculated for ARRC compared to usual ward care using deterministic and probabilistic sensitivity analysis. RESULTS The Markov model accurately described patient disposition after surgery. For each patient, ARRC provided 4.3 more DAH within the first 90 days after surgery and decreased overall hospital costs by $1081 per patient. Probabilistic sensitivity analysis revealed that ARRC had a 99.3% probability of increased DAH and a 77.4% probability that ARRC was dominant from the perspective of the hospital, with improved outcomes and decreased costs. CONCLUSIONS Early high-acuity care for approximately 24 hours after surgery in medium-risk patients provides highly cost-effective improvements in outcomes when compared to usual ward care.
Collapse
Affiliation(s)
- Esrom E Leaman
- From the Department of Anaesthesia, Royal Adelaide Hospital, Adelaide, Australia
- Discipline of Acute Care Medicine, University of Adelaide, Adelaide, Australia
| | - Guy L Ludbrook
- From the Department of Anaesthesia, Royal Adelaide Hospital, Adelaide, Australia
- Discipline of Acute Care Medicine, University of Adelaide, Adelaide, Australia
| |
Collapse
|
2
|
Stanton E, Buser Z, Mesregah MK, Hu K, Pickering TA, Schafer B, Hah R, Hsieh P, Wang JC, Liu JC. The impact of enhanced recovery after surgery (ERAS) on opioid consumption and postoperative pain levels in elective spine surgery. Clin Neurol Neurosurg 2024; 242:108350. [PMID: 38788543 DOI: 10.1016/j.clineuro.2024.108350] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2024] [Revised: 05/17/2024] [Accepted: 05/21/2024] [Indexed: 05/26/2024]
Abstract
OBJECTIVE Enhanced Recovery after Surgery (ERAS) protocols were developed to counteract the adverse effects of the surgical stress response, aiming for quicker postoperative recovery. Initially applied in abdominal surgeries, ERAS principles have extended to orthopedic spine surgery, but research in this area is still in its infancy. The current study investigated the impact of ERAS on postoperative pain and opioid consumption in elective spine surgeries. METHODS A single-center retrospective study of patients undergoing elective spine surgery from May 2019 to July 2020. Patients were categorized into two groups: those enrolled in the ERAS pathway and those adhering to traditional surgical protocols. Data on demographics, comorbidities, length of stay (LOS), surgical procedures, and postoperative outcomes were collected. Postoperative pain was evaluated using the Numerical Rating Scale (NRS), while opioid utilization was quantified in morphine milligram equivalents (MME). NRS and MME were averaged for each patient across all days under observation. Differences in outcomes between groups (ERAS vs. treatment as usual) were tested using the Wilcoxon rank sum test for continuous variables and Pearson's or Fisher's exact tests for categorical variables. RESULTS The median of patient's mean daily NRS scores for postoperative pain were not statistically significantly different between groups (median = 5.55 (ERAS) and 5.28 (non-ERAS), p=.2). Additionally, the median of patients' mean daily levels of MME were similar between groups (median = 17.24 (ERAS) and 16.44 (non-ERAS), p=.3) ERAS patients experienced notably shorter LOS (median=2 days) than their non-ERAS counterparts (median=3 days, p=.001). The effect of ERAS was moderated by whether the patient had ACDF surgery. ERAS (vs. non-ERAS) patients who had ACDF surgery had 1.64 lower average NRS (p=.006). ERAS (vs. non-ERAS) patients who had a different surgery had 0.72 higher average NRS (p=.02) but had almost half the length of stay, on average (p<.001). CONCLUSIONS The current study underscores the dynamic nature of ERAS protocols within the realm of spine surgery. While ERAS demonstrates advantages such as reduced LOS and improved patient-reported outcomes, it requires careful implementation and customization to address the specific demands of each surgical discipline. The potential to expedite recovery, optimize resource utilization, and enhance patient satisfaction cannot be overstated. However, the fine balance between achieving these benefits and ensuring comprehensive patient care, especially in the context of postoperative pain management, must be maintained. As ERAS continues to evolve and find its place in diverse surgical domains, it is crucial for healthcare providers to remain attentive to patient needs, adapting ERAS protocols to suit individual patient populations and surgical contexts.
Collapse
Affiliation(s)
- Eloise Stanton
- Department of Orthopedic Surgery, Keck School of Medicine, University of Southern California, Los Angeles, United States
| | - Zorica Buser
- Department of Orthopedic Surgery, Keck School of Medicine, University of Southern California, Los Angeles, United States; Department of Orthopedic Surgery, Grossman School of Medicine, New York University, New York, United States; Gerling Institute, Brooklyn, NY, United States.
| | - Mohamed Kamal Mesregah
- Department of Orthopaedic Surgery, Menoufia University Faculty of Medicine, Shebin El-Kom, Menoufia, Egypt
| | - Kelly Hu
- Department of Neurological Surgery, Keck School of Medicine, University of Southern California, Los Angeles, United States
| | - Trevor A Pickering
- Department of Population and Public Health Sciences, Keck School of Medicine, University of Southern California, Los Angeles, United States
| | - Betsy Schafer
- Department of Neurological Surgery, Keck School of Medicine, University of Southern California, Los Angeles, United States
| | - Raymond Hah
- Department of Orthopedic Surgery, Keck School of Medicine, University of Southern California, Los Angeles, United States
| | - Patrick Hsieh
- Department of Orthopedic Surgery, Grossman School of Medicine, New York University, New York, United States
| | - Jeffrey C Wang
- Department of Orthopedic Surgery, Keck School of Medicine, University of Southern California, Los Angeles, United States
| | - John C Liu
- Department of Neurological Surgery, Keck School of Medicine, University of Southern California, Los Angeles, United States
| |
Collapse
|
3
|
Paradis T, Robitaille S, Wang A, Gervais C, Liberman AS, Charlebois P, Stein BL, Fiore JF, Feldman LS, Lee L. Predictive Factors for Successful Same-Day Discharge After Minimally Invasive Colectomy and Stoma Reversal. Dis Colon Rectum 2024; 67:558-565. [PMID: 38127647 DOI: 10.1097/dcr.0000000000003149] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2023]
Abstract
BACKGROUND Same-day discharge after minimally invasive colorectal surgery is a safe, effective practice in specific patients that can enhance the efficiency of enhanced recovery pathways. OBJECTIVE To identify predictive factors associated with success or failure of same-day discharge. DESIGN Prospective cohort study from January 2020 to March 2023. SETTINGS Tertiary colorectal center. PATIENTS Adult patients eligible for same-day discharge with remote postdischarge follow-up included those with minimal comorbidities, residing near the hospital, having sufficient home support, and owning a mobile device. INTERVENTIONS Patients were discharged on the day of surgery upon meeting specific criteria, including adequate pain control, tolerance of oral intake, independent mobility, urination, and the absence of complications. Successful same-day discharge was defined as discharge on the day of surgery without unplanned visits in the first 72 hours. MAIN OUTCOME MEASURES Factors associated with successful or failed same-day discharge after minimally invasive colorectal surgery. RESULTS A total of 175 patients (85.3%) were discharged on the day of surgery, with 14 patients (8%) having an unplanned visit within 72 hours. Overall, 161 patients (78.5%) were categorized as same-day discharge success and 44 patients (21.5%) as same-day discharge failure. The same-day discharge failure group had a higher Charlson Comorbidity Index (3.7 vs 2.8, p = 0.03). Mean length of stay (0.8 vs 3.0, p = 0.00), 30-day complications (10% vs 48%, p = 0.00), and readmissions (8% vs 27%, p = 0.00) were higher in the same-day discharge failure group. Regression analysis showed that failed same-day discharge was associated with higher comorbidities (OR 0.79; 95% CI, 0.66-0.95) and prolonged postanesthesia care unit time (OR 0.99; 95% CI, 0.99-0.99). Individuals who received a regional nerve block (OR 4.1; 95% CI, 1.2-14) and those who did not consume postoperative opioids (OR 4.6; 95% CI, 1-21) were more likely to have successful same-day discharge. LIMITATIONS Single-center study. CONCLUSIONS Our findings indicate that comorbidities and prolonged postanesthesia care unit stays were associated with same-day discharge failure, whereas regional nerve blocks and minimal postoperative opioids were related to success. These factors may inform future research aiming to enhance colorectal surgery recovery protocols. See Video Abstract . FACTORES PREDICTIVOS PARA UN ALTA EXITOSA EL MISMO DA DESPUS DE UNA COLECTOMA MNIMAMENTE INVASIVA Y REVERSIN DEL ESTOMA ANTECEDENTES:El alta el mismo día después de una cirugía colorrectal mínimamente invasiva es una práctica segura y eficaz en pacientes específicos que puede mejorar la eficiencia de las vías de recuperación mejoradas.OBJETIVO:Identificar factores predictivos asociados con el éxito o fracaso del alta el mismo día.DISEÑO:Estudio de cohorte prospectivo del 01/2020 al 03/2023.AJUSTES:Centro colorrectal terciario.PACIENTES:Los pacientes adultos elegibles para el alta el mismo día con seguimiento remoto posterior al alta incluyeron aquellos con comorbilidades mínimas, que residían cerca del hospital, tenían suficiente apoyo en el hogar y poseían un dispositivo móvil.INTERVENCIONES:Los pacientes fueron dados de alta el día de la cirugía al cumplir con criterios específicos, incluido un control adecuado del dolor, tolerancia a la ingesta oral, movilidad independiente, micción y ausencia de complicaciones. El alta exitosa el mismo día se definió como el alta el día de la cirugía sin visitas no planificadas en las primeras 72 horas.PRINCIPALES MEDIDAS DE RESULTADO:Factores asociados con el alta exitosa o fallida el mismo día después de una cirugía colorrectal mínimamente invasiva.RESULTADOS:Un total de 175 (85,3%) pacientes fueron dados de alta el día de la cirugía y 14 (8%) pacientes tuvieron una visita no planificada dentro de las 72 horas. En total, 161 (78,5%) pacientes se clasificaron como éxito del alta el mismo día y 44 (21,5%) pacientes como fracaso del alta el mismo día. El grupo de fracaso del alta el mismo día tuvo un índice de comorbilidad de Charlson más alto (3,7, 2,8, p = 0,03). La duración media de la estancia hospitalaria (0,8, 3,0, p = 0,00), las complicaciones a los 30 días (10%, 48%, p = 0,00) y los reingresos (8%, 27%, p = 0,00) fueron mayores en el mismo día grupo de fallo de descarga. El análisis de regresión mostró que el alta fallida el mismo día se asoció con mayores comorbilidades (OR 0,79; IC del 95 %: 0,66; 0,95) y tiempo prolongado en la unidad de cuidados postanestésicos (OR 0,99; IC del 95 %: 0,99; 0,99). Las personas que recibieron un bloqueo nervioso regional (OR 4,1; IC del 95 %: 1,2, 14) y aquellos que no consumieron opioides posoperatorios (OR 4,6, IC del 95 %: 1-21) tuvieron más probabilidades de tener éxito en el mismo día -descarga.LIMITACIONES:Estudio unicéntrico.CONCLUSIONES:Nuestros hallazgos indican que las comorbilidades y las estancias prolongadas en la unidad de cuidados postanestésicos se asociaron con el fracaso del alta el mismo día, mientras que los bloqueos nerviosos regionales y los opioides postoperatorios mínimos se relacionaron con el éxito. Estos factores pueden informar investigaciones futuras destinadas a mejorar los protocolos de recuperación de la cirugía colorrectal. (Traducción-Yesenia Rojas-Khalil ).
Collapse
Affiliation(s)
- Tiffany Paradis
- Department of Surgery, McGill University Health Centre, Montreal, Quebec, Canada
| | - Stephan Robitaille
- Department of Surgery, McGill University Health Centre, Montreal, Quebec, Canada
| | - Anna Wang
- Department of Surgery, McGill University Health Centre, Montreal, Quebec, Canada
| | - Camille Gervais
- Department of Medicine, Faculty of Medicine, McGill University, Montreal, Quebec, Canada
| | - A Sender Liberman
- Department of Surgery, McGill University Health Centre, Montreal, Quebec, Canada
- Department of General Surgery, Steinberg-Bernstein Centre for Minimally Invasive Surgery and Innovation, McGill University Health Centre, Montreal, Quebec, Canada
| | - Patrick Charlebois
- Department of Surgery, McGill University Health Centre, Montreal, Quebec, Canada
- Department of General Surgery, Steinberg-Bernstein Centre for Minimally Invasive Surgery and Innovation, McGill University Health Centre, Montreal, Quebec, Canada
| | - Barry L Stein
- Department of Surgery, McGill University Health Centre, Montreal, Quebec, Canada
- Department of General Surgery, Steinberg-Bernstein Centre for Minimally Invasive Surgery and Innovation, McGill University Health Centre, Montreal, Quebec, Canada
| | - Julio F Fiore
- Department of Medicine, Faculty of Medicine, McGill University, Montreal, Quebec, Canada
| | - Liane S Feldman
- Department of Surgery, McGill University Health Centre, Montreal, Quebec, Canada
- Department of General Surgery, Steinberg-Bernstein Centre for Minimally Invasive Surgery and Innovation, McGill University Health Centre, Montreal, Quebec, Canada
| | - Lawrence Lee
- Department of Surgery, McGill University Health Centre, Montreal, Quebec, Canada
- Department of General Surgery, Steinberg-Bernstein Centre for Minimally Invasive Surgery and Innovation, McGill University Health Centre, Montreal, Quebec, Canada
| |
Collapse
|
4
|
Qin X, Li H, Long J, Feng C. A meta-analysis of the implementation of enhanced recovery after surgery pathways in anterior cervical spine surgery for degenerative cervical spine diseases. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2024; 33:1283-1291. [PMID: 38212410 DOI: 10.1007/s00586-023-08105-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/11/2023] [Revised: 11/28/2023] [Accepted: 12/14/2023] [Indexed: 01/13/2024]
Abstract
OBJECTIVE To systematically evaluate the perioperative effects of enhanced recovery after surgery (ERAS) protocol on anterior cervical spine surgery by means of meta-analysis. METHODS According to the PRISMA guidelines, the article's search on the China National Knowledge Infrastructure (CNKI), Wanfang data resource system, VIP, PubMed database and Cochrane library was conducted to identify clinical studies investigating the effects of ERAS protocols on anterior cervical spine surgery. A quantitative meta-analysis was performed for the clinical outcomes extracted from the studies that met inclusion criteria. RESULTS Of the 21 studies identified from the article search, 10 studies met inclusion criteria. The meta-analysis showed shorter length of stay (LOS) (MD = -2.16, 95% CI (-2.57, -1.75), P < 0.00001) and higher patient satisfaction for the ERAS protocols (OR = 3.13, 95% CI (1.97, 4.98), P < 0.00001). Furthermore, ERAS programs led to significant decreases in cost (MD = -0.81, 95% CI (-1.08, -0.53), P < 0.00001) and complication rates (OR = 0.15, 95% CI (0.08, 0.27), P < 0.00001), but no difference in 90-day readmission (OR = 0.63, 95% CI (0.30, 1.35), P = 0.24). CONCLUSIONS The data of this study suggest that the implementation of ERAS protocol decreases LOS, cost and complications rates and improve satisfaction for the patients undergoing anterior cervical spine surgery. To support the practice use of ERAS in anterior cervical spine surgery further, controlled trials will be indispensable.
Collapse
Affiliation(s)
- Xia Qin
- Department of Orthopedics, Xinqiao Hospital, Army Medical University, 183 Xinqiao Main Street, Shapingba, Chongqing, 400037, People's Republic of China
| | - Huaxi Li
- Department of Orthopedics, Xinqiao Hospital, Army Medical University, 183 Xinqiao Main Street, Shapingba, Chongqing, 400037, People's Republic of China
| | - Jiang Long
- Department of Orthopedics, Xinqiao Hospital, Army Medical University, 183 Xinqiao Main Street, Shapingba, Chongqing, 400037, People's Republic of China
| | - Chencheng Feng
- Department of Orthopedics, Xinqiao Hospital, Army Medical University, 183 Xinqiao Main Street, Shapingba, Chongqing, 400037, People's Republic of China.
| |
Collapse
|
5
|
Magableh HM, Ibrahim S, Pennington Z, Nathani KR, Johnson SE, Katsos K, Freedman BA, Bydon M. Transforming Outcomes of Spine Surgery-Exploring the Power of Enhanced Recovery After Surgery Protocol: A Systematic Review and Meta-Analyses of 15 198 Patients. Neurosurgery 2024:00006123-990000000-01058. [PMID: 38358272 DOI: 10.1227/neu.0000000000002865] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2023] [Accepted: 12/05/2023] [Indexed: 02/16/2024] Open
Abstract
BACKGROUND AND OBJECTIVES Enhanced recovery after surgery (ERAS) protocols aim to optimize patient outcomes by reducing the surgical stress response, expediting recovery, and reducing care costs. We aimed to evaluate the impact of implementing ERAS protocols on the perioperative surgical outcomes and financial implications associated with spine surgeries. METHODS A systematic review and meta-analysis of peer-reviewed studies directly comparing outcome differences between spine surgeries performed with and without utilization of ERAS pathways was conducted along Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. RESULTS Of 676 unique articles identified, 59 with 15 198 aggregate patients (7748 ERAS; 7450 non-ERAS) were included. ERAS-treated patients had shorter operative times (mean difference [MD]: 10.2 mins; P < .01), shorter hospitalizations (MD: 1.41 days, P < .01), fewer perioperative complications (relative risk [RR] = 0.64, P < .01), lower postoperative opioid use (MD of morphine equivalent dose: 164.36 mg; P < .01), and more rapid mobilization/time to first out-of-bed ambulation (MD: 0.92 days; P < .01). Spine surgeries employing ERAS were also associated with lower total costs (MD: $1140.26/patient; P < .01), especially in the United States (MD: $2869.11/patient, P < .01) and lower postoperative visual analog pain scores (MD = 0.56, P < .01), without any change in odds of 30-day readmission (RR: 0.80, P = .13) or reoperation (RR: 0.88, P = .60). Subanalyses based on the region of spine showed significantly lower length of stay in both cervical and lumbar surgeries implementing ERAS. Type of procedure showed a significantly lesser time-to-initiate mobilization in fusion surgeries using ERAS protocols compared with decompression. CONCLUSION The present meta-analysis indicates that current literature supports ERAS implementation as a means of reducing care costs and safely accelerating hospital discharge for patients undergoing spine surgery.
