Economic Benefits of Enhanced Recovery After Surgery

Enhanced recovery after surgery (ERAS) consists of standardized, coordinated, interdisciplinary perioperative care plans that incorporate evidence-based interventions to minimize surgical stress, improve physiologic and functional recovery, reduce complications, and thereby facilitate earlier discharge from the hospital.(1)

Initially, this approach was named “fast-track surgery.” The term “fast track,” however, caused confusion about the goal of the approach. The goal is not just reduction in length of hospital stay; the primary aims are to hasten recovery time, decrease morbidity, improve efficiency, and decrease variability, which will be reflected in a reduction in hospital stay.(2,3)

An increasing body of evidence supports the clinical effectiveness of ERAS for a wide range of procedures.

Since the early 1990s, ERAS has gradually become the standard of care in colorectal surgery.(4) ERAS has been investigated and implemented worldwide.(5-10) An ERAS protocol includes more than 20 elements.(11,12)

An increasing body of evidence supports the clinical effectiveness of ERAS for a wide range of procedures. In addition to colorectal surgery, the benefits of ERAS also have been demonstrated in patients undergoing urologic, gynecologic, orthopedic, upper gastrointestinal, hepatobiliary, cardiac, and vascular surgery.

Clinical Outcomes

Meta-analyses of randomized trials comparing an enhanced recovery pathway with traditional perioperative care in colorectal surgery have reported that the ERAS program is associated with earlier recovery and discharge after colonic resection.

Two systematic reviews(13,14) demonstrated that ERAS reduced hospital length of stay (LOS) after colon resection. However, the mortality rate and readmission rate stayed the same.

A Cochrane review(13) included four randomized controlled trials (RCTs) with 237 patients (119 ERAS vs. 118 conventional). The primary LOS was shorter for the ERAS-treated patients (mean difference –2.94 days; 95% CI, –3.69 to –2.19). There was a significant risk reduction for all complications (RR 0.50; 95% CI, 0.35-0.72). Readmission rates were the same in both groups.

ERAS programs can improve clinical outcomes and may also be associated with a reduction in cost.

Varadhan et al.(14) reported on six RCTs with 452 patients, 226 in each group. Patients undergoing major open colonic or colorectal surgery and managed with a perioperative ERAS pathway had a primary hospital stay 2.5 days shorter than those managed with a traditional care pathway [weighted mean difference (random, 95% CI), –2.51 (–3.54, –1.47)]. Management with an ERAS plan resulted in significantly fewer postoperative complications [RR (95% CI): 0.53 (0.41, 0.69)]; there were no statistically significant differences in readmission [RR (95% CI): 0.80 (0.32, 1.98)] and mortality rates [RR (95% CI): 0.53 (0.09, 3.15)].

Economic Benefits

Because of rising healthcare costs, clinical protocols that both improve clinical outcomes and decrease costs are increasingly attractive. Economic evaluations are an essential part of assessments of new health technologies and are important for funding decisions made by hospital administrators, insurers, governments, and policy developers.(15)

ERAS programs can improve clinical outcomes and may also be associated with a reduction in costs as a result of the reduction in LOS and morbidity. A recent systemic review describes economic evaluations in a wide variety of abdominal surgical procedures conducted in an ERAS program. Almost all studies showed decreases in LOS and costs, and none of the included studies found a significant increase in the incidence of either readmission or morbidity.(15)

Colorectal Surgery

The cost reductions following implementation of ERAS programs for patients undergoing elective colorectal surgery are well documented.(16-18) Lemanu et al.(19) reported on seven studies in colorectal surgery, all of which demonstrated cost reductions. Lee et al.(20) reported on 10 studies. Five of those studies provided enough information to calculate incremental cost-effectiveness ratios, and all 10 studies showed ERAS programs were less costly and more effective for reducing LOS. Roulin et al.(21) demonstrated that ERPs have resulted in a mean savings of €1651 ($2245) per colorectal surgical patient.

Bariatric Surgery

Lemanu et al.(22) conducted an RCT comparing patients undergoing laparoscopic sleeve gastrectomy in an ERAS protocol with those receiving conventional care. The LOS was significantly shorter in the ERAS group than in the control and historical groups. There was no difference in readmission rates or postoperative complications, and the mean cost per patient was significantly lower in the ERAS group than in the historical group.

Gastric Surgery

A systematic review assessed ERAS in gastric surgery.(23) Five studies with a total of 400 patients were included in the meta-analysis. All included studies reported that postoperative hospital stay was significantly lower for the ERAS group in comparison with the conventional perioperative care group. There was no significant difference in readmission rates between the two groups. ERAS did not increase postoperative complications compared with the conventional group. The LOS was significantly shorter in the ERAS group than in the control group. Mortality, morbidity, and readmissions were similar between groups, and hospital costs were significantly less in the ERAS group than in the conventional group. Total costs were significantly decreased with ERAS.

