Nurses, surgeons, and anesthesia providers all have one main goal for patients undergoing surgery—a smooth recovery that returns patients to their daily lives as quickly as possible. Some healthcare providers have adopted enhanced recovery after surgery (ERAS) protocols as a strategy for meeting that goal, and preliminary research suggests merits of this approach vs traditional patient care models. However, data are still being gathered in an effort to better quantify ERAS-related outcomes.
“Enhanced recovery is a multimodal, interdisciplinary approach to the care of the perioperative patient, with targeted interventions along the continuum of surgical care beginning in the preoperative phase of care and continuing out to the 30-, 60-, or 90-day mark,” says Julie K. Thacker, MD, FACS, FASCRS, a surgical oncologist, colorectal surgeon, and assistant professor of surgery at Duke University Medical Center in Durham, North Carolina. “It is evidence-based perioperative care,” she says (sidebar, p 8).
Dr Thacker was one of several speakers at the 2015 American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) national conference who discussed the current state of ERAS. Here are some highlights from those presentations.
The Enhanced Recovery In NSQIP (ERIN) collaborative is a nationwide initiative focused on quality improvement and outcomes that occur as a result of guided implementation of ERAS with ongoing auditing. Selection of participating sites began in July 2014. Currently, 17 hospitals and healthcare systems are enrolled in the collaborative and participating in a pilot study related to colon resection.
Dr Thacker says the study’s primary outcome of interest is decreased length of stay after colon resection, but the collaborative is also investigating secondary outcomes such as incidence of pneumonia, venous thromboembolism, urinary tract infection, surgical site infection, and readmission.
Since January 2015, participating hospitals have been tracking 13 process variables, such as urinary catheters removed on or before the first postoperative day, and three outcome variables: return of bowel function, toleration of diet, and pain managed with oral medication.
Baseline data from 1,764 cases provide “an interesting snapshot of what we think is going on right now in the US and Canada,” Dr Thacker says. The data, which reflect compliance with the process variables, showed some gaps. For example:
• In 60% of cases, patients were not allowed clear fluids until 3 hours after surgery.
• Fewer than half (42%) used goal-directed intraoperative fluid therapy.
• Nearly a quarter (24%) don’t mobilize patients by postoperative day 2.
Early results of ERAS are promising. For example, length of stay before and after ERIN participation has decreased from 7.3 days to 4.8 days, and surgical site infections have also dropped.
All the sites have created a multidisciplinary team for ERAS, and these teams are already reporting changes; for instance, one hospital created a pain management protocol. “Overall, our collaborative is active, and we’ve had some early successes,” Dr Thacker says.
Understanding cost-effectiveness of colorectal ERAS programs depends on understanding what is meant by “value” in healthcare, says Lawrence Lee, MD, MSc, PhD, general surgery resident at McGill University Health Centre in Montreal. Dr Lee quotes a definition from Michael E. Porter, a professor in the Harvard Business School: “Attainment of the best possible outcomes that matter to the patient at the lowest cost.”
On the clinical outcomes side, a meta-analysis of 13 randomized trials related to ERAS and colorectal surgery (total of 1,910 patients) published by Zhuang and colleagues shows that length of stay is reduced on average by about 2.5 days and the complication rate by about 30%.
On the economics side, Dr Lee says many studies show savings, including a 2015 study by Thiele and colleagues that found a cost savings of $7,129 per patient. Dr Lee notes that many of the economic studies suffer from limitations in design.
In a study of 180 patients in two institutions conducted by Dr Lee and his colleagues, those in the ERAS group had a shorter length of stay compared to conventional treatment, and the cost of the program was $153 (2013 Canadian dollars) per patient. Societal costs, as measured through questionnaires on lost productivity and caregiver burden, were lower as well because patients returned to work more quickly.
When it comes to implementation, “Most costs are related to the salary of the enhanced recovery nurse coordinator, a full-time position needed for successful implementation of the program,” Dr Lee says, adding that the cost can be amortized over a large number of patients. At his institution, about 700 patients were managed by ERAS at a cost of about $150 per patient.
In terms of institutional costs, Dr Lee says, “There is really no difference between enhanced recovery and conventional care in the Canadian health system.” However, he adds, when costs such as outpatient rehabilitation, assisted-care facilities, lost productivity, and caregiver compensation are considered, ERAS is less expensive than conventional care.
An organization with several elements of ERAS in place will likely see less of a cost savings. Dr Lee says a challenge related to the ERAS elements is that, “We don’t really know at this point which enhanced recovery elements are the most important, and we don’t know the relative impact of each element in terms of the overall cost-effectiveness.”