Collapse
Affiliation(s)
- Hamzah M Magableh
- Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota, USA
- Mayo Clinic Neuro-Informatics Laboratory, Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota, USA
- College of Medicine, Alfaisal University, Riyadh, Saudi Arabia
| | - Sufyan Ibrahim
- Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota, USA
- Mayo Clinic Neuro-Informatics Laboratory, Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Zachary Pennington
- Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Karim Rizwan Nathani
- Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota, USA
- Mayo Clinic Neuro-Informatics Laboratory, Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Sarah E Johnson
- Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota, USA
- Mayo Clinic Neuro-Informatics Laboratory, Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Konstantinos Katsos
- Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota, USA
- Mayo Clinic Neuro-Informatics Laboratory, Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Brett A Freedman
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Mohamad Bydon
- Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota, USA
- Mayo Clinic Neuro-Informatics Laboratory, Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota, USA
| |
Collapse
|
6
|
Mazni Y, Syaiful RA, Ibrahim F, Jeo WS, Putranto AS, Sihardo L, Marbun V, Lalisang AN, Putranto R, Natadisastra RM, Sumariyono S, Nugroho AM, Manikam NRM, Karimah N, Hastuty V, Sutisna EN, Widiati E, Mutiara R, Wardhani RK, Liastuti LD, Lalisang TJM. The enhanced recovery after surgery (ERAS) protocol implementation in a national tertiary-level hospital: a prospective cohort study. Ann Med Surg (Lond) 2024; 86:85-91. [PMID: 38222714 PMCID: PMC10783346 DOI: 10.1097/ms9.0000000000001609] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2023] [Accepted: 11/29/2023] [Indexed: 01/16/2024] Open
Abstract
Introduction Successful colorectal surgery is determined based on postoperative mortality and morbidity rates, complication rates, and cost-effectiveness. One of the methods to obtain an excellent postoperative outcome is the enhanced recovery after surgery (ERAS) protocol. This study aims to see the effects of implementing an ERAS protocol in colorectal surgery patients. Methods Eighty-four patients who underwent elective colorectal surgery at National Tertiary-level Hospital were included between January 2021 and July 2022. Patients were then placed into ERAS (42) and control groups (42) according to the criteria. The Patients in the ERAS group underwent a customized 18-component ERAS protocol and were assessed for adherence. Postoperatively, both groups were monitored for up to 30 days and assessed for complications and readmission. The authors then analyzed the length of stay and total patient costs in both groups. Results The length of stay in the ERAS group was shorter than the control group [median (interquartile range) 6 (5-7) vs. 13 (11-19), P<0.001], with a lower total cost of [USD 1875 (1234-3722) vs. USD 3063 (2251-4907), P<0.001]. Patients in the ERAS group had a lower incidence of complications, 10% vs. 21%, and readmission 5% vs. 10%, within 30 days after discharge than patients in the control group; however, the differences were not statistically significant. The adherence to the ERAS protocol within the ERAS group was 97%. Conclusion Implementing the ERAS protocol in colorectal patients reduces the length of stay and total costs.
Collapse
Affiliation(s)
| | | | | | | | | | | | | | | | - Rudi Putranto
- Division of Psychosomatic and Palliative Care, Department of Internal Medicine
| | | | | | | | - Nurul Ratna Mutu Manikam
- Department of Nutrition, Faculty of Medicine, Universitas Indonesia—Dr. Cipto Mangunkusumo Hospital
| | - Nurrul Karimah
- Dr. Cipto Mangunkusumo General Hospital
- Nutrition and Food Production Installation Unit, Cipto Mangunkusumo, National General Hospital
| | - Vyanty Hastuty
- Dr. Cipto Mangunkusumo General Hospital
- Nutrition and Food Production Installation Unit, Cipto Mangunkusumo, National General Hospital
| | | | | | - Rina Mutiara
- Dr. Cipto Mangunkusumo General Hospital
- Nutrition and Food Production Installation Unit, Cipto Mangunkusumo, National General Hospital
| | - Rizky Kusuma Wardhani
- Department of Physical Medicine and Rehabilitation, Cipto Mangunkusumo, National General Hospital, Faculty of Medicine, Universitas Indonesia, Jakarta, Indonesia
| | | | | |
Collapse
|
7
|
Robertson SC. Enhanced Recovery After Surgery (ERAS) Spine Pathways and the Role of Perioperative Checklists. Adv Tech Stand Neurosurg 2024; 49:73-94. [PMID: 38700681 DOI: 10.1007/978-3-031-42398-7_5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/01/2024]
Abstract
Enhanced recovery after surgery (ERAS) proposes a multimodal, evidence-based approach to perioperative care. ERAS pathways have been shown to help reduce complications, hospital length of stay (LOS), 30-day readmission rates, pain scores, and ultimately surgical costs, while improving patient satisfaction scores and outcomes in multiple surgical subspecialties [1-6]. Numerous specialties have implemented ERAS programs across the globe, providing a foundation for spine surgeons to begin the process themselves. Over the last few years, a significant number of papers have been addressing ERAS pathways for spinal surgery [7-19]. The majority have addressed the lumbar spine [9, 20-26]. The number of cervical ERAS pathways has been limited [27-29]. Many spine programs have begun the implementation of ERAS pathways, incorporating principles and interventions to various spine surgical procedures. Although differences in implementation across programs exist, there are a few common elements that promote a successful enhanced recovery approach [11, 16, 23, 25, 30-33]. All spinal ERAS pathways have three major elements, which are preoperative, perioperative, and postoperative phases. Within these phases some common elements include preoperative and intraoperative surgical checklists. Intraoperative checklist in addition to the "surgical time out" has been integrated into the workflow of most hospitals doing surgeries and have become a standard of care. The surgical checklist is designed to help reduce surgical errors and prevent wrong site/patient surgeries. Several surgical checklists have been developed throughout the years. Despite these safety protocols wrong site/level and other surgical errors continue to occur. Many cases of wrong level spine surgery (WLSS) still occur even when intraoperative imaging is performed [34, 35]. One survey reported that about 50% of spine surgeons have performed at least one WLSS during their career [36, 37]. Another survey reported that 36% of spine surgeons had performed at least one WLSS that was not recognized intraoperatively [38]. On a similar account, about 30% of spine surgery fellows have experienced wrong-site surgery [39]. From raw incidence rates, WLSS may seem rare, but these surveys show that the experience of WLSS is rather common among spine surgeons. WLSS is not yet a "never event." This may be due to poor quality of the intraoperative images, hindering subsequent level identification [34, 35, 38, 40]. Errors in interpretation of the imaging may also occur, including inconsistency in numbering vertebrae, inconsistency in landmark usage for level counting, and problems with numbering vertebrae due to lumbosacral transitional vertebrae (LSTV) and other anatomical variants [34, 38, 41-43]. This chapter will describe a framework for the development and implementation of ERAS pathway for patients undergoing spine surgery. In addition, we will propose preoperative imaging guidelines and a comprehensive spine surgical checklist to incorporate into the perioperative phase to help reduce further surgical errors and WLSS.
Collapse
|
8
|
Ludbrook GL, Grocott MPW. Estimating value in surgical and perioperative care: an essential component of quality. ANZ J Surg 2023; 93:2783-2785. [PMID: 38149713 DOI: 10.1111/ans.18763] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2023] [Revised: 10/18/2023] [Accepted: 10/23/2023] [Indexed: 12/28/2023]
Affiliation(s)
- Guy L Ludbrook
- Central Adelaide Local Health Network, Adelaide, South Australia, Australia
- Discipline of Acute Care Medicine, The University of Adelaide, Adelaide, South Australia, Australia
- Centre for Perioperative Health Economics and Policy, University of Adelaide, Adelaide, South Australia, Australia
| | - Michael P W Grocott
- Centre for Perioperative Health Economics and Policy, University of Adelaide, Adelaide, South Australia, Australia
- Perioperative and Critical Care Research Theme, Southampton NIHR Biomedical Research Centre, University Hospital Southampton, University of Southampton, Southampton, UK
| |
Collapse
|
9
|
Kinsey D, Febrey S, Briscoe S, Kneale D, Thompson Coon J, Carrieri D, Lovegrove C, McGrath J, Hemsley A, Melendez-Torres GJ, Shaw L, Nunns M. Impact of interventions to improve recovery of older adults following planned hospital admission on quality-of-life following discharge: linked-evidence synthesis. HEALTH AND SOCIAL CARE DELIVERY RESEARCH 2023; 11:1-164. [PMID: 38140881 DOI: 10.3310/ghty5117] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/24/2023]
Abstract
Objectives To understand the impact of multicomponent interventions to improve recovery of older adults following planned hospital treatment, we conducted two systematic reviews, one of quantitative and one of qualitative evidence, and an overarching synthesis. These aimed to: • understand the effect of multicomponent interventions which aim to enhance recovery and/or reduce length of stay on patient-reported outcomes and health and social care utilisation • understand the experiences of patients, carers and staff involved in the delivery of interventions • understand how different aspects of the content and delivery of interventions may influence patient outcomes. Review methods We searched bibliographic databases including MEDLINE ALL, Embase and the Health Management Information Consortium, CENTRAL, and Cumulative Index to Nursing and Allied Health Literature and Allied and Complementary Medicine Database, conducted forward and backward citation searching and examined reference lists of topically similar qualitative reviews. Bibliographic database searches were completed in May/June 2021 and updated in April 2022. We sought primary research from high-income countries regarding hospital inpatients with a mean/median age of minimum 60 years, undergoing planned surgery. Patients experienced any multicomponent hospital-based intervention to reduce length of stay or improve recovery. Quantitative outcomes included length of stay and any patient-reported outcome or experience or service utilisation measure. Qualitative research focused on the experiences of patients, carers/family and staff of interventions received. Quality appraisal was undertaken using the Effective Public Health Practice Project Quality Assessment Tool or an adapted version of the Wallace checklist. We used random-effects meta-analysis to synthesise quantitative data where appropriate, meta-ethnography for qualitative studies and qualitative comparative analysis for the overarching synthesis. Results Quantitative review: Included 125 papers. Forty-nine studies met criteria for further synthesis. Enhanced recovery protocols resulted in improvements to length of stay, without detriment to other outcomes, with minimal improvement in patient-reported outcome measures for patients admitted for lower-limb or colorectal surgery. Qualitative review: Included 43 papers, 35 of which were prioritised for synthesis. We identified six themes: 'Home as preferred environment for recovery', 'Feeling safe', 'Individualisation of structured programme', 'Taking responsibility', 'Essential care at home' and 'Outcomes'. Overarching synthesis: Intervention components which trigger successful interventions represent individualised approaches that allow patients to understand their treatment, ask questions and build supportive relationships and strategies to help patients monitor their progress and challenge themselves through early mobilisation. Discussion Interventions to reduce hospital length of stay for older adults following planned surgery are effective, without detriment to other patient outcomes. Findings highlight the need to reconsider how to evaluate patient recovery from the perspective of the patient. Trials did not routinely evaluate patient mid- to long-term outcomes. Furthermore, when they did evaluate patient outcomes, reporting is often incomplete or conducted using a narrow range of patient-reported outcome measures or limited through asking the wrong people the wrong questions, with lack of longer-term evaluation. Findings from the qualitative and overarching synthesis will inform policy-making regarding commissioning and delivering services to support patients, carers and families before, during and after planned admission to hospital. Study registration This trial is registered as PROSPERO registration number CRD42021230620. Funding This award was funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme (NIHR award ref: 130576) and is published in full in Health and Social Care Delivery Research; Vol. 11, No. 23. See the NIHR Funding and Awards website for further award information.
Collapse
Affiliation(s)
- Debbie Kinsey
- Faculty of Health and Life Sciences, University of Exeter, Exeter, UK
| | - Samantha Febrey
- Faculty of Health and Life Sciences, University of Exeter, Exeter, UK
| | - Simon Briscoe
- Faculty of Health and Life Sciences, University of Exeter, Exeter, UK
| | - Dylan Kneale
- EPPI-Centre, UCL Social Research Institute, University College London, London, UK
| | - Jo Thompson Coon
- Faculty of Health and Life Sciences, University of Exeter, Exeter, UK
| | - Daniele Carrieri
- Faculty of Health and Life Sciences, University of Exeter, Exeter, UK
| | - Christopher Lovegrove
- School of Health Professions, Faculty of Health and Human Sciences, University of Plymouth, Plymouth, UK
| | - John McGrath
- Royal Devon University Healthcare NHS Foundation Trust, Exeter, UK
| | - Anthony Hemsley
- Department of Healthcare for Older People, Royal Devon and Exeter NHS Foundation Trust, Exeter, UK
| | | | - Liz Shaw
- Faculty of Health and Life Sciences, University of Exeter, Exeter, UK
| | - Michael Nunns
- Faculty of Health and Life Sciences, University of Exeter, Exeter, UK
| |
Collapse
|
10
|
Hong M, Ghajar M, Allen W, Jasti S, Alvarez-Downing MM. Evaluating Implementation Costs of an Enhanced Recovery After Surgery (ERAS) Protocol in Colorectal Surgery: A Systematic Review. World J Surg 2023; 47:1589-1596. [PMID: 37149554 DOI: 10.1007/s00268-023-07024-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/26/2023] [Indexed: 05/08/2023]
Abstract
BACKGROUND Enhanced recovery after surgery (ERAS) protocols have been well documented in the current literature to improve healthcare outcomes by decreasing length of stay, resource utilization, and morbidity without increasing readmission rates or complications. This subsequently leads to a net decrease in hospital costs. However, the initial costs of implementing such a program have not been well described, which is crucial information for hospitals with less resources. The aim of this study was to provide a cohesive review of the current literature for the costs of implementing a colorectal surgery ERAS protocol. METHODS A comprehensive review was conducted on five databases (Google Scholar, Web of Science, PROSPERO, PubMed, and Cochrane) with the assistance of a professional librarian. All relevant English articles published between 1995 and June 2021 were screened for eligibility prior to inclusion in the review. Cost data were converted to US dollars based on the exchange rate at the end time of the study period for standardization. RESULTS Seven studies were included for review. The studies evaluated a range of 50-1295 patients through their respective ERAS programs, which were followed for 5 to 22 months. ERAS implementation costs ranged from $57 to $1536 per patient. Components for each ERAS program varied for each study, but ultimately, the greatest costs were attributed to personnel. CONCLUSIONS Despite data heterogeneity and inconsistencies between cost breakdowns, a majority of the implementation cost was found to be secondary to personnel. This review demonstrates the need for a more standardized approach for reporting ERAS implementation costs through an open database as well as a potential streamlining of the ERAS protocol to facilitate implementation in institutions with less financial resources.