Gynecology

Yoong et al.(24) described implementation of an ERAS protocol in vaginal hysterectomy. Fifty patients who underwent vaginal hysterectomy after implementation of ERAS were compared with 50 control patients before ERAS. The LOS was reduced by 51.6%, and the percentage of patients discharged within 24 hours was increased five-fold. A cost savings of 9.25% per patient was realized with an ERAS protocol.

In a case-control study, Relph et al.(25) reported on similar cost data in their study of 100 patients undergoing vaginal hysterectomy (50 ERAS and 50 control patients). The inpatient readmission rate was similar in both groups. Establishing the program incurred additional expenditures, including delivering a patient-orientated gynecology “school” and employing a specialist enhanced recovery nurse, but despite these, they demonstrated a saving of 15.2% (or £164.86) per patient.

Kalogera et al.(26) reported on 241 patients who underwent a variety of different types of gynecologic surgery after implementation of an ERP protocol compared with 235 historic controls from one year earlier matched by procedure type. The ERAS program resulted in a 4-day reduction in LOS, with stable readmission rates and a 30-day cost savings of more than $7600 per patient (18.8% reduction).

Gerardi(27) studied the patients with advanced ovarian and primary peritoneal cancers who required rectosigmoid colectomy as part of cytoreductive surgery. Nineteen patients had their postoperative management prescribed by an ERAS pathway, whereas 45 patients were cared for by individual surgeon preference (conventional). Patients in the ERAS group had a shorter median LOS. The median total hospital cost of postoperative care for patients in the ERAS group was $19,700, compared with a median total cost of $25,110 for patients in the conventional group. Overall, clinical pathway–directed management was associated with a median reduction in total direct and indirect hospital cost of postoperative care of $5410 per patient.

Pancreatic Surgery

Coolsen et al.(28) systematically reviewed ERAS programs in pancreaticoduodenectomies. They included five case-control studies, two retrospective studies, and one prospective study, with a total of 1558 patients. Meta-analysis of four studies focusing on pancreaticoduodenectomies showed that complication rates were significant lower in the ERAS group. Neither mortality nor readmissions increased after introduction of an ERAS protocol. All studies reported a decrease in total hospital costs after introduction of their ERAS pathways, and this decrease was significant in the three studies focusing on pancreaticoduodenectomy.

Esophageal Surgery

Lee et al.(29) investigated the clinical and economic outcomes of an ERAS program in esophagectomy. A total of 106 patients were included (47 traditional care, 59 ERAS). The LOS was lower in the ERAS group than in the traditional care group, and there was no difference in 30-day complication rates between the two groups. Costs were significantly lower after implementation of the ERAS. The ERAS pathway resulted in €2013 overall cost saving per patient.

Vascular Surgery

Tatsuishi et al.(30) reported on the clinical and economic outcomes in patients undergoing open aortic aneurysm repair. The postoperative LOS was significantly shorter for the ERAS group, and in-hospital medical costs for the ERAS group decreased by 8% compared with those for the conventionally managed group.

Setup Costs

ERAS programs require significant time and money to implement and maintain. Sammour et al.(17) reported on establishing an ERAS program in New Zealand. Setup costs included salaries for research personnel, ERAS patient materials, supplemental nutrition drinks, preoperative carbohydrate drink, resource supplements, preoperative patient education, and time for establishing ERAS protocols. Although the ERAS program required an additional cost of approximately 2000 NZD per patient to implement, these costs were paid off after only 15 patients had participated in the program, with an overall saving per patient of just under 7000 NZD.(17) Successful implementation of ERAS pathways has been reported following a brief preparatory period, including the requirements for staff and patient education.( 31,32)

Conclusion

Evidence from clinical and economic evaluations indicates that ERAS protocols across many abdominal surgical specialties are clinically efficacious and cost effective. Evidence from RCTs, systematic reviews, and meta-analyses has demonstrated that ERAS can improve healthcare quality with lower cost.

When performing an economic evaluation of an intervention, the costs are determined by payer costs directly or indirect societal costs indirectly.(33) The costs (and effectiveness) of an intervention often are evaluated by the amount of in-hospital resource utilization or the costs incurred during readmissions.(15) Measurement of such direct costs may not represent the costs/benefits to the welfare of the population as a whole.(15) From a societal perspective, the influence of return to work, mood, and quality of life should be included in the costs of an intervention.(15) Therefore, these results must be interpreted with caution, as there is significant study heterogeneity and limited generalizability across countries and institutions.(20)

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