In the case of pre-ERAS outcomes, Dr Lee says, “If your length of stay for uncomplicated cases is much worse than expected, you can probably expect that enhanced recovery will have a very significant impact on your overall bottom line. If your length of stay in the absence of complications prior to the implementation of enhanced recovery is already in the range of 3 to 4 days, you’re really not going to see that much of an impact, and subsequently, not much of an economic impact.”
Unit costs relate to length of stay, and Dr Lee says that intuitively, if length of stay decreases, so will costs. He notes that complications are what drive costs up.
“Enhanced recovery appears to be cost-effective—at least, this is what the preliminary data says—although there still is not very good high-quality data,” Dr Lee adds. “The economic impact of enhanced recovery depends a lot on the current institutional costs and outcomes.”
ERAS goals for patients undergoing hepatic surgery at the University of Texas MD Anderson Cancer Center in Houston include return of the patient to intended oncologic therapies (RIOT) and return of the patient to normal function as rapidly as possible, according to Thomas A. Aloia, MD, FACS, a hepatobiliary surgical oncologist.
RIOT, which was coined in a recent MD Anderson publication, consists of the number of patients who initiate adjuvant therapy after surgery over the number of patients planned to receive adjuvant therapy, and the time from surgery to next treatment.
Results of a study of 118 patients from September 2013 to January 2015 by Dr Aloia and his colleagues were recently published in the Journal of the American College of Surgeons. They found that implementing ERAS increased the baseline RIOT rate for hepatic surgical patients from 87% to 95% and shortened the time to initiation by 10 days.
The team at MD Anderson is now asking whether faster surgical recovery could reduce cancer recurrence and improve survival. “Our paradigm is that enhanced recovery leads to better RIOT, which decreases recurrences, which improves survivals,” Dr Aloia says. “We’re hoping to prove this over time by following our patients.”
Dr Aloia says it was initially difficult to address the goal of returning patients to normal function because it’s hard to quantify recovery. Although symptoms need to be addressed, it’s also important to talk with patients about how these symptoms are affecting their lives, mobility, driving, ability to care for others and themselves, and enjoyment of life.
To measure life interference from symptom burden, staff at MD Anderson have developed the MD Anderson Symptom Inventory, which asks questions such as, how have your symptoms interfered with your life? With regard to his recent study, Dr Aloia reports that since ERAS was implemented, life interference scores for patients, measured for 31 days after surgery, have significantly improved.
Dr Aloia says education and setting patient expectations are key for a successful ERAS program. “Your preoperative educational piece and organization of your team are incredibly important,” he says.
Dr Aloia views ERAS elements as the tactics for returning patients to normal function. Reducing anxiety and reducing or eliminating narcotics and fluid overload lead to less symptom interference (sidebar, p 9).
In discussing the outcomes of the initiative, Dr Aloia says, “We were able to lower the length of stay for open hepatectomy by 3 days, and we dropped half a day for minimally invasive hepatectomy.”
For a nurse leader’s perspective on ERAS, see the article on p 11.
Dr Thacker says, “Enhanced recovery is a more principle-based, patient-focused care, so if you’re looking at your health system, why would you not want to run it this way?”
She adds that ERAS is also an excellent change management program. “With an enhanced recovery program, you have to be able to impact change along the entire continuum,” she says. “When you get that in place, you can change anything that comes along in the literature or whatever Medicare wants you to do because you have a process already in place.”
Dr Thacker believes ERAS is the best way to reduce patient stress and obtain the best outcomes. She adds that ERAS doesn’t need to be specific to a surgical procedure or a surgeon.
Looking to the future, Dr Thacker calls for ERAS to become more patient focused and for more research on how to best manage complications such as ileus and to determine what interventions have the most impact.
“I don’t know which are the most important, but most of them are easy to put in place, so there’s not really a reason to not do them,” she says. ✥
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Day R W, Cleeland C S, Wang X S. Patient-reported outcomes accurately measure the value of an enhanced recovery program in liver surgery. J Am Coll Surg. 2015;221(6), 1023-1030.e2.
Geltzeiler C B, Rotramel A, Wilson C, et al. Prospective study of colorectal enhanced recovery after surgery in a community hospital. JAMA Surg. 2014;149(9):955-961.
Lee L, Mata J, Ghitulescu G, et al. Cost-effectiveness of enhanced recovery versus conventional perioperative management for colorectal surgery. Ann Surg. 2015;262(6):1026-1033.
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