Collapse
Affiliation(s)
- Minki Hong
- Rutgers New Jersey Medical School, Newark, NJ, USA
| | - Mina Ghajar
- Rutgers University, George F. Smith Library of the Health Sciences, Newark, NJ, USA
| | | | | | - Melissa M Alvarez-Downing
- Department of Surgery, Division of Colorectal Surgery, Rutgers New Jersey Medical School, 185 South Orange Avenue, Medical Science Building, G-514, Newark, NJ, 07103, USA.
| |
Collapse
|
11
|
Cost Drivers of Elective Colon and Rectal Surgery: A Retrospective Cohort Analysis. Dis Colon Rectum 2023; 66:609-616. [PMID: 35213878 DOI: 10.1097/dcr.0000000000002267] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND Colorectal surgery is expensive. Few studies have evaluated complications as an economic cost driver, and there is little evidence comparing multiple cost drivers of colorectal surgery to determine the most effective means of reducing total cost. OBJECTIVE This study aimed to determine the effects of surgical techniques, use of enhanced recovery protocols, and presence or absence of complications on the total cost of hospitalization for elective colorectal surgery. DESIGN A retrospective cohort analysis using data from 2011 to 2018 was performed. The primary end point was a mean cost per hospitalization. The cost was compared between patients who experienced minimally invasive versus open surgeries, enhanced recovery after surgery protocols versus not, and complications versus none. SETTINGS This study was conducted at a university-affiliated teaching hospital in the Northeastern United States. PATIENTS Adult patients who have undergone elective colorectal surgery were included. MAIN OUTCOME MEASURES The primary outcome for this study was the mean cost per hospitalization calculated using inpatient cost based on the total cost of the episode of care. RESULTS A total of 1039 patients met the criteria for inclusion. The average cost of all hospitalizations was $19,801. Multivariate analysis demonstrated that enhanced recovery protocols substantially lowered the cost of care by $6392 ( p = 0.001), whereas complications increased the cost of care by $16,780 per episode ( p < 0.001). When complications occurred, enhanced recovery protocols reduced the cost by $17,963 ( p = 0.010). LIMITATIONS This retrospective cohort study performed at a single institution has inherent limitations, including confounding and selection bias. CONCLUSIONS For elective colorectal surgery, complications are associated with significantly increased costs. Avoiding complications should be a priority to reduce costs. Enhanced recovery protocols are associated with significantly reduced costs. Surgeons should focus future research efforts on improving protocols and processes that decrease postoperative complications to improve patient outcomes and to reduce costs associated with elective colorectal hospitalizations. See Video Abstract at http://links.lww.com/DCR/B927 . FACTORES DE COSTO DE LA CIRUGA ELECTIVA DE COLON Y RECTO UN ANLISIS DE COHORTE RETROSPECTIVE ANTECEDENTES:La cirugía colorrectal es costosa. Pocos estudios han examinado las complicaciones como un factor de costo económico, y hay poca evidencia que compare múltiples factores de costo de la cirugía colorrectal para determinar los medios más efectivos para reducir el costo total.OBJETIVO:Este estudio tiene como objetivo determinar los efectos de las técnicas quirúrgicas, el uso de protocolos de enhanced recovery y la presencia o ausencia de complicaciones en el costo total de hospitalización por cirugía colorrectal electiva.DISEÑO:Se realizó un análisis retrospectivo de cohortes utilizando data del 2011-2018. El punto principal fue el costo medio por hospitalización. Se comparó el costo entre los pacientes que experimentaron: cirugías mínimamente invasivas versus abiertas, protocolos de enhanced recovery después de la cirugía versus no, y complicaciones versus no.FUENTE DE DATOS:Se consultó la base de datos financiera y contable del hospital y el registro médico electrónico para la obtencion de datos.ENTORNO CLINICO:Este estudio se realizó en un hospital docente afiliado a una universidad en el noreste de los Estados Unidos.PACIENTES:Se incluyeron pacientes adultos sometidos a cirugía colorrectal electiva.PRINCIPALES MEDIDAS DE RESULTADO:El resultado principal de este estudio fue el costo medio por hospitalización calculado utilizando el costo de hospitalización basado en el costo total del episodio de atención.RESULTADOS:Un total de 1.039 pacientes cumplieron los criterios de inclusión. El costo promedio de todas las hospitalizaciones fue de $19801. El análisis multivariante demostró que los protocolos de enhanced recovery redujeron sustancialmente el costo de la atención en $6392 ( p = 0,001), mientras que las complicaciones aumentaron el costo en $16780 por episodio ( p < 0,001). Cuando ocurrieron complicaciones, los protocolos de enhanced recovery redujeron el costo en $17963 ( p = 0,010).LIMITACIONES:Este es un estudio de cohorte retrospectivo realizado en una sola institución y tiene limitaciones inherentes que incluyen confusión y sesgo de selección.CONCLUSIONES:Video Resumen en http://links.lww.com/DCR/B927 . (Traducción- Dr. Francisco M. Abarca-Rendon ).
Collapse
|
12
|
Monk SH, Rossi VJ, Atkins TG, Karimian B, Pfortmiller D, Kim PK, Adamson TE, Smith MD, McGirt MJ, Holland CM, Deshmukh VR, Branch BC. Minimally Invasive Transforaminal Lumbar Interbody Fusion in the Ambulatory Setting with an Enhanced Recovery After Surgery Protocol. World Neurosurg 2023; 171:e471-e477. [PMID: 36526224 DOI: 10.1016/j.wneu.2022.12.047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2022] [Accepted: 12/09/2022] [Indexed: 12/15/2022]
Abstract
OBJECTIVE Enhanced Recovery After Surgery (ERAS) is a multidisciplinary approach to surgical care that aims to improve outcomes and reduce costs. Its application to spine surgery has been increasing in recent years, with a notable focus on lumbar fusion. This study describes the development, implementation, and outcomes of the first ERAS pathway for ambulatory spine surgery and the largest ambulatory minimally invasive transforaminal lumbar interbody fusion (MIS TLIF) series to date. METHODS A comprehensive protocol for ambulatory lumbar fusion is described, including patient selection criteria, a multimodal analgesia regimen, and discharge assessment. Consecutive patients undergoing 1- or 2-level MIS TLIF using the described protocol at a single ambulatory surgery center (ASC) over a five-year period were queried. RESULTS A total of 215 patients underwent ambulatory MIS TLIF over the study period. There were no intraoperative or immediate postoperative complications. All but one patient (99.5%) were discharged home from the ASC. Almost three-quarters (71.2%) were discharged on the day of surgery. Thirty- and 90-day readmission rates were 1.4% and 2.8%, respectively. Only one readmission (0.5%) was for intractable back pain. There were no reoperations or mortalities within 90 days of surgery. CONCLUSIONS MIS TLIF can be performed safely in a freestanding ambulatory surgery center with minimal perioperative and short-term morbidity. The addition of comprehensive ERAS protocols to the ambulatory setting can promote the transition of fusion procedures to this lower cost environment in an effort to provide higher value care.
Collapse
Affiliation(s)
- Steve H Monk
- Carolina Neurosurgery & Spine Associates, Charlotte, North Carolina, USA; SpineFirst, Atrium Health, Charlotte, North Carolina, USA.
| | - Vincent J Rossi
- Carolina Neurosurgery & Spine Associates, Charlotte, North Carolina, USA; SpineFirst, Atrium Health, Charlotte, North Carolina, USA
| | - Tyler G Atkins
- Carolina Neurosurgery & Spine Associates, Charlotte, North Carolina, USA; SpineFirst, Atrium Health, Charlotte, North Carolina, USA
| | - Brandon Karimian
- Carolina Neurosurgery & Spine Associates, Charlotte, North Carolina, USA
| | - Deborah Pfortmiller
- Carolina Neurosurgery & Spine Associates, Charlotte, North Carolina, USA; SpineFirst, Atrium Health, Charlotte, North Carolina, USA
| | - Paul K Kim
- Carolina Neurosurgery & Spine Associates, Charlotte, North Carolina, USA; SpineFirst, Atrium Health, Charlotte, North Carolina, USA
| | - Tim E Adamson
- Carolina Neurosurgery & Spine Associates, Charlotte, North Carolina, USA; SpineFirst, Atrium Health, Charlotte, North Carolina, USA
| | - Mark D Smith
- Carolina Neurosurgery & Spine Associates, Charlotte, North Carolina, USA; SpineFirst, Atrium Health, Charlotte, North Carolina, USA
| | - Matthew J McGirt
- Carolina Neurosurgery & Spine Associates, Charlotte, North Carolina, USA; SpineFirst, Atrium Health, Charlotte, North Carolina, USA
| | - Christopher M Holland
- Carolina Neurosurgery & Spine Associates, Charlotte, North Carolina, USA; SpineFirst, Atrium Health, Charlotte, North Carolina, USA
| | - Vinay R Deshmukh
- Carolina Neurosurgery & Spine Associates, Charlotte, North Carolina, USA; SpineFirst, Atrium Health, Charlotte, North Carolina, USA
| | - Byron C Branch
- Carolina Neurosurgery & Spine Associates, Charlotte, North Carolina, USA; SpineFirst, Atrium Health, Charlotte, North Carolina, USA
| |
Collapse
|
13
|
Enhanced Recovery Protocols Reduce Mortality Across Eight Surgical Specialties at Academic and University-affiliated Community Hospitals. Ann Surg 2023; 277:101-108. [PMID: 33214486 DOI: 10.1097/sla.0000000000004642] [Citation(s) in RCA: 16] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To determine if implementation of a simplified ERP across multiple surgical specialties in different hospitals is associated with improved short and long-term mortality. Secondary aims were to examine ERP effect on length of stay, 30-day readmission, discharge disposition, and complications. SUMMARY BACKGROUND DATA Enhanced recovery after surgery and various derivative ERPs have been successfully implemented. These protocols typically include elaborate sets of multimodal and multidisciplinary approaches, which can make implementation challenging or are variable across different specialties. Few studies have shown if a simplified version of ERP implemented across multiple surgical specialties can improve clinical outcomes. METHODS A simplified ERP with 7 key domains (minimally invasive surgical approach when feasible, pre-/intra-operative multimodal analgesia, postoperative multimodal analgesia, postoperative nausea and vomiting prophylaxis, early diet advancement, early ambulation, and early removal of urinary catheter) was implemented in 5 academic and community hospitals within a single health system. Patients who underwent nonemergent, major orthopedic or abdominal surgery including hip/knee replacement, hepatobiliary, colorectal, gynecology oncology, bariatric, general, and urological surgery were included. Propensity-matched, retrospective case-control analysis was performed on all eligible surgical patients between 2014 and 2017 after ERP implementation or in the 12 months preceding ERP implementation (control population). RESULTS A total of 9492 patients (5185 ERP and 4307 controls) underwent ERP eligible surgery during the study period. Three thousand three hundred sixty-seven ERP patients were matched by surgical specialty and hospital site to control non-ERP patients. Short and long-term mortality was improved in ERP patients: 30 day: ERP 0.2% versus control 0.6% ( P = 0.002); 1-year: ERP 3.9% versus control 5.1% ( P < 0.0001); 2-year: ERP 6.2% versus control 9.0% ( P < 0.0001). Length of stay was significantly lower in ERP patients (ERP: 3.9 ± 3.8 days; control: 4.8 ± 5.0 days, P < 0.0001). ERP patients were also less likely to be discharged to a facility (ERP: 11.3%; control: 14.8%, P < 0.0001). There was no significant difference for 30-day readmission. All complications except venous thromboembolism were significantly reduced in the ERP population (P < 0.02). CONCLUSIONS A simplified ERP can uniformly be implemented across multiple surgical specialties and hospital types. ERPs improve short and long-term mortality, clinical outcomes, length of stay, and discharge disposition to home.
Collapse
|
14
|
Archer V, Cloutier Z, Berg A, McKechnie T, Wiercioch W, Eskicioglu C. Short-stay compared to long-stay admissions for loop ileostomy reversals: a systematic review and meta-analysis. Int J Colorectal Dis 2022; 37:2113-2124. [PMID: 36151483 DOI: 10.1007/s00384-022-04256-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/18/2022] [Indexed: 02/04/2023]
Abstract
PURPOSE Short-stay admissions, with lengths of stay less than 24 h, are used for various surgeries without increasing adverse events. However, it is unclear if short-stay admissions would be safe for loop ileostomy reversals. This review aimed to compare outcomes between short (≤24 hours) and long (>24 hours) admissions for adults undergoing loop ileostomy reversals. METHODS Medline, Embase, CINAHL, Web of Science, and the Cochrane Library were systematically searched for studies comparing short- to long-stay admissions in adults undergoing loop ileostomy reversals. Meta-analyses were conducted for mortality, reoperation, readmission, and non-reoperative complications. Quality of evidence was assessed with grading of recommendations, assessment, development, and evaluations (GRADE) guidelines. RESULTS Four observational studies enrolling 24,628 patients were included. Moderate certainty evidence suggests there is no difference in readmissions between short- and long-stay admissions (relative risk (RR) 0.98, 95% CI 0.75 to 1.28, p 0.86). Low certainty evidence demonstrates that short stays may reduce non-reoperative complications (RR 0.44, 95% CI 0.31 to 0.62, p < 0.01). Very low certainty evidence demonstrates that there is no difference in reoperations between short and long stays (RR 1.14, 95% CI 0.26 to 5.04, p 0.87). CONCLUSIONS Moderate certainty evidence demonstrates that there is no difference in readmission rates between short- and long-stay admissions for loop ileostomy reversals. Less robust evidence suggests equivalence in reoperations and a decrease in non-reoperative complications. Future prospective trials are required to evaluate the feasibility and efficacy of short-stay admissions. TRIAL REGISTRATION https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=307381 Prospero (CRD42022307381), January 30, 2022.
Collapse
Affiliation(s)
- Victoria Archer
- Department of Surgery, Division of General Surgery, McMaster University, Hamilton, ON, Canada. .,Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada.
| | - Zacharie Cloutier
- Department of Surgery, Division of General Surgery, McMaster University, Hamilton, ON, Canada
| | - Annie Berg
- Michael G. DeGroote School of Medicine, McMaster University, Hamilton, ON, Canada
| | - Tyler McKechnie
- Department of Surgery, Division of General Surgery, McMaster University, Hamilton, ON, Canada
| | - Wojtek Wiercioch
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada
| | - Cagla Eskicioglu
- Department of Surgery, Division of General Surgery, McMaster University, Hamilton, ON, Canada
| |
Collapse
|
15
|
Analysis of Outcomes for Robotic-Assisted Lobectomy with an Enhanced Recovery after Surgery Protocol. Ann Thorac Surg 2022; 115:1353-1359. [PMID: 36075397 DOI: 10.1016/j.athoracsur.2022.08.039] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2022] [Revised: 06/17/2022] [Accepted: 08/22/2022] [Indexed: 11/23/2022]
Abstract
BACKGROUND The impact on cost relative to clinical efficacy of Enhanced Recovery after Surgery (ERAS) protocols for patients who undergo robotic-assisted lobectomy is currently unknown. The objective of this study was to compare cost and perioperative outcomes of robotic-assisted lobectomy before and after implementation of an ERAS protocol. METHODS This is a retrospective analysis of 574 patients who underwent robotic-assisted lobectomy for primary lung carcinoma from May 1, 2017 - June 1, 2021. The ERAS protocol was implemented on October 17, 2019. Inverse probability of treatment weighting (IPTW) of propensity scores was used to balance baseline characteristics. The primary outcomes of the study were mean direct and indirect hospital costs, complication rates, and hospital length of stay. RESULTS A total of 315 patients underwent robotic-assisted lobectomy prior to implementation of the ERAS protocol and 259 patients were enrolled on the protocol. A significantly higher percentage of patients were discharged home in less than 3 days following the ERAS protocol implementation [24.5% vs 9.8% (p =0.001)]. There was a significant decrease in the IPTW adjusted mean direct hospital costs (p< 0.001) and mean indirect costs (p= 0.018) for the total hospital stay after ERAS protocol implementation. The mean initial discharge opioid medication dose (Morphine Equivalent Dose) was significantly lower (p< 0.001) following the ERAS protocol. CONCLUSIONS Increased early discharge and decreased hospital costs were observed for robotic-assisted lobectomy after implementation of an ERAS protocol. There was also an observed significant decrease in the discharge opioid medication doses prescribed.
Collapse
|
16
|
Delivery of drinking, eating and mobilising (DrEaMing) and its association with length of hospital stay after major noncardiac surgery: observational cohort study. Br J Anaesth 2022; 129:114-126. [PMID: 35568508 PMCID: PMC9284668 DOI: 10.1016/j.bja.2022.03.021] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2021] [Revised: 03/24/2022] [Accepted: 03/24/2022] [Indexed: 12/11/2022] Open
Abstract
Background Enhanced recovery pathways are associated with improved postoperative outcomes. However, as enhanced recovery pathways have become more complex and varied, compliance has reduced. The ‘DrEaMing’ bundle re-prioritises early postoperative delivery of drinking, eating, and mobilising. We investigated relationships between DrEaMing compliance, postoperative hospital length of stay (LOS), and complications in a prospective multicentre major surgical cohort. Methods We interrogated the UK Perioperative Quality Improvement Programme dataset. Analyses were conducted in four stages. In an exploratory cohort, we identified independent predictors of DrEaMing. We quantified the association between delivery of DrEaMing (and its component variables) and prolonged LOS in a homogenous colorectal subgroup and assessed generalisability in multispecialty patients. Finally, LOS and complications were compared across hospitals, stratified by DrEaMing compliance. Results The exploratory cohort comprised 22 218 records, the colorectal subgroup 7230, and the multispecialty subgroup 5713. DrEaMing compliance was 59% (13 112 patients), 60% (4341 patients), and 60% (3421), respectively, but varied substantially between hospitals. Delivery of DrEaMing predicted reduced odds of prolonged LOS in colorectal (odds ratio 0.51 [0.43–0.59], P<0.001) and multispecialty cohorts (odds ratio 0.47 [0.41–0.53], P<0.001). At the hospital level, complications were not the primary determinant of LOS after colorectal surgery, but consistent delivery of DrEaMing was associated with significantly shorter LOS. Conclusions Delivery of bundled and unbundled DrEaMing was associated with substantial reductions in postoperative LOS, independent of the effects of confounder variables. Consistency of process delivery, and not complications, predicted shorter hospital-level length of stay. DrEaMing may be adopted by perioperative health systems as a quality metric to support improved patient outcomes and reduced hospital length of stay.
Collapse
|
17
|
Enhanced Recovery After Surgery Protocol for Oblique Lumbar Interbody Fusion. Indian J Orthop 2022; 56:1073-1082. [PMID: 35669015 PMCID: PMC9123140 DOI: 10.1007/s43465-022-00641-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2021] [Accepted: 04/04/2022] [Indexed: 02/04/2023]
Abstract
BACKGROUND Enhanced recovery after surgery (ERAS) attempts to decrease the surgical stress response to minimize postoperative complications and improve functional rehabilitation after major surgery, but it has not been widely utilized in spinal surgery. The study reported the development and implementation of an ERAS pathway for patients with lumbar spondylolisthesis undergoing oblique lumbar interbody fusion (OLIF). METHODS Seventy-six patients underwent OLIF surgery from January 2018 to December 2019 were enrolled. Thirty-seven patients were included in pre-ERAS group and 39 patients were included in ERAS group. Major outcomes that were collected included demographics, comorbidities, blood loss, operative time, length of hospital stay (LOS), cost, time to walk, blood transfusion, complications, Visual analogue scale (VAS) scores, Oswestry Disability Index (ODI) and factors affecting LOS were also recorded. The ERAS pathway and compliance with pathway elements were also recorded. RESULTS After ERAS implementation, the blood loss, LOS, the financial costs, and the time to walk were significantly lower in the ERAS group compared to the pre-ERAS group (all P < 0.05). There was no significant difference in operative time, complications, and blood transfusion between both groups. VAS and ODI between the two groups showed a significant difference during postoperative 3 days and postoperative 1 month (both P < 0.05). The preoperative time to walk was significant factors for hospital stay at the final follow-up. CONCLUSION Institution of an ERAS protocol for OLIF surgery appears to accelerate functional recovery, reduce length of stay and financial costs.
Collapse
|
18
|
Suvi R, Tuukka T, Matti P, Vilma B, Tom S, Alexey S. ERAS failure and major complications in elective colon surgery: common risk factors. SURGERY IN PRACTICE AND SCIENCE 2022. [DOI: 10.1016/j.sipas.2022.100080] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
|
19
|
Bamdad MC, Brown CS, Kamdar N, Weng W, Englesbe MJ, Lussiez A. Patient, Surgeon, or Hospital: Explaining Variation in Outcomes after Colectomy. J Am Coll Surg 2022; 234:300-309. [PMID: 35213493 PMCID: PMC10369366 DOI: 10.1097/xcs.0000000000000063] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Complication rates after colectomy remain high. Previous work has failed to establish the relative contribution of patient comorbidities, surgeon performance, and hospital systems in the development of complications after elective colectomy. STUDY DESIGN We identified all patients undergoing elective colectomy between 2012 and 2018 at hospitals participating in the Michigan Surgical Quality Collaborative. The primary outcome was development of a postoperative complication. We used risk- and reliability-adjusted generalized linear mixed models to estimate the degree to which variance in patient-, surgeon-, and hospital-level factors contribute to complications. RESULTS A total of 15,755 patients were included in the study. The mean hospital-level complication rate was 15.8% (range, 8.7% to 30.2%). The proportion of variance attributable to the patient level was 35.0%, 2.4% was attributable to the surgeon level, and 1.8% was attributable to the hospital level. The predicted probability of complication for the least comorbid patient was 1.5% (CI 0.7-3.1%) at the highest performing hospital with the highest performing surgeon, and 6.6% (CI 3.2-12.2%) at the lowest performing hospital with the lowest performing surgeon. By contrast, the most comorbid patient in the cohort had a 66.3% (CI 39.5-85.6%) or 89.4% (CI 73.7-96.2%) risk of complication. CONCLUSIONS This study demonstrated that variance from measured factors at the patient level contributed more than 8-fold more to the development of complications after colectomy compared with variance at the surgeon and hospital level, highlighting the impact of patient comorbidities on postoperative outcomes. These results underscore the importance of initiatives that optimize patient foundational health to improve surgical care.
Collapse
Affiliation(s)
- Michaela C Bamdad
- From the Department of Surgery, University of Michigan, Ann Arbor, MI
| | | | | | | | | | | |
Collapse
|
20
|
Karunakaran M, Jonnada PK, Chandrashekhar SH, Vinayachandran G, Kaambwa B, Barreto SG. Enhancing the cost-effectiveness of surgical care in pancreatic cancer: a systematic review and cost meta-analysis with trial sequential analysis. HPB (Oxford) 2022; 24:309-321. [PMID: 34848126 DOI: 10.1016/j.hpb.2021.11.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2021] [Revised: 10/21/2021] [Accepted: 11/07/2021] [Indexed: 12/12/2022]
Abstract
BACKGROUND Clinical pathways (CP) based on Enhanced recovery after surgery (ERAS®) are increasingly utilised in patients undergoing pancreatoduodenectomy (PD). This systematic review aimed to compare the impact of CPs versus conventional care (CC) on peri-PD costs. METHODS A systematic review of major reference databases was undertaken. Quality assessment was performed using the CHEERS checklist. Incremental cost-effectiveness ratios were calculated as part of the cost-effectiveness analysis. A meta-analysis was performed using random-effects models and Trial sequential analysis (TSA) was used to assess the precision and conclusiveness of the results. RESULTS 14 studies meeting inclusion criteria were included for full qualitative synthesis. All studies reported a reduction in overall costs, length of stay and overall complication rates for CPs when compared to CC. Meta-analysis performed on nine studies demonstrated significantly reduced costs in the CP group, with considerable heterogeneity (Pooled mean difference of $ 4.28 × 103, p < 0.01, I2 = 95%). Cost-effectiveness analysis in relation to complications demonstrated dominance of CPs over CC in being cheaper as well as more effective. TSA supported the cost benefit of enhanced-recovery CPs, displaying minimal type 1 error. CONCLUSION Peri-PD CPs result in significant cost-reduction in comparison to CC.
Collapse
Affiliation(s)
- Monish Karunakaran
- Department of Surgical Gastroenterology, SK Hospital, Thiruvananthapuram, India
| | - Pavan K Jonnada
- Department of Surgical Oncology, Basavatarakam Indo-American Cancer Hospital & Research Institute, Hyderabad, India
| | - Sagar H Chandrashekhar
- Department of Gastrointestinal Surgery, Gastrointestinal Oncology, and Bariatric Surgery, Medanta- The Medicity, Gurgaon, India
| | | | - Billingsley Kaambwa
- College of Medicine and Public Health, Flinders University, South Australia, Australia
| | - Savio G Barreto
- College of Medicine and Public Health, Flinders University, South Australia, Australia; Division of Surgery and Perioperative Medicine, Flinders Medical Center, Bedford Park, Adelaide, South Australia, Australia.
| |
Collapse
|
21
|
Lee A, Seyednejad N, Lawati YA, Mattice A, Anstee C, Legacy M, Gilbert S, Maziak DE, Sundaresan RS, Villeneuve PJ, Thompson C, Seely AJE. Evolution of Process and Outcome Measures during an Enhanced Recovery after Thoracic Surgery Program. J Chest Surg 2022; 55:118-125. [PMID: 35135904 PMCID: PMC9005934 DOI: 10.5090/jcs.21.139] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2021] [Revised: 12/07/2021] [Accepted: 12/14/2021] [Indexed: 11/21/2022] Open
Abstract
Background A time course analysis was undertaken to evaluate how perioperative process-of-care and outcome measures evolved after implementation of an enhanced recovery after thoracic surgery (ERATS) program. Methods Outcome and process-of-care measures were compared between patients undergoing major elective thoracic surgery during a 9-month pre-ERATS implementation period to those at 1–3, 4–6, and 7–9 months post-ERATS implementation. Outcome measures included length of stay, the 30-day readmission rate, 30-day emergency department visits, and minor and major adverse events. Process measures included first time to activity, out-of-bed, ambulation, fluid diet, diet as tolerated, as well as removal of the first and last chest tube, epidural, patient-controlled analgesia, and Foley and intravenous catheters. Results In total, 704 patients (352 pre-ERATS, 352 post-ERATS) were included. Mobilization-related process measures, including time to first activity (16.5 vs. 6.8 hours, p<0.001), out-of-bed (17.6 vs. 8.9 hours, p<0.001), and ambulation (32.4 vs. 25.4 hours, p=0.04) saw statistically significant improvements by 1–3 months post-ERATS implementation compared to pre-ERATS. Time to Foley removal improved by 4–6 months post-ERATS (19.5 vs. 18.2 hours, p=0.003). Outcome measures, including the 30-day readmission rate and emergency department visits, steadily decreased post-ERATS. By 7–9 months post-ERATS, both minor (18.2% vs. 7.9%, p=0.009) and major (13.6% vs. 4.4%, p=0.007) adverse events demonstrated statistically significant improvements. Length of stay trended towards improvement from 6.2 days pre-ERATS to 4.8 days by 7–9 months post-ERATS (p=0.06). Conclusion The adoption of ERATS led to improvements in multiple process-of-care measures, which may collectively and gradually achieve optimization of clinical outcomes.
Collapse
Affiliation(s)
- Alex Lee
- Ottawa Hospital Research Institute, The Ottawa Hospital, Ottawa, ON, Canada
| | - Nazgol Seyednejad
- Division of Thoracic Surgery, Department of Surgery, University of Ottawa, Ottawa, ON, Canada
| | - Yaseen Al Lawati
- Division of Thoracic Surgery, Department of Surgery, University of Ottawa, Ottawa, ON, Canada
| | - Amanda Mattice
- Ottawa Hospital Research Institute, The Ottawa Hospital, Ottawa, ON, Canada
| | - Caitlin Anstee
- Ottawa Hospital Research Institute, The Ottawa Hospital, Ottawa, ON, Canada.,Division of Thoracic Surgery, Department of Surgery, University of Ottawa, Ottawa, ON, Canada
| | - Mark Legacy
- Ottawa Hospital Research Institute, The Ottawa Hospital, Ottawa, ON, Canada
| | - Sebastien Gilbert
- Division of Thoracic Surgery, Department of Surgery, University of Ottawa, Ottawa, ON, Canada
| | - Donna E Maziak
- Division of Thoracic Surgery, Department of Surgery, University of Ottawa, Ottawa, ON, Canada
| | - Ramanadhan S Sundaresan
- Division of Thoracic Surgery, Department of Surgery, University of Ottawa, Ottawa, ON, Canada
| | - Patrick J Villeneuve
- Division of Thoracic Surgery, Department of Surgery, University of Ottawa, Ottawa, ON, Canada
| | - Calvin Thompson
- Department of Anesthesiology and Pain Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Andrew J E Seely
- Ottawa Hospital Research Institute, The Ottawa Hospital, Ottawa, ON, Canada.,Division of Thoracic Surgery, Department of Surgery, University of Ottawa, Ottawa, ON, Canada
| |
Collapse
|
22
|
Ludbrook GL, Leaman E. Cost-Effectiveness in Perioperative Care: Application of Markov Modeling to Pathways of Perioperative Care. VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2022; 25:215-221. [PMID: 35094794 DOI: 10.1016/j.jval.2021.07.018] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/01/2021] [Revised: 06/23/2021] [Accepted: 07/30/2021] [Indexed: 06/14/2023]
Abstract
OBJECTIVES This study aimed to evaluate the application of cost-effectiveness modeling to redesign of perioperative care pathways, from a hospital perspective. METHODS A Markov cost-effectiveness model of patient transition between care locations, each with different characteristics and cost, was developed. Inputs were derived from clinical trials piloting a preoperative call center and a postoperative medium-acuity care unit. The effect chosen was days at home (DAH) after surgery, reflecting quality of in-hospital care, acknowledged financially by fundholders, and relevant to consumers. Cost was from the hospital's perspective. A model cycle time of 4 hours for 30 days reflected relevant timelines and costs. RESULTS A Markov model was successfully created, accounting for the care locations in the 2 pathways as model states and accounting for consequences and costs. Cost-effectiveness analysis allowed the calculation of an incremental cost-effectiveness ratio comparing these pathways, providing a mean incremental cost-effectiveness ratio of -$427 per additional DAH, where incremental costs and DAH were -$644 and +1.51, respectively. Probabilistic sensitivity analysis suggested the new pathway had a 61% probability of reduced costs and a 74% probability of increased DAH and a 58% probability this pathway was dominant. Tornado analysis revealed the major contributor to increased costs as intensive care unit stay and the major contributor to decreased costs as ward stay. For the new pathway, the probability of transfer from ward to home and the probability of staying at home had the greatest impact on DAH. CONCLUSIONS These data suggest Markov modeling may be a useful tool for the cost-effectiveness analysis of initiatives in perioperative care.
Collapse
Affiliation(s)
- Guy L Ludbrook
- Department of Anaesthesia, Royal Adelaide Hospital and Discipline of Acute Care Medicine, University of Adelaide, Adelaide, South Australia, Australia.
| | - Esrom Leaman
- Department of Anaesthesia, Royal Adelaide Hospital and Discipline of Acute Care Medicine, University of Adelaide, Adelaide, South Australia, Australia
| |
Collapse
|
23
|
Mejia OAV, Mioto BM, Borgomoni GB, Camilo JM, Watanabe DM, Nunes SP, Sallai VS, Lima MPLD, Palomo JDSH, Costa HMD, Arita ET, Feltrim MIZ, Coimbra V, Dias RD, Galas FRBG, Auler JOC, Jatene FB. Preparando Pacientes e Otimizando Processos no Perioperatório das Cirurgias Cardíacas: Como Redesenhar os Fluxos de Assistência após a COVID-19. Arq Bras Cardiol 2022; 118:110-114. [PMID: 35195218 PMCID: PMC8959051 DOI: 10.36660/abc.20210484] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2021] [Accepted: 07/28/2021] [Indexed: 11/29/2022] Open
|
24
|
Dong Y, Zhang Y, Jin C. Comprehensive economic evaluation of enhanced recovery after surgery in hepatectomy. Int J Equity Health 2021; 20:245. [PMID: 34774038 PMCID: PMC8590288 DOI: 10.1186/s12939-021-01583-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2021] [Accepted: 10/30/2021] [Indexed: 01/16/2023] Open
Abstract
BACKGROUND Enhanced recovery after surgery (ERAS) is attracting extensive attention and being widely applied to reduce postoperative stress and accelerate recovery. However, the economic benefits of ERAS are less clarified at the social level. We aimed to assess the economic impact of ERAS in hepatectomy from the perspectives of patients, hospitals and society, as well as identify the approach to create the economic benefits of ERAS. METHODS By combining the literature and national statistical data, the cost-effectiveness framework was clarified, and parameter values were determined. Cost-effectiveness analysis, cost-benefit analysis and cost-minimisation analysis were used to compare ERAS and conventional treatment from the perspectives of patients, hospitals and society. The capital flow diagram was used to analyse the change between them. RESULTS ERAS significantly reduced the economic burden of disease on patients ($8935.02 vs $10,470.02). The hospital received an incremental benefit in ERAS (the incremental benefit cost ratio value is 1.09), and the total social cost was reduced ($5958.67 vs $6725.80). Capital flow diagram analysis demonstrated that the average daily cost per capita in the ERAS group increased ($669.51 vs $589.98), whereas the benefits depended on the reduction of hospital stay and productivity loss. CONCLUSION The mechanism by which ERAS works is to reduce the average length of stay, thereby reducing the economic burden and productivity loss on patients and promoting the hospital bed turnover rate. Therefore, ERAS should further focus on accelerating the rehabilitation process, and more economic support (such as subsidies) should be given to hospitals to carry out ERAS.
Collapse
Affiliation(s)
- Yihan Dong
- School of Medicine and Health Management, Tongji Medical College, Huazhong University of Science and Technology, No.13 Hangkong Road, Qiaokou District, Wuhan, 430030, Hubei, China.,Research Centre for Rural Health Service, Key Research Institute of Humanities & Social Sciences of Hubei Provincial Department of Education, Wuhan, 430030, China
| | - Yan Zhang
- School of Medicine and Health Management, Tongji Medical College, Huazhong University of Science and Technology, No.13 Hangkong Road, Qiaokou District, Wuhan, 430030, Hubei, China. .,Research Centre for Rural Health Service, Key Research Institute of Humanities & Social Sciences of Hubei Provincial Department of Education, Wuhan, 430030, China.
| | - Chengcheng Jin
- School of Medicine and Health Management, Tongji Medical College, Huazhong University of Science and Technology, No.13 Hangkong Road, Qiaokou District, Wuhan, 430030, Hubei, China.,Department of Surgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, China
| |
Collapse
|
25
|
Ludbrook GL. The Hidden Pandemic: the Cost of Postoperative Complications. CURRENT ANESTHESIOLOGY REPORTS 2021; 12:1-9. [PMID: 34744518 PMCID: PMC8558000 DOI: 10.1007/s40140-021-00493-y] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/14/2021] [Indexed: 12/17/2022]
Abstract
Purpose of Review Population-based increases in ageing and medical co-morbidities are expected to substantially increase the incidence of expensive postoperative complications. This threatens the sustainability of essential surgical care, with negative impacts on patients' health and wellbeing. Recent Findings Identification of key high-risk areas, and implementation of proven cost-effective strategies to manage both outcome and cost across the end-to-end journey of the surgical episode of care, is clearly feasible. However, good programme design and formal cost-effectiveness analysis is critical to identify, and implement, true high value change. Summary Both outcome and cost need to be a high priority for both fundholders and clinicians in perioperative care, with the focus for both groups on delivering high-quality care, which in itself, is the key to good cost management.
Collapse
Affiliation(s)
- Guy L. Ludbrook
- The University of Adelaide, and Royal Adelaide Hospital, C/O Royal Adelaide Hospital, 3G395, 1 Port Road, Adelaide, South Australia 5000 Australia
| |
Collapse
|
26
|
Brophy L, Birkhimer D, DeVilliers A, Davis L, Meade K, Pervo V. Oncologic Surgical Care Using an Enhanced Recovery Approach. AACN Adv Crit Care 2021; 32:286-296. [PMID: 34490448 DOI: 10.4037/aacnacc2021151] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
Enhanced recovery programs are multimodal, evidence-based perioperative programs designed to improve a patient's functional recovery after surgery. Enhanced recovery programs promote standardized, multidisciplinary care throughout the perioperative course to improve patient outcomes, rather than focusing on surgical technique. It is important for nurses working in acute and critical care to be aware of the paradigm shift created by the trend toward the enhanced recovery approach. By learning more about facets of the approach, the nurse will be better prepared to adopt whatever aspects of enhanced recovery their institution implements for the surgical oncology population. An overview is provided of the potential components of enhanced recovery.
Collapse
Affiliation(s)
- Lynne Brophy
- Lynne Brophy is Breast Oncology Clinical Nurse Specialist, The Ohio State University Comprehensive Cancer Center-Arthur G. James Cancer Hospital and Richard M. Solve Research Institute, Administration-Room 2040, 1145 Olentangy River Road, Columbus, OH 43212
| | - Danette Birkhimer
- Danette Birkhimer is Oncology Clinical Nurse Specialist, The Ohio State University Comprehensive Cancer Center-Arthur G. James Cancer Hospital and Richard M. Solve Research Institute, Columbus, Ohio
| | - Allison DeVilliers
- Allison DeVilliers is Oncology Clinical Nurse Specialist, The Ohio State University Comprehensive Cancer Center-Arthur G. James Cancer Hospital and Richard M. Solve Research Institute, Columbus, Ohio
| | - Loletia Davis
- Loletia Davis is Oncology Clinical Nurse Specialist, The Ohio State University Comprehensive Cancer Center-Arthur G. James Cancer Hospital and Richard M. Solve Research Institute, Columbus, Ohio
| | - Karen Meade
- Karen Meade is Oncology Clinical Nurse Specialist, The Ohio State University Comprehensive Cancer Center-Arthur G. James Cancer Hospital and Richard M. Solve Research Institute, Columbus, Ohio
| | - Valerie Pervo
- Valerie Pervo is Clinical Outcomes Manager, The Ohio State University Comprehensive Cancer Center-Arthur G. James Cancer Hospital and Richard M. Solve Research Institute, Columbus, Ohio
| |
Collapse
|
27
|
Grass F, Hübner M, Behm KT, Mathis KL, Hahnloser D, Day CN, Harmsen WS, Demartines N, Larson DW. Development and validation of a prediction score for safe outpatient colorectal resections. Surgery 2021; 171:336-341. [PMID: 34503851 DOI: 10.1016/j.surg.2021.07.028] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2021] [Revised: 07/13/2021] [Accepted: 07/16/2021] [Indexed: 12/31/2022]
Abstract
BACKGROUND Avoiding unnecessary inpatient stay may decrease hospital-acquired complications and costs while increasing patient satisfaction. This study aimed to develop and validate a score to identify patients eligible for safe same-day discharge after colorectal resections. METHODS This bi-institutional retrospective cohort study included consecutive patients undergoing elective colon and rectal resections (2011-2018) for benign and malignant indications. Two multivariable logistic models were developed based on demographic and surgical risk factors to predict a combined endpoint (ileus, anastomotic leak, intra-abdominal abscess, and readmission). Development and validation datasets were randomly sampled from the entire cohort. Areas under the receiver operating characteristic curves (AUC) were evaluated, and Hosmer-Lemeshow goodness-of-fit tests were used to assess validation model fit. RESULTS Of 5,389 patients, 1,182 (21.9%) experienced at least one complication of the combined endpoint. Male gender, open surgery, ASA ≥3, wound class ≥3, ileostomy, surgical duration >3 hours, and perioperative IV fluids >3 L all had significantly greater odds of the combined endpoint in the parsimonious multivariable model (all P < .05). The reduced model considering only the 4 variables with the highest OR (>1.5) contained open surgery, ASA ≥3, wound class ≥3, and surgical duration ≥3 hours as predictors (all P < .05, AUC of 0.65; 95% CI 0.63, 0.68). Both the parsimonious model and the reduced model demonstrated no lack of fit in the validation cohort. CONCLUSION The suggested score composed of preand intraoperative items may help physicians decide on patients' same-day discharge after colorectal resection.
Collapse
Affiliation(s)
- Fabian Grass
- Division of Colon and Rectal Surgery, Mayo Clinic, Rochester, MN; Department of Visceral Surgery, Lausanne University Hospital CHUV, University of Lausanne (UNIL), Switzerland
| | - Martin Hübner
- Department of Visceral Surgery, Lausanne University Hospital CHUV, University of Lausanne (UNIL), Switzerland
| | - Kevin T Behm
- Division of Colon and Rectal Surgery, Mayo Clinic, Rochester, MN
| | - Kellie L Mathis
- Division of Colon and Rectal Surgery, Mayo Clinic, Rochester, MN
| | - Dieter Hahnloser
- Department of Visceral Surgery, Lausanne University Hospital CHUV, University of Lausanne (UNIL), Switzerland
| | - Courtney N Day
- Division of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, MN
| | - William S Harmsen
- Division of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, MN
| | - Nicolas Demartines
- Department of Visceral Surgery, Lausanne University Hospital CHUV, University of Lausanne (UNIL), Switzerland
| | - David W Larson
- Division of Colon and Rectal Surgery, Mayo Clinic, Rochester, MN.
| |
Collapse
|
28
|
An overview of the evidence for enhanced recovery. SEMINARS IN COLON AND RECTAL SURGERY 2021. [DOI: 10.1016/j.scrs.2021.100826] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
|
29
|
|
30
|
El-Kefraoui C, Rajabiyazdi F, Pecorelli N, Carli F, Lee L, Feldman LS, Fiore JF. Prognostic value of the Duke Activity Status Index (DASI) in patients undergoing colorectal surgery. World J Surg 2021; 45:3677-3685. [PMID: 34448918 DOI: 10.1007/s00268-021-06256-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/14/2021] [Indexed: 01/02/2023]
Abstract
BACKGROUND Complications are common after colorectal surgery and remain a target for quality improvement. Lower preoperative physical functioning is associated with poor postoperative outcomes, but assessment often relies on subjective judgment or resource-intensive tests. Recent literature suggests that self-reported functional capacity, measured using the Duke Activity Status Index (DASI), is a strong predictor of postoperative outcomes. This study aimed to estimate the extent to which DASI predicts 30-day complications after colorectal surgery. METHODS In this observational study, 100 patients undergoing colorectal resection [median age 63, 57% men, 81% laparoscopic, 37% rectal surgery] responded to DASI two weeks preoperatively. Complications were classified according to Clavien-Dindo and quantified using the comprehensive complication index (CCI). Our primary analysis targeted the relationship between preoperative DASI and odds of complications. Secondary analyses focused on 30-day severe complications, CCI, readmissions, and length of stay (LOS). We also explored the predictive ability of DASI with scores dichotomized based on a previously validated threshold (≤ 34). RESULTS Mean preoperative DASI was 48 ± 12. Forty-six patients (46%) experienced 30-day complications (8% severe, CCI 9.6 ± 15). Lower DASI scores were associated with higher odds of complications (OR 1.08, 95%CI 1.03-1.14; p = 0.001). Preoperative DASI was also an independent predictor of severe complications, CCI, and readmissions. The predictive ability was supported when scores were dichotomized at ≤ 34. CONCLUSION DASI is a significant predictor of postoperative complications after colorectal surgery. This questionnaire can be easily implemented in clinical practice to identify patients with low preoperative functional capacity and target interventions to those at higher risk.
Collapse
Affiliation(s)
- Charbel El-Kefraoui
- Division of Experimental Surgery, McGill University, Montreal, QC, Canada.,Steinberg-Bernstein Centre for Minimally Invasive Surgery and Innovation, McGill University Health Centre, Montreal, QC, Canada
| | - Fateme Rajabiyazdi
- Division of Experimental Surgery, McGill University, Montreal, QC, Canada.,Steinberg-Bernstein Centre for Minimally Invasive Surgery and Innovation, McGill University Health Centre, Montreal, QC, Canada
| | - Nicolò Pecorelli
- Pancreas Translational & Clinical Research Center, San Raffaele Hospital, Milan, Italy
| | - Franco Carli
- Department of Anesthesia, McGill University, Montreal, QC, Canada
| | - Lawrence Lee
- Division of Experimental Surgery, McGill University, Montreal, QC, Canada.,Steinberg-Bernstein Centre for Minimally Invasive Surgery and Innovation, McGill University Health Centre, Montreal, QC, Canada.,Department of Surgery, McGill University, Montreal, QC, Canada.,Centre for Outcomes Research and Evaluation (CORE), Research Institute of the McGill University Health Centre, Montreal, QC, Canada
| | - Liane S Feldman
- Division of Experimental Surgery, McGill University, Montreal, QC, Canada.,Steinberg-Bernstein Centre for Minimally Invasive Surgery and Innovation, McGill University Health Centre, Montreal, QC, Canada.,Department of Surgery, McGill University, Montreal, QC, Canada.,Centre for Outcomes Research and Evaluation (CORE), Research Institute of the McGill University Health Centre, Montreal, QC, Canada
| | - Julio F Fiore
- Division of Experimental Surgery, McGill University, Montreal, QC, Canada. .,Steinberg-Bernstein Centre for Minimally Invasive Surgery and Innovation, McGill University Health Centre, Montreal, QC, Canada. .,Department of Surgery, McGill University, Montreal, QC, Canada. .,Centre for Outcomes Research and Evaluation (CORE), Research Institute of the McGill University Health Centre, Montreal, QC, Canada.
| |
Collapse
|
31
|
Return on Investment in Endovascular Care: The Case of Endovascular Reperfusion Alberta. Can J Neurol Sci 2021; 49:629-635. [PMID: 34353400 DOI: 10.1017/cjn.2021.189] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
OBJECTIVE We examined the return on investment (ROI) from the Endovascular Reperfusion Alberta (ERA) project, a provincially funded population-wide strategy to improve access to endovascular therapy (EVT), to inform policy regarding sustainability. METHODS We calculated net benefit (NB) as benefit minus cost and ROI as benefit divided by cost. Patients treated with EVT and their controls were identified from the ESCAPE trial. Using the provincial administrative databases, their health services utilization (HSU), including inpatient, outpatient, physician, long-term care services, and prescription drugs, were compared. This benefit was then extrapolated to the number of patients receiving EVT increased in 2018 and 2019 by the ERA implementation. We used three time horizons, including short (90 days), medium (1 year), and long-term (5 years). RESULTS EVT was associated with a reduced gross HSU cost for all the three time horizons. Given the total costs of ERA were $2.04 million in 2018 ($11,860/patient) and $3.73 million in 2019 ($17,070/patient), NB per patient in 2018 (2019) was estimated at -$7,313 (-$12,524), $54,592 ($49,381), and $47,070 ($41,859) for short, medium, and long-term time horizons, respectively. Total NB for the province in 2018 (2019) were -$1.26 (-$2.74), $9.40 ($10.78), and $8.11 ($9.14) million; ROI ratios were 0.4 (0.3), 5.6 (3.9) and 5.0 (3.5). Probabilities of ERA being cost saving were 39% (31%), 97% (96%), and 94% (91%), for short, medium, and long-term time horizons, respectively. CONCLUSION The ERA program was cost saving in the medium and long-term time horizons. Results emphasized the importance of considering a broad range of HSU and long-term impact to capture the full ROI.
Collapse
|
32
|
Regenbogen SE, Cain-Nielsen AH, Syrjamaki JD, Norton EC. Clinical and Economic Outcomes of Enhanced Recovery Dissemination in Michigan Hospitals. Ann Surg 2021; 274:199-205. [PMID: 33351489 PMCID: PMC8211908 DOI: 10.1097/sla.0000000000004726] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
OBJECTIVE To evaluate real-world effects of enhanced recovery protocol (ERP) dissemination on clinical and economic outcomes after colectomy. SUMMARY BACKGROUND DATA Hospitals aiming to accelerate discharge and reduce spending after surgery are increasingly adopting perioperative ERPs. Despite their efficacy in specialty institutions, most studies have lacked adequate control groups and diverse hospital settings and have considered only in-hospital costs. There remain concerns that accelerated discharge might incur unintended consequences. METHODS Retrospective, population-based cohort including patients in 72 hospitals in the Michigan Surgical Quality Collaborative clinical registry (N = 13,611) and/or Michigan Value Collaborative claims registry (N = 14,800) who underwent elective colectomy, 2012 to 2018. Marginal effects of ERP on clinical outcomes and risk-adjusted, price-standardized 90-day episode payments were evaluated using mixed-effects models to account for secular trends and hospital performance unrelated to ERP. RESULTS In 24 ERP hospitals, patients Post-ERP had significantly shorter length of stay than those Pre-ERP (5.1 vs 6.5 days, P < 0.001), lower incidence of complications (14.6% vs 16.9%, P < 0.001) and readmissions (10.4% vs 11.3%, P = 0.02), and lower episode payments ($28,550 vs $31,192, P < 0.001) and postacute care ($3,384 vs $3,909, P < 0.001). In mixed-effects adjusted analyses, these effects were significantly attenuated-ERP was associated with a marginal length of stay reduction of 0.4 days (95% confidence interval 0.2-0.6 days, P = 0.001), and no significant difference in complications, readmissions, or overall spending. CONCLUSIONS ERPs are associated with small reduction in postoperative length of hospitalization after colectomy, without unwanted increases in readmission or postacute care spending. The real-world effects across a variety of hospitals may be smaller than observed in early-adopting specialty centers.
Collapse
Affiliation(s)
- Scott E Regenbogen
- Department of Surgery, University of Michigan, Ann Arbor, Michigan
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, Michigan
- Michigan Value Collaborative, University of Michigan, Ann Arbor, Michigan
| | - Anne H Cain-Nielsen
- Department of Surgery, University of Michigan, Ann Arbor, Michigan
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, Michigan
| | - John D Syrjamaki
- Department of Surgery, University of Michigan, Ann Arbor, Michigan
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, Michigan
- Michigan Value Collaborative, University of Michigan, Ann Arbor, Michigan
| | - Edward C Norton
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, Michigan
- Michigan Value Collaborative, University of Michigan, Ann Arbor, Michigan
- Department of Health Management and Policy, University of Michigan, Ann Arbor, Michigan
- Department of Economics, University of Michigan, Ann Arbor, Michigan
| |
Collapse
|
33
|
de Queiroz FL, Lacerda-Filho A, Alves AC, de Oliveira FH, Neto PRF, de Almeida Paiva R. Conditions associated with worse acceptance of a simplified accelerated recovery after surgery protocol in laparoscopic colorectal surgery. BMC Surg 2021; 21:229. [PMID: 33941146 PMCID: PMC8091501 DOI: 10.1186/s12893-021-01206-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2020] [Accepted: 04/14/2021] [Indexed: 11/15/2022] Open
Abstract
Background Enhanced Recovery Surgical Programs were initially applied to colorectal procedures and used as multimodal approach to relieve the response to surgical stress. An important factor that negatively impacts the success of these programs is the poor tolerance of these patients to certain items in the adopted protocol, especially with regard to post-operative measures. The identification of these factors may help to increase the success rate of such programs, ensuring that benefits reach a greater number of patients and that resources are better allocated. Thus, the aims of this study were to assess the results of the implementation of a Simplified Accelerated Recovery Protocol (SARP) and to identify possible factors associated with failure to implement postoperative protocol measures in patients submitted to laparoscopic colorectal surgery. Methods 161 patients were randomly divided into two groups. The SARP group (n = 84) was submitted to the accelerated recovery program and the CC group (n = 77), to conventional postoperative care. The SARP group was further divided into two subgroups: patients who tolerated the protocol (n = 51) and those who did not (n = 33), in order to analyze factors contributing to protocol nontolerance. Results The groups had similar sociodemographic and clinical characteristics. The SARP group had a shorter hospital stay, better elimination of flatus, was able to walk and to tolerate a diet sooner (p < 0.0001). Complications rates and readmissions to emergency room were similar between groups. Multivariate analysis revealed that prolonged operating time, stoma creation and rates of surgical complications were independently associated with poor adherence to SARP (p < 0.0001). Conclusions The use of our SARP resulted in improved recovery from laparoscopic colorectal surgery and proved to be safe for patients. Extensive surgeries, occurrence of complications, and the need for ostomy were variables associated with poor program adhesion. Trial registration Trial Registry: RBR2b4fyr—Date of registration: 03 October 2017.
Collapse
Affiliation(s)
- Fábio Lopes de Queiroz
- Colorectal Surgery Department, Hospital Felicio Rocho, Rua Felipe Dos Santos, 760, 501-3, Belo Horizonte, Minas Gerais, CEP 30180160, Brazil.
| | - Antonio Lacerda-Filho
- Department of Surgery at the School of Medicine, Federal University of Minas Gerais, Belo Horizonte, Brazil
| | - Adriana Cherem Alves
- School of Medicine, Federal University of Minas Gerais, Belo Horizonte, Brazil.,Semper Hospital- Belo Horizonte, Belo Horizonte, Brazil
| | | | | | | |
Collapse
|
34
|
Bellas-Cot.ín S, Casans-Franc..s R, Ib.í..ez C, Muguruza I, Mu..oz-Alameda LE. Implementation of an ERAS program in patients undergoing thoracic surgery at a third-level university hospital: an ambispective cohort study. BRAZILIAN JOURNAL OF ANESTHESIOLOGY (ELSEVIER) 2021; 73:16-24. [PMID: 33930342 PMCID: PMC9801216 DOI: 10.1016/j.bjane.2021.04.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/05/2020] [Revised: 03/16/2021] [Accepted: 04/14/2021] [Indexed: 02/01/2023]
Abstract
OBJECTIVE To analyze the effects of an ERAS program on complication rates, readmission, and length of stay in patients undergoing pulmonary resection in a tertiary university hospital. METHODS Ambispective cohort study with a prospective arm of 50 patients undergoing thoracic surgery within an ERAS program (ERAS group) versus a retrospective arm of 50 patients undergoing surgery before the protocol was implemented (Standard group). The primary outcome was the number of patients with 30-day surgical complications. Secondary outcomes included ERAS adherence, non-surgical complications, mortality, readmission, reintervention rate, pain, and hospital length of stay. We performed a multivariate logistic analysis to study the correlation between outcomes and ERAS adherence. RESULTS In the univariate analysis, we found no difference between the two groups in terms of surgical complications (Standard 18 [36%] vs. ERAS 12 [24%], p=0.19). In the ERAS group, only the readmission rate was significantly lower (Standard 15 [30%] vs. ERAS 6 [12%], p=0.03). In the multivariate analysis, ERAS adherence was the only factor associated with a reduction in surgical complications (OR [95% CI]=0.02 [0.00, 0.59], p=0.03) and length of stay (HR [95% CI]=18.5 [4.39, 78.4], p<0.001). CONCLUSIONS The ERAS program significantly reduced the readmission rate at our hospital. Adherence to the ERAS protocol reduced surgical complications and length of stay.
Collapse
Affiliation(s)
- Soledad Bellas-Cot.ín
- Hospital Universitario Fundaci..n Jim..nez D.¡az, Department of Anaesthesiology, Madrid, Spain,Corresponding author.
| | - Rub..n Casans-Franc..s
- Hospital Universitario Infanta Elena, Department of Anaesthesiology, Valdemoro, Madrid, Spain
| | - Cristina Ib.í..ez
- Hospital Universitario Fundaci..n Jim..nez D.¡az, Department of Anaesthesiology, Madrid, Spain
| | - Ignacio Muguruza
- Hospital Universitario Fundaci..n Jim..nez D.¡az, Department of Thoracic Surgery, Madrid, Spain
| | - Luis E. Mu..oz-Alameda
- Hospital Universitario Fundaci..n Jim..nez D.¡az, Department of Anaesthesiology, Madrid, Spain
| |
Collapse
|
35
|
Wang C, Lai Y, Li P, Su J, Che G. Influence of enhanced recovery after surgery (ERAS) on patients receiving lung resection: a retrospective study of 1749 cases. BMC Surg 2021; 21:115. [PMID: 33676488 PMCID: PMC7936477 DOI: 10.1186/s12893-020-00960-z] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2020] [Accepted: 11/12/2020] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND The study aimed to evaluate the outcomes following the implementation of enhanced recovery after surgery (ERAS) for patients undergoing lung cancer surgery. METHOD A retrospective cohort study involving 1749 patients with lung cancer undergoing pulmonary resection was conducted. The patients were divided into two time period groups for analysis (routine pathway and ERAS pathway). Logistic regression analysis was performed to assess the risks of developing postoperative pulmonary complications. RESULTS Among the 1749 patients, 691 were stratified into the ERAS group, and 1058 in to the routine group. The ERAS group presented with shorter postoperative in-hospital length of stay (LOS) (4.0 vs 6.0, P < 0.001), total LOS (10.0 vs. 13.0 days, P < 0.001), and lower total in-hospital costs (P < 0.001), including material (P < 0.001) and drug expenses (P < 0.001). Furthermore, the ERAS group also presented with a lower occurrence of postoperative pulmonary complications (PPCs) than the routine group (15.2% vs. 19.5%, P = 0.022). Likewise, a significantly lower occurrence of pneumonia (8.4% vs. 14.2%, P < 0.001) and atelectasis (5.9% vs. 9.8%, P = 0.004) was found in the ERAS group. Regarding the binary logistic regression, the ERAS intervention was the sole independent factor for the occurrence of PPCs (OR: 0.601, 95% CI 0.434-0.824, P = 0.002). In addition, age (OR: 1.032, 95% CI 1.018-1.046), COPD (OR: 1.792, 95% CI 1.196-2.686), and FEV1 (OR: 0.205, 95% CI 0.125-0.339) were also independent predictors of PPCs. CONCLUSION Implementation of an ERAS pathway shows improved postoperative outcomes, including shortened LOS, lower in-hospital costs, and reduced occurrence of PPCs, providing benefits to the postoperative recovery of patients with lung cancer undergoing surgical treatment.
Collapse
Affiliation(s)
- Chunmei Wang
- Department of Thoracic Surgery, West China Hospital, Sichuan University, Chengdu, 610041, People's Republic of China
| | - Yutian Lai
- Lung Cancer Center, West China Hospital, Sichuan University, Chengdu, 610041, People's Republic of China
| | - Pengfei Li
- Department of Thoracic Surgery, West China Hospital, Sichuan University, Chengdu, 610041, People's Republic of China
| | - Jianhuan Su
- Rehabilitation Department, West China Hospital, Sichuan University, Chengdu, 610041, People's Republic of China
| | - Guowei Che
- Department of Thoracic Surgery, West China Hospital, Sichuan University, Chengdu, 610041, People's Republic of China.
| |
Collapse
|
36
|
Jones CN, Morrison BL, Kelliher LJ, Dickinson M, Scott M, Cecconi Ebm C, Karanjia N, Quiney N. Hospital Costs and Long-term Survival of Patients Enrolled in an Enhanced Recovery Program for Open Liver Resection: Prospective Randomized Controlled Trial. JMIR Perioper Med 2021; 4:e16829. [PMID: 33522982 PMCID: PMC7884210 DOI: 10.2196/16829] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2019] [Revised: 12/15/2020] [Accepted: 01/10/2021] [Indexed: 12/20/2022] Open
Abstract
Background The clinical benefits of enhanced recovery programs (ERPs) have been extensively researched, but few studies have evaluated their cost-effectiveness. Our ERP for open liver resection is based closely on the guidelines produced by the Enhanced Recovery After Surgery Society (2016). This study follows on from a previous randomized controlled trial. We also undertook a long-term follow-up of the patients enrolled in the original trial alongside an analysis of the associated health economics. Objective We aimed to undertake a health economic and long-term survival analysis as part of a trial investigating the implementation of an ERP for open liver resection. Methods The enhanced recovery elements utilized included extra preoperative education, carbohydrate loading, oral nutritional supplements, postresection goal-directed fluid therapy (LiDCOrapid), early mobilization, and physiotherapy (twice a
day compared with once per day in the standard care group). A decision-analytic model was used to compare the study endpoints for ERP versus standard care provided to patients undergoing open liver resection. Outcomes obtained included costs per life-years gained. Resource use and costs were estimated from the perspective of the National Health Service of the United Kingdom. A decision tree and Markov model were constructed using results from our earlier trial and augmented by external data from other published clinical trials. Long-term follow-up was also undertaken for up to 5 years after the surgery, and data were analyzed to ascertain if the ERP conferred any benefit on long-term survival. Results Patients receiving ERP had an average life expectancy of 6.9 years versus 6.1 years in the standard care group. The overall costs were £9538.279 (£1=US $1.60) for ERP and £14,793.05 for standard treatment. This results in a cost-effectiveness ratio of –£6748.33/QALY. Patients receiving ERP required fewer visits to their general practitioner (P=.006) and required lesser help at home with day-to-day activities (P=.04) than patients in the standard care group. Survival was significantly improved at 2 years at 91% (42/46) for patients receiving ERP versus 73% (33/45) for the standard care group (P=.03). There was no statistically significant difference at 5 years after the surgery. Conclusions ERPs for patients undergoing open liver resection can improve their medium-term survival and are cost-effective for both hospital and community settings.
Collapse
Affiliation(s)
- Chris N Jones
- Royal Surrey NHS Foundation Trust, Guildford, United Kingdom
| | - Ben L Morrison
- Royal Surrey NHS Foundation Trust, Guildford, United Kingdom
| | | | | | - Michael Scott
- Royal Surrey NHS Foundation Trust, Guildford, United Kingdom
| | | | | | - Nial Quiney
- Royal Surrey NHS Foundation Trust, Guildford, United Kingdom
| |
Collapse
|
37
|
Gadiya AD, Koch JEJ, Patel MS, Shafafy M, Grevitt MP, Quraishi NA. Enhanced recovery after surgery (ERAS) in adolescent idiopathic scoliosis (AIS): a meta-analysis and systematic review. Spine Deform 2021; 9:893-904. [PMID: 33725329 PMCID: PMC8270839 DOI: 10.1007/s43390-021-00310-w] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/08/2020] [Accepted: 02/13/2021] [Indexed: 12/28/2022]
Abstract
STUDY DESIGN A systematic review reporting on the efficacy of an ERAS protocol in patients undergoing spinal fusion for AIS. OBJECTIVE To systematically evaluate the relevant literature pertaining to the efficacy of ERAS protocols with respect to the length of stay, complication, and readmission rates in patients undergoing posterior spinal corrective surgery for AIS. ERAS is a multidisciplinary approach aimed at improving outcomes of surgery by a specific evidence-based protocol. The rationale of this rapid recovery regimen is to maintain homeostasis so as to reduce the postoperative stress response and pain. No thorough review of available information for its use in AIS has been published. METHODS A systematic review of the English language literature was undertaken using search criteria (postoperative recovery AND adolescent idiopathic scoliosis) using the PRISMA guidelines (Jan 1999-May 2020). Isolated case reports and case series with < 5 patients were excluded. Length of stay (LOS), complication and readmission rates were used as outcome measures. Statistical analysis was done using the random effects model. RESULTS Of a total of 24 articles, 10 studies met the inclusion criteria (9 were Level III and 1 of level IV evidence) and were analyzed. Overall, 1040 patients underwent an ERAS-type protocol following posterior correction of scoliosis and were compared to 959 patients following traditional protocols. There was a significant reduction in the length of stay in patients undergoing ERAS when compared to traditional protocols (p < 0.00001). There was no significant difference in the complication (p = 0.19) or readmission rates (p = 0.30). Each protocol employed a multidisciplinary approach focusing on optimal pain management, nursing care, and physiotherapy. CONCLUSION This systematic review demonstrates advantages with ERAS protocols by significantly reducing the length of stay without increasing the complications or readmission rates as compared to conventional protocols. However, current literature on ERAS in AIS is restricted largely to retrospective studies with non-randomized data, and initial cohort studies lacking formal control groups. LEVEL OF EVIDENCE 3.
Collapse
Affiliation(s)
- Akshay D. Gadiya
- Centre for Spinal Studies and Surgery, D Floor, West Block, Queens Medical Centre, Derby Road, Nottingham, NG7 2UH UK
| | - Jonathan E. J. Koch
- Centre for Spinal Studies and Surgery, D Floor, West Block, Queens Medical Centre, Derby Road, Nottingham, NG7 2UH UK
| | - Mohammed Shakil Patel
- Centre for Spinal Studies and Surgery, D Floor, West Block, Queens Medical Centre, Derby Road, Nottingham, NG7 2UH UK
| | - Masood Shafafy
- Centre for Spinal Studies and Surgery, D Floor, West Block, Queens Medical Centre, Derby Road, Nottingham, NG7 2UH UK
| | - Michael P. Grevitt
- Centre for Spinal Studies and Surgery, D Floor, West Block, Queens Medical Centre, Derby Road, Nottingham, NG7 2UH UK
| | - Nasir A. Quraishi
- Centre for Spinal Studies and Surgery, D Floor, West Block, Queens Medical Centre, Derby Road, Nottingham, NG7 2UH UK
| |
Collapse
|
38
|
Joliat GR, Hübner M, Roulin D, Demartines N. Cost Analysis of Enhanced Recovery Programs in Colorectal, Pancreatic, and Hepatic Surgery: A Systematic Review. World J Surg 2020; 44:647-655. [PMID: 31664495 DOI: 10.1007/s00268-019-05252-z] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND Enhanced recovery programs (ERPs) have been shown to improve postoperative outcomes after abdominal surgery. This study aimed to review the current literature to assess if ERPs in colorectal, pancreas, and liver surgery induce cost savings. METHODS A systematic review was performed including prospective and retrospective studies comparing conventional management versus ERP in terms of costs. All kinds of ERP were considered (fast-track, ERAS®, or home-made protocols). Studies with no mention of a clear protocol and no reporting of protocol compliance were excluded. RESULTS Thirty-seven articles out of 144 identified records were scrutinized as full articles. Final analysis included 16 studies. In colorectal surgery, two studies were prospective (1 randomized controlled trial, RCT) and six retrospective, totaling 1277 non-ERP patients and 2078 ERP patients. Three of the eight studies showed no difference in cost savings between the two groups. The meta-analysis found a mean cost reduction of USD3010 (95% CI: 5370-650, p = 0.01) in favor of ERP. Among the five included studies in pancreas surgery (all retrospective, 552 non-ERP vs. 348 ERP patients), the mean cost reduction in favor of the ERP group was USD7020 (95% CI: 11,600-2430, p = 0.003). In liver surgery, only three studies (two retrospective and 1 RCT, 180 non-ERP vs. 197 ERP patients) were found, which precluded a sound cost analysis. CONCLUSIONS The present systematic review suggests that ERPs in colorectal and pancreas surgery are associated with cost savings compared to conventional perioperative management. Cost data in liver surgery are scarce.
Collapse
Affiliation(s)
- Gaëtan-Romain Joliat
- Department of Visceral Surgery, Lausanne University Hospital CHUV, Rue du Bugnon 46, 1011, Lausanne, Switzerland
| | - Martin Hübner
- Department of Visceral Surgery, Lausanne University Hospital CHUV, Rue du Bugnon 46, 1011, Lausanne, Switzerland
| | - Didier Roulin
- Department of Visceral Surgery, Lausanne University Hospital CHUV, Rue du Bugnon 46, 1011, Lausanne, Switzerland
| | - Nicolas Demartines
- Department of Visceral Surgery, Lausanne University Hospital CHUV, Rue du Bugnon 46, 1011, Lausanne, Switzerland.
| |
Collapse
|
39
|
Thanh N, Nelson A, Wang X, Faris P, Wasylak T, Gramlich L, Nelson G. Return on investment of the Enhanced Recovery After Surgery (ERAS) multiguideline, multisite implementation in Alberta, Canada. Can J Surg 2020; 63:E542-E550. [PMID: 33253512 DOI: 10.1503/cjs.006720] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
Background Enhanced Recovery After Surgery (ERAS) is a global surgical qualityimprovement initiative. Little is known about the economic effects of implementing multiple ERAS guidelines in both the short and long term. Methods We performed a return on investment (ROI) analysis of the implementation of multiple ERAS guidelines (for colorectal, pancreas, cystectomy, liver and gynecologic oncology procedures) across multiple sites (9 hospitals) in Alberta using 30-, 180- and 365-day time horizons. The effects of ERAS on health services utilization (length of stay of the primary admission, number of readmissions, length of stay of the readmissions, number of emergency department visits, number of outpatient clinic visits, number of specialist visits and number of general practitioner visits) were assessed by mixed-effect multilevel multivariate negative binomial regressions. Net benefits and ROI were estimated by a decision analytic modelling analysis. All costs were reported in 2019 Canadian dollars. Results The net health system savings per patient ranged from $26.35 to $3606.44 and ROI ranged from 1.05 to 7.31, meaning that every dollar invested in ERAS brought $1.05 to $7.31 in return. Probabilities for ERAS to be cost-saving were from 86.5% to 99.9%. The effects of ERAS were found to be larger in the longer time horizons, indicating that if only the 30-day time horizon had been used, the benefits of ERAS would have been underestimated. Conclusion These results demonstrated that ERAS multiguideline implementation was cost-saving in Alberta. To produce a better ROI, it is important to consider a broad range of health service utilizations, long-term impact, economies of scale, productive efficiency and allocative efficiency for sustainability, scale and spread of ERAS implementations.
Collapse
Affiliation(s)
- Nguyen Thanh
- From the Strategic Clinical Networks, Alberta Health Services, Edmonton and Calgary, Alta. (Thanh, Wasylak); the Surgery Strategic Clinical Network, Alberta Health Services, Calgary, Alta. (A. Nelson); Analytics, Data Integration, Measurement and Reporting, Alberta Health Services, Edmonton and Calgary, Alta. (Wang, Faris); the Department of Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alta. (Gramlich); and the Section of Gynecologic Oncology, Tom Baker Cancer Centre, University of Calgary, Calgary, Alta. (G. Nelson)
| | - Alison Nelson
- From the Strategic Clinical Networks, Alberta Health Services, Edmonton and Calgary, Alta. (Thanh, Wasylak); the Surgery Strategic Clinical Network, Alberta Health Services, Calgary, Alta. (A. Nelson); Analytics, Data Integration, Measurement and Reporting, Alberta Health Services, Edmonton and Calgary, Alta. (Wang, Faris); the Department of Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alta. (Gramlich); and the Section of Gynecologic Oncology, Tom Baker Cancer Centre, University of Calgary, Calgary, Alta. (G. Nelson)
| | - Xiaoming Wang
- From the Strategic Clinical Networks, Alberta Health Services, Edmonton and Calgary, Alta. (Thanh, Wasylak); the Surgery Strategic Clinical Network, Alberta Health Services, Calgary, Alta. (A. Nelson); Analytics, Data Integration, Measurement and Reporting, Alberta Health Services, Edmonton and Calgary, Alta. (Wang, Faris); the Department of Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alta. (Gramlich); and the Section of Gynecologic Oncology, Tom Baker Cancer Centre, University of Calgary, Calgary, Alta. (G. Nelson)
| | - Peter Faris
- From the Strategic Clinical Networks, Alberta Health Services, Edmonton and Calgary, Alta. (Thanh, Wasylak); the Surgery Strategic Clinical Network, Alberta Health Services, Calgary, Alta. (A. Nelson); Analytics, Data Integration, Measurement and Reporting, Alberta Health Services, Edmonton and Calgary, Alta. (Wang, Faris); the Department of Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alta. (Gramlich); and the Section of Gynecologic Oncology, Tom Baker Cancer Centre, University of Calgary, Calgary, Alta. (G. Nelson)
| | - Tracy Wasylak
- From the Strategic Clinical Networks, Alberta Health Services, Edmonton and Calgary, Alta. (Thanh, Wasylak); the Surgery Strategic Clinical Network, Alberta Health Services, Calgary, Alta. (A. Nelson); Analytics, Data Integration, Measurement and Reporting, Alberta Health Services, Edmonton and Calgary, Alta. (Wang, Faris); the Department of Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alta. (Gramlich); and the Section of Gynecologic Oncology, Tom Baker Cancer Centre, University of Calgary, Calgary, Alta. (G. Nelson)
| | - Leah Gramlich
- From the Strategic Clinical Networks, Alberta Health Services, Edmonton and Calgary, Alta. (Thanh, Wasylak); the Surgery Strategic Clinical Network, Alberta Health Services, Calgary, Alta. (A. Nelson); Analytics, Data Integration, Measurement and Reporting, Alberta Health Services, Edmonton and Calgary, Alta. (Wang, Faris); the Department of Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alta. (Gramlich); and the Section of Gynecologic Oncology, Tom Baker Cancer Centre, University of Calgary, Calgary, Alta. (G. Nelson)
| | - Gregg Nelson
- From the Strategic Clinical Networks, Alberta Health Services, Edmonton and Calgary, Alta. (Thanh, Wasylak); the Surgery Strategic Clinical Network, Alberta Health Services, Calgary, Alta. (A. Nelson); Analytics, Data Integration, Measurement and Reporting, Alberta Health Services, Edmonton and Calgary, Alta. (Wang, Faris); the Department of Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alta. (Gramlich); and the Section of Gynecologic Oncology, Tom Baker Cancer Centre, University of Calgary, Calgary, Alta. (G. Nelson)
| |
Collapse
|
40
|
Pennington Z, Cottrill E, Lubelski D, Ehresman J, Lehner K, Groves ML, Sponseller P, Sciubba DM. Clinical utility of enhanced recovery after surgery pathways in pediatric spinal deformity surgery: systematic review of the literature. J Neurosurg Pediatr 2020; 27:225-238. [PMID: 33254141 DOI: 10.3171/2020.7.peds20444] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2020] [Accepted: 07/02/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVES More than 7500 children undergo surgery for scoliosis each year, at an estimated annual cost to the health system of $1.1 billion. There is significant interest among patients, parents, providers, and payors in identifying methods for delivering quality outcomes at lower costs. Enhanced recovery after surgery (ERAS) protocols have been suggested as one possible solution. Here the authors conducted a systematic review of the literature describing the clinical and economic benefits of ERAS protocols in pediatric spinal deformity surgery. METHODS The authors identified all English-language articles on ERAS protocol use in pediatric spinal deformity surgery by using the following databases: PubMed/MEDLINE, Web of Science, Cochrane Reviews, EMBASE, CINAHL, and OVID MEDLINE. Quantitative analyses of comparative articles using random effects were performed for the following clinical outcomes: 1) length of stay (LOS); 2) complication rate; 3) wound infection rate; 4) 30-day readmission rate; 5) reoperation rate; and 6) postoperative pain scores. RESULTS Of 950 articles reviewed, 7 were included in the qualitative analysis and 6 were included in the quantitative analysis. The most frequently cited benefits of ERAS protocols were shorter LOS, earlier urinary catheter removal, and earlier discontinuation of patient-controlled analgesia pumps. Quantitative analyses showed ERAS protocols to be associated with shorter LOS (mean difference -1.12 days; 95% CI -1.51, -0.74; p < 0.001), fewer postoperative complications (OR 0.37; 95% CI 0.20, 0.68; p = 0.001), and lower pain scores on postoperative day (POD) 0 (mean -0.92; 95% CI -1.29, -0.56; p < 0.001) and POD 2 (-0.61; 95% CI -0.75, -0.47; p < 0.001). There were no differences in reoperation rate or POD 1 pain scores. ERAS-treated patients had a trend toward higher 30-day readmission rates and earlier discontinuation of patient-controlled analgesia (both p = 0.06). Insufficient data existed to reach a conclusion about cost differences. CONCLUSIONS The results of this systematic review suggest that ERAS protocols may shorten hospitalizations, reduce postoperative complication rates, and reduce postoperative pain scores in children undergoing scoliosis surgery. Publication biases exist, and therefore larger, prospective, multicenter data are needed to validate these results.
Collapse
Affiliation(s)
| | | | | | | | | | | | - Paul Sponseller
- 2Orthopaedic Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | | |
Collapse
|
41
|
Carli F, Bousquet-Dion G, Awasthi R, Elsherbini N, Liberman S, Boutros M, Stein B, Charlebois P, Ghitulescu G, Morin N, Jagoe T, Scheede-Bergdahl C, Minnella EM, Fiore JF. Effect of Multimodal Prehabilitation vs Postoperative Rehabilitation on 30-Day Postoperative Complications for Frail Patients Undergoing Resection of Colorectal Cancer: A Randomized Clinical Trial. JAMA Surg 2020; 155:233-242. [PMID: 31968063 DOI: 10.1001/jamasurg.2019.5474] [Citation(s) in RCA: 245] [Impact Index Per Article: 61.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
Importance Research supports use of prehabilitation to optimize physical status before and after colorectal cancer resection, but its effect on postoperative complications remains unclear. Frail patients are a target for prehabilitation interventions owing to increased risk for poor postoperative outcomes. Objective To assess the extent to which a prehabilitation program affects 30-day postoperative complications in frail patients undergoing colorectal cancer resection compared with postoperative rehabilitation. Design, Setting, and Participants This single-blind, parallel-arm, superiority randomized clinical trial recruited patients undergoing colorectal cancer resection from September 7, 2015, through June 19, 2019. Patients were followed up for 4 weeks before surgery and 4 weeks after surgery at 2 university-affiliated tertiary hospitals. A total of 418 patients 65 years or older were assessed for eligibility. Of these, 298 patients were excluded (not frail [n = 290], unable to exercise [n = 3], and planned neoadjuvant treatment [n = 5]), and 120 frail patients (Fried Frailty Index,≥2) were randomized. Ten patients were excluded after randomization because they refused surgery (n = 3), died before surgery (n = 3), had no cancer (n = 1), had surgery without bowel resection (n = 1), or were switched to palliative care (n = 2). Hence, 110 patients were included in the intention-to-treat analysis (55 in the prehabilitation [Prehab] and 55 in the rehabilitation [Rehab] groups). Data were analyzed from July 25 through August 21, 2019. Interventions Multimodal program involving exercise, nutritional, and psychological interventions initiated before (Prehab group) or after (Rehab group) surgery. All patients were treated within a standardized enhanced recovery pathway. Main Outcomes and Measures The primary outcome included the Comprehensive Complications Index measured at 30 days after surgery. Secondary outcomes were 30-day overall and severe complications, primary and total length of hospital stay, 30-day emergency department visits and hospital readmissions, recovery of walking capacity, and patient-reported outcome measures. Results Of 110 patients randomized, mean (SD) age was 78 (7) years; 52 (47.3%) were men and 58 (52.7%) were women; 31 (28.2%) had rectal cancer; and 87 (79.1%) underwent minimally invasive surgery. There was no between-group difference in the primary outcome measure, 30-day Comprehensive Complications Index (adjusted mean difference, -3.2; 95% CI, -11.8 to 5.3; P = .45). Secondary outcome measures were also not different between groups. Conclusions and Relevance In frail patients undergoing colorectal cancer resection (predominantly minimally invasive) within an enhanced recovery pathway, a multimodal prehabilitation program did not affect postoperative outcomes. Alternative strategies should be considered to optimize treatment of frail patients preoperatively. Trial Registration ClinicalTrials.gov identifier: NCT02502760.
Collapse
Affiliation(s)
- Francesco Carli
- Department of Anesthesia, Montreal General Hospital, McGill University Health Centre, Montreal, Quebec, Canada
| | - Guillaume Bousquet-Dion
- Department of Anesthesia, Montreal General Hospital, McGill University Health Centre, Montreal, Quebec, Canada
| | - Rashami Awasthi
- Department of Anesthesia, Montreal General Hospital, McGill University Health Centre, Montreal, Quebec, Canada
| | - Noha Elsherbini
- Currently a medical student at Montreal General Hospital, McGill University Health Centre, Montreal, Quebec, Canada
| | - Sender Liberman
- Department of Surgery, Montreal General Hospital, McGill University Health Centre, Montreal, Quebec, Canada
| | - Marylise Boutros
- Department of Surgery, Sir Mortimer B. Davis Jewish General Hospital, Montreal, Quebec, Canada
| | - Barry Stein
- Department of Surgery, Montreal General Hospital, McGill University Health Centre, Montreal, Quebec, Canada
| | - Patrick Charlebois
- Department of Surgery, Montreal General Hospital, McGill University Health Centre, Montreal, Quebec, Canada
| | - Gabriela Ghitulescu
- Department of Surgery, Sir Mortimer B. Davis Jewish General Hospital, Montreal, Quebec, Canada
| | - Nancy Morin
- Department of Surgery, Sir Mortimer B. Davis Jewish General Hospital, Montreal, Quebec, Canada
| | - Thomas Jagoe
- Department of Medicine, Sir Mortimer B. Davis Jewish General Hospital, Montreal, Quebec, Canada
| | - Celena Scheede-Bergdahl
- Department of Anesthesia, McGill Research Centre for Physical Activity and Health, McGill University, Montreal, Quebec, Canada
| | - Enrico Maria Minnella
- Department of Anesthesia, Montreal General Hospital, McGill University Health Centre, Montreal, Quebec, Canada
| | - Julio F Fiore
- Department of Surgery, Montreal General Hospital, McGill University Health Centre, Montreal, Quebec, Canada
| |
Collapse
|
42
|
Louie PK, Vaishnav AS, Qureshi SA. Commentary: Relationship Between Preoperative Opioid Use and Postoperative Pain in Patients Undergoing Minimally-Invasive Stand-Alone Lateral Lumbar Interbody Fusion. Neurosurgery 2020; 87:E625-E627. [PMID: 32521020 DOI: 10.1093/neuros/nyaa236] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2020] [Accepted: 03/31/2020] [Indexed: 11/13/2022] Open
Affiliation(s)
| | | | - Sheeraz A Qureshi
- Hospital for Special Surgery, New York, New York.,Weill Cornell Medical College, New York, New York
| |
Collapse
|
43
|
Chan DKH, Ang JJ. A simple prediction score for prolonged length of stay following elective colorectal cancer surgery. Langenbecks Arch Surg 2020; 406:319-327. [PMID: 33188439 DOI: 10.1007/s00423-020-02030-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2020] [Accepted: 11/08/2020] [Indexed: 11/25/2022]
Abstract
BACKGROUND Current enhanced recovery after surgery (ERAS) protocols are designed for all patients without tailored programmes for at-risk groups. A risk score to determine elective colorectal cancer patients at risk for prolonged length of stay (LOS) would help to identify this group for preoperative intervention. METHODS Multivariate analysis of demographic and preoperative variables was performed to identify independent risk factors for prolonged LOS, defined as 7 days or more. A stepwise variable selection approach using logistic regression was then used to build a risk prediction model. RESULTS Among 172 patients in our population, 41.9% of patients had prolonged LOS. Five variables were included in our risk prediction model. These were age ≥ 65 years (OR 13.9 5.09-38.0; p < 0.0001), neoadjuvant therapy (OR 7.60 2.51-23.0; p < 0.0001), open approach (OR 3.96 1.68-15.9); p = 0.008), history of smoking (OR 5.18 1.68-15.9; p = 0.004) and white blood cell (WBC) count (OR 0.83/unit 0.69-0.99; p = 0.040). These variables were combined to produce a score, for which the area under the receiving operator curve was 0.82 (95% CI 0.76-0.88), and Hosmer-Lemeshow test showed a χ2 statistic of 9.14 and p = 0.519. Using 0.9 as a cut-off, the score has sensitivity of 81.9% and specificity of 65.0%. CONCLUSION A simple, clinical score can be used to predict for prolonged LOS based on preoperative variables, allowing for intervention before surgery. Age, neoadjuvant therapy, smoking status, open approach and WBC count are independent risk factors for prolonged length of stay following elective colorectal cancer surgery. A risk score comprising the above independent variables was developed with area under the receiving operator curve of 0.82 (95% CI 0.76-0.88), and a Hosmer-Lemeshow test showing a χ2 statistic of 9.14 and p = 0.519.
Collapse
Affiliation(s)
- Dedrick Kok Hong Chan
- Division of Colorectal Surgery, University Surgical Cluster, National University Health System, 1E Kent Ridge Road, Singapore, 119228, Singapore.
- Department of Surgery, Yong Loo Lin School of Medicine, National University of Singapore, 1E Kent Ridge Road, Singapore, 119228, Singapore.
| | - Jia Jun Ang
- Division of Colorectal Surgery, University Surgical Cluster, National University Health System, 1E Kent Ridge Road, Singapore, 119228, Singapore
| |
Collapse
|
44
|
Pennington Z, Cottrill E, Lubelski D, Ehresman J, Theodore N, Sciubba DM. Systematic review and meta-analysis of the clinical utility of Enhanced Recovery After Surgery pathways in adult spine surgery. J Neurosurg Spine 2020; 34:325-347. [PMID: 33157522 DOI: 10.3171/2020.6.spine20795] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2020] [Accepted: 06/16/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Spine surgery has been identified as a significant source of healthcare expenditures in the United States. Prolonged hospitalization has been cited as one source of increased spending, and there has been drive from providers and payors alike to decrease inpatient stays. One strategy currently being explored is the use of Enhanced Recovery After Surgery (ERAS) protocols. Here, the authors review the literature on adult spine ERAS protocols, focusing on clinical benefits and cost reductions. They also conducted a quantitative meta-analysis examining the following: 1) length of stay (LOS), 2) complication rate, 3) wound infection rate, 4) 30-day readmission rate, and 5) 30-day reoperation rate. METHODS Using the PRISMA guidelines, a search of the PubMed/Medline, Web of Science, Cochrane Reviews, Embase, CINAHL, and OVID Medline databases was conducted to identify all full-text articles in the English-language literature describing ERAS protocol implementation for adult spine surgery. A quantitative meta-analysis using random-effects modeling was performed for the identified clinical outcomes using studies that directly compared ERAS protocols with conventional care. RESULTS Of 950 articles reviewed, 34 were included in the qualitative analysis and 20 were included in the quantitative analysis. The most common protocol types were general spine surgery protocols and protocols for lumbar spine surgery patients. The most frequently cited benefits of ERAS protocols were shorter LOS (n = 12), lower postoperative pain scores (n = 6), and decreased complication rates (n = 4). The meta-analysis demonstrated shorter LOS for the general spine surgery (mean difference -1.22 days [95% CI -1.98 to -0.47]) and lumbar spine ERAS protocols (-1.53 days [95% CI -2.89 to -0.16]). Neither general nor lumbar spine protocols led to a significant difference in complication rates. Insufficient data existed to perform a meta-analysis of the differences in costs or postoperative narcotic use. CONCLUSIONS Present data suggest that ERAS protocol implementation may reduce hospitalization time among adult spine surgery patients and may lead to reductions in complication rates when applied to specific populations. To generate high-quality evidence capable of supporting practice guidelines, though, additional controlled trials are necessary to validate these early findings in larger populations.
Collapse
|
45
|
Attaar M, Su B, Wong HJ, Kuchta K, Denham W, Linn JG, Ujiki MB. Comparing cost and outcomes between peroral endoscopic myotomy and laparoscopic heller myotomy. Am J Surg 2020; 222:208-213. [PMID: 33162014 DOI: 10.1016/j.amjsurg.2020.10.037] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2020] [Revised: 10/20/2020] [Accepted: 10/29/2020] [Indexed: 12/20/2022]
Abstract
BACKGROUND Peroral endoscopic myotomy (POEM) has previously been shown to be equally if not more expensive than laparoscopic Heller myotomy (LHM). We compare perioperative outcomes and charges between POEM and LHM at a single institution. METHODS Outcomes and charge data of 33 patients who underwent LHM and 126 patients who underwent POEM were analyzed. Patients who did not present electively were excluded. RESULTS There were no demographic differences between groups. Patients who underwent POEM had a significantly shorter mean operative time and median length of stay (both p < 0.001). Patients who underwent POEM stopped narcotics earlier and had faster return to activities of daily living (both p < 0.05). When adjusted for inflation, POEM incurred less in hospital charges than LHM (35.5 ± 12.8 vs 30.7 ± 10.3 in thousands of US dollars, p = 0.006). CONCLUSIONS Patients who underwent POEM compared to LHM had significantly better perioperative outcomes. Our results suggest POEM may be the more cost-effective option.
Collapse
Affiliation(s)
- Mikhail Attaar
- Department of Surgery, NorthShore University Health System, 2650 Ridge Ave, GCSI Suite B665, Evanston, IL, 60201, United States; Department of Surgery, University of Chicago Medical Center, 5841 S. Maryland Avenue, Chicago, IL, 60637, United States.
| | - Bailey Su
- Department of Surgery, NorthShore University Health System, 2650 Ridge Ave, GCSI Suite B665, Evanston, IL, 60201, United States; Department of Surgery, University of Chicago Medical Center, 5841 S. Maryland Avenue, Chicago, IL, 60637, United States
| | - Harry J Wong
- Department of Surgery, NorthShore University Health System, 2650 Ridge Ave, GCSI Suite B665, Evanston, IL, 60201, United States; Department of Surgery, University of Chicago Medical Center, 5841 S. Maryland Avenue, Chicago, IL, 60637, United States
| | - Kristine Kuchta
- NorthShore University Research Institute, 1001 University Pl, Evanston, IL, 60201, United States
| | - Woody Denham
- Department of Surgery, NorthShore University Health System, 2650 Ridge Ave, GCSI Suite B665, Evanston, IL, 60201, United States
| | - John G Linn
- Department of Surgery, NorthShore University Health System, 2650 Ridge Ave, GCSI Suite B665, Evanston, IL, 60201, United States
| | - Michael B Ujiki
- Department of Surgery, NorthShore University Health System, 2650 Ridge Ave, GCSI Suite B665, Evanston, IL, 60201, United States
| |
Collapse
|
46
|
The concept of peri-operative medicine to prevent major adverse events and improve outcome in surgical patients: A narrative review. Eur J Anaesthesiol 2020; 36:889-903. [PMID: 31453818 DOI: 10.1097/eja.0000000000001067] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
: Peri-operative Medicine is the patient-centred and value-based multidisciplinary peri-operative care of surgical patients. Peri-operative stress, that is the collective response to stimuli occurring before, during and after surgery, is, together with pre-existing comorbidities, the pathophysiological basis of major adverse events. The ultimate goal of Peri-operative Medicine is to promote high quality recovery after surgery. Clinical scores and/or biomarkers should be used to identify patients at high risk of developing major adverse events throughout the peri-operative period. Allocation of high-risk patients to specific care pathways with peri-operative organ protection, close surveillance and specific early interventions is likely to improve patient-relevant outcomes, such as disability, health-related quality of life and mortality.
Collapse
|
47
|
Brooks NA, Kokorovic A, McGrath JS, Kassouf W, Collins JW, Black PC, Douglas J, Djaladat H, Daneshmand S, Catto JWF, Kamat AM, Williams SB. Critical analysis of quality of life and cost-effectiveness of enhanced recovery after surgery (ERAS) for patient's undergoing urologic oncology surgery: a systematic review. World J Urol 2020; 40:1325-1342. [PMID: 32648071 DOI: 10.1007/s00345-020-03341-6] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2020] [Accepted: 07/02/2020] [Indexed: 12/12/2022] Open
Abstract
PURPOSE Enhanced recovery after surgery (ERAS) protocols have been implemented across a variety of disciplines to improve outcomes. Herein we describe the impact of ERAS on quality of life (QOL) and cost for patients undergoing urologic oncology surgery. METHODS A systematic literature search using the MEDLINE, Scopus, Clinictrials.gov, and Cochrane Review databases for studies published between 1946 and 2020 was conducted. Articles were reviewed and assigned a risk of bias by two authors and were included if they addressed ERAS and either QOL or cost-effectiveness for patients undergoing urologic oncology surgery. RESULTS The literature search yielded a total of 682 studies after removing duplicates, of which 10 (1.5%) were included in the review. Nine articles addressed radical cystectomy, while one addressed ERAS and QOL for laparoscopic nephrectomy. Six publications assessed the impact of ERAS on QOL domains. Questionnaires used for assessment of QOL varied across studies, and timing of administration was heterogeneous. Overall, ERAS improved patient QOL during early phases of recovery within the realms of bowel function, physical/social/cognitive functioning, sleep and pain control. Costs were assessed in 4 retrospective studies including 3 conducted in the United States and one from China all addressing radical cystectomy. Studies demonstrated either decreased costs associated with ERAS as a result of decreased length of stay or no change in cost based on ERAS implementation. CONCLUSION While limited studies are published on the subject, ERAS implementation for radical cystectomy and laparoscopic nephrectomy improved patient-reported QOL during early phases of recovery. For radical cystectomy, there was a decreased or neutral overall financial cost associated with ERAS. Further studies assessing QOL and cost-effectiveness over the entire global period of care in a variety of urologic oncology surgeries are warranted.
Collapse
Affiliation(s)
- Nathan A Brooks
- Department of Urology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Andrea Kokorovic
- Department of Urology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - John S McGrath
- Department of Urology, Royal Devon and Exeter NHS Trust, Exeter, UK
| | - Wassim Kassouf
- Department of Urology, McGill University Health Center, McGill, Montreal, QC, Canada
| | - Justin W Collins
- Department of Urology, University College London Hospital, London, UK
| | - Peter C Black
- Department of Urologic Sciences, University of British Columbia, Vancouver, BC, Canada
| | - James Douglas
- Department of Urology, University Hospital of Southampton, Hampshire, UK
| | - Hooman Djaladat
- USC Institute of Urology, Norris Comprehensive Cancer Center, University of Southern California, Los Angeles, CA, USA
| | - Siamak Daneshmand
- USC Institute of Urology, Norris Comprehensive Cancer Center, University of Southern California, Los Angeles, CA, USA
| | - James W F Catto
- Academic Urology Unit, University of Sheffield, Sheffield, UK
| | - Ashish M Kamat
- Department of Urology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Stephen B Williams
- Division of Urology, The University of Texas Medical Branch, 301 University Blvd, Galveston, TX, 77555, USA.
| |
Collapse
|
48
|
Enhanced Recovery after Surgery Protocols Decrease Outpatient Opioid Use in Patients Undergoing Abdominally Based Microsurgical Breast Reconstruction. Plast Reconstr Surg 2020; 145:645-651. [PMID: 32097300 DOI: 10.1097/prs.0000000000006546] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
BACKGROUND Enhanced recovery after surgery (ERAS) protocols have known benefits in the inpatient setting, but little is known about their impact in the subsequent outpatient setting. On discharge, multimodal analgesia has been discontinued, nerve blocks and pain pumps have worn off, and patients enter a substantially different physical environment, potentially resulting in a rebound effect. The objective of this study was to investigate the effect of ERAS protocol implementation on outpatient opioid use and recovery. METHODS Patients who underwent abdominally based microsurgical breast reconstruction before and after ERAS implementation were reviewed retrospectively. Ohio state law mandates that no more than 7 days of opioids may be prescribed at a time, with the details of all prescriptions recorded in a statewide reporting system, from which opioid use was determined. RESULTS A total of 105 patients met inclusion criteria, of which 46 (44 percent) were in the pre-ERAS group and 59 (56 percent) were in the ERAS group. Total outpatient morphine milligram equivalents used in the ERAS group were less than in the pre-ERAS group (337.5 morphine milligram equivalents versus 668.8 morphine milligram equivalents, respectively; p =0.016). This difference was specifically significant at postoperative week 1 (p =0.044), with gradual convergence over subsequent weeks. Although opioid use was significantly less in the ERAS group, pain scores in the ERAS group were comparable to those in the pre-ERAS group. CONCLUSIONS The benefits of ERAS protocols appear to extend into the outpatient setting, further supporting their use to facilitate recovery, and highlighting their potential role in helping to address the prescription opioid abuse problem. CLINICAL QUESTION/LEVEL OF EVIDENCE Therapeutic, III.
Collapse
|
49
|
Heathcote S, Duggan K, Rosbrugh J, Hill B, Shaker R, Hope WW, Fillion MM. Enhanced Recovery after Surgery (ERAS) Protocols Expanded over Multiple Service Lines Improves Patient Care and Hospital Cost. Am Surg 2020. [DOI: 10.1177/000313481908500951] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Enhanced recovery after surgery (ERAS) may improve patients’ postoperative course. Our center implemented the ERAS protocol for the colorectal service in 2016, and then expanded to multiple service lines over the course of 1.5 years. Our aim was to determine whether broad implementation of ERAS protocols across different service lines could improve patient care. All ERAS patients from 2018 were captured prospectively. For each service line using ERAS, one full year of data preceding ERAS was compared. ERAS service lines included colorectal, gynecology laparoscopic, gynecology open, hepatopancreaticobiliary, urology – nephrectomy and cystectomy, spinal fusion, cardiac surgery—coronary artery bypass grafting. ERAS and pre-ERAS services were compared based on length of stay (LOS), complications, readmission, and mortality rates. In addition, hospital costs were collected during this time frame. ERAS protocols significantly decreased LOS for colorectal, gynecology, and spine. Complications were significantly decreased in colorectal, gynecology, urology, and spine. Readmissions did not significantly increase in any service line except spine. There was no significant change in mortality. ERAS proved to save the hospital 1847 days and cost saving of almost $5 million in 2018. Implementing ERAS broadly improved patient outcomes (LOS, complications, readmission, and mortality) while providing cost savings to the hospital.
Collapse
Affiliation(s)
- Sam Heathcote
- From the New Hanover Regional Medical Center, Wilmington, North Carolina
| | - Kim Duggan
- From the New Hanover Regional Medical Center, Wilmington, North Carolina
| | - Jared Rosbrugh
- From the New Hanover Regional Medical Center, Wilmington, North Carolina
| | - Brandon Hill
- From the New Hanover Regional Medical Center, Wilmington, North Carolina
| | - Robert Shaker
- From the New Hanover Regional Medical Center, Wilmington, North Carolina
| | - William W. Hope
- From the New Hanover Regional Medical Center, Wilmington, North Carolina
| | | |
Collapse
|
50
|
Tahiri M, Goudie E, Jouquan A, Martin J, Ferraro P, Liberman M. Enhanced recovery after video-assisted thoracoscopic surgery lobectomy: a prospective, historically controlled, propensity-matched clinical study. Can J Surg 2020; 63:E233-E240. [PMID: 32386474 DOI: 10.1503/cjs.001919] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023] Open
Abstract
Background Enhanced recovery pathways or fast-tracking following surgery can decrease the rate of postoperative complications and hospital length of stay. The objectives of this study were to implement an enhanced recovery after surgery (ERAS) pathway for patients undergoing a video-assisted thoracoscopic surgery (VATS) lobectomy, to assess the safety and efficiency of this protocol by measuring associated postoperative outcomes, and to compare the outcomes for patients in the ERAS group with the outcomes for patients in a propensity-matched control group. Methods The study was a prospective clinical trial. Patients who were scheduled to undergo VATS lobectomy at the Centre hospitalier de l'Université de Montréal in Montréal, Quebec, Canada, were enrolled between November 2015 and October 2016. The ERAS pathway was used for all enrolled patients. The primary outcome was the number and severity of complications measured by the Comprehensive Complication Index. Secondary outcomes included length of stay, readmission and recovery. Recovery of patients was measured using EQ-5D-5L preoperatively and at 1 week, 1 month and 4 months after surgery. Prospectively enrolled patients were propensity matched to historical controls. Results Ninety-eight patients (36 men and 62 women) in the ERAS group and 98 patients in the control group (29 men and 69 women) were included in the analysis. The mean age was 65.2 ± 9.3 years, the mean body mass index (BMI) was 26.9 ± 5.9 kg/m2 and the median Charlson Comorbidity Index score was 2 (interquartile range [IQR] 2-3) in the ERAS group. In the control group, the mean age was 66.2 ± 9.4 years, the mean BMI was 27.4 ± 5.6 kg/m2 and the median Charlson Comorbidity Index score was 3 (IQR 2-3). A total of 23 patients (23.4%) in the ERAS group and 28 (28.6%) in the control group experienced 1 or more postoperative complications. The mean Comprehensive Complication Index score was 7.4 ± 16.8 in the ERAS group compared with 8.0 ± 14.3 in the control group (p = 0.79). The median postoperative length of stay was 3 days in the ERAS group and 5 days in the control group (p < 0.001). Five patients in the ERAS group and 4 patients in the control group were readmitted. The protocol adherence rate was 64.3%. Conclusion It is feasible to implement an enhanced recovery protocol after VATS lobectomy. Although the pathway is still early in its development in Canada, implementation of an ERAS pathway after VATS lobectomy was associated with decreased length of stay, with no observable increase in complication or readmission rates.
Collapse
Affiliation(s)
- Mehdi Tahiri
- From the Division of Thoracic Surgery, Université de Montréal, Montreal, Que. (Tahiri, Goudie, Jouquan, Thiffault, Martin, Ferraro, Liberman); and the CHUM Endoscopic Tracheobronchial and Oesophageal Centre (CETOC), Montreal, Que. (Tahiri, Goudie, Jouquan, Thiffault, Martin, Ferraro, Liberman)
| | - Eric Goudie
- From the Division of Thoracic Surgery, Université de Montréal, Montreal, Que. (Tahiri, Goudie, Jouquan, Thiffault, Martin, Ferraro, Liberman); and the CHUM Endoscopic Tracheobronchial and Oesophageal Centre (CETOC), Montreal, Que. (Tahiri, Goudie, Jouquan, Thiffault, Martin, Ferraro, Liberman)
| | - Adeline Jouquan
- From the Division of Thoracic Surgery, Université de Montréal, Montreal, Que. (Tahiri, Goudie, Jouquan, Thiffault, Martin, Ferraro, Liberman); and the CHUM Endoscopic Tracheobronchial and Oesophageal Centre (CETOC), Montreal, Que. (Tahiri, Goudie, Jouquan, Thiffault, Martin, Ferraro, Liberman)
| | - Jocelyne Martin
- From the Division of Thoracic Surgery, Université de Montréal, Montreal, Que. (Tahiri, Goudie, Jouquan, Thiffault, Martin, Ferraro, Liberman); and the CHUM Endoscopic Tracheobronchial and Oesophageal Centre (CETOC), Montreal, Que. (Tahiri, Goudie, Jouquan, Thiffault, Martin, Ferraro, Liberman)
| | - Pasquale Ferraro
- From the Division of Thoracic Surgery, Université de Montréal, Montreal, Que. (Tahiri, Goudie, Jouquan, Thiffault, Martin, Ferraro, Liberman); and the CHUM Endoscopic Tracheobronchial and Oesophageal Centre (CETOC), Montreal, Que. (Tahiri, Goudie, Jouquan, Thiffault, Martin, Ferraro, Liberman)
| | - Moishe Liberman
- From the Division of Thoracic Surgery, Université de Montréal, Montreal, Que. (Tahiri, Goudie, Jouquan, Thiffault, Martin, Ferraro, Liberman); and the CHUM Endoscopic Tracheobronchial and Oesophageal Centre (CETOC), Montreal, Que. (Tahiri, Goudie, Jouquan, Thiffault, Martin, Ferraro, Liberman)
| |
Collapse
|