Advertisement

Surgical Endoscopy

, Volume 33, Issue 7, pp 2222–2230 | Cite as

An enhanced recovery program in colorectal surgery is associated with decreased organ level rates of complications: a difference-in-differences analysis

  • Alexander T. HawkinsEmail author
  • Timothy M. Geiger
  • Adam B. King
  • Jonathan P. Wanderer
  • Vikram Tiwari
  • Roberta L. Muldoon
  • Molly M. Ford
  • Roger R. Dmochowski
  • Warren S. Sandberg
  • Barbara Martin
  • M. Benjamin Hopkins
  • Matthew D. McEvoy
Article

Abstract

Background

Perioperative care has lacked coordination and standardization. Enhanced recovery programs (ERPs) have been shown to decrease aggregate complications across surgical specialties. We hypothesize that the sustained implementation of an ERP will be associated with a decrease in a broad range of complications at the organ system level.

Study design

Adult patients undergoing elective colorectal procedures between 1/2011 and 10/2016 were included. Patients were stratified based on exposure to a sustained ERP (7/2014–10/2016) after an 18-month wash-in period in a pre-post analysis. The primary outcome was 30-day complication rate by organ category as collected by National Surgical Quality Improvement Program (NSQIP) abstractors. Demographic and other patient level data were collected. Complication rates were compared using multivariable regression employing a differences-in-differences (DiD) approach using the national NSQIP PUF file to account for secular trends.

Results

A total of 1182 patients were included in this study, with 47% treated in an ERP. The two groups were similar in age, gender, race, BMI, comorbidity index, and procedure type. In a multivariable DiD analysis, significant reductions were seen in surgical site infection (OR 0.30; 95% CI 0.20–0.43), postoperative pulmonary complications (OR 0.46; 95% CI 0.24–0.90), transfusion (OR 0.27; 95% CI 0.15–0.51), urinary tract infections (OR 0.34; 95% CI 0.18–0.66), sepsis (OR 0.35; 95% CI 0.20–0.61), and cardiac complications (OR 0.10; 95% CI 0.01–0.84). A reduction in return to the operating room and 30-day readmission was also observed. Median length of stay (LOS) decreased from 5.2 to 3.5 days (p < 0.001). No significant changes occurred for acute kidney injury and hematologic complications.

Conclusion

An ERP was associated with reduced complication rates across a wide range of organ categories and > 1.5-day reduction in LOS in a colorectal surgery population.

Keywords

Colorectal surgery Outcomes Enhanced recovery after surgery Enhanced recovery program Surgical site infection Perioperative care 

Notes

Compliance with ethical standards

Disclosures

The American College of Surgeons National Surgical Quality Improvement Program and the hospitals participating in the ACS NSQIP are the source of the data used herein; they have not verified and are not responsible for the statistical validity of the data analysis or the conclusions derived by the authors. Drs. Alexander T. Hawkins, Timothy M. Geiger, Adam B. King, Jonathan P. Wanderer, Vikram Tiwari, Roberta L. Muldoon, Molly M. Ford, Roger R. Dmochowski, Warren S. Sandberg M. Benjamin Hopkins, Matthew D. McEvoy, and Ms. Barbara Martin have no conflicts of interest or financial ties to disclose.

References

  1. 1.
    Spanjersberg WR, Reurings J, Keus F et al (2011) Fast track surgery versus conventional recovery strategies for colorectal surgery. Cochrane Database Syst Rev.  https://doi.org/10.1002/14651858.CD007635.pub2 Google Scholar
  2. 2.
    Batdorf NJ, Lemaine V, Lovely JK et al (2015) Enhanced recovery after surgery in microvascular breast reconstruction. J Plast Reconstr Aesthet Surg 68(3):395–402CrossRefGoogle Scholar
  3. 3.
    Bona S, Molteni M, Rosati R et al (2014) Introducing an enhanced recovery after surgery program in colorectal surgery: a single center experience. World J Gastroenterol 20(46):17578–17587CrossRefGoogle Scholar
  4. 4.
    Keenan JE, Speicher PJ, Nussbaum DP et al (2015) Improving outcomes in colorectal surgery by sequential implementation of multiple standardized care programs. J Am Coll Surg 221(2):404–414CrossRefGoogle Scholar
  5. 5.
    Miller TE, Thacker JK, White WD et al (2014) Reduced length of hospital stay in colorectal surgery after implementation of an enhanced recovery protocol. Anesth Analg 118(5):1052–1061CrossRefGoogle Scholar
  6. 6.
    Page AJ, Ejaz A, Spolverato G et al (2015) Enhanced recovery after surgery protocols for open hepatectomy–physiology, immunomodulation, and implementation. J Gastrointest Surg 19(2):387–399CrossRefGoogle Scholar
  7. 7.
    Persson B, Carringer M, Andren O et al (2015) Initial experiences with the enhanced recovery after surgery (ERAS) protocol in open radical cystectomy. Scand J Urol 49(4):302–307CrossRefGoogle Scholar
  8. 8.
    Wang C, Chen HN, Zhou ZG (2015) Two-day hospital stay after laparoscopic colorectal surgery: is enhanced recovery program a healthcare system-specific issue? World J Surg 39(5):1329–1330CrossRefGoogle Scholar
  9. 9.
    Zhuang CL, Ye XZ, Zhang XD et al (2013) Enhanced recovery after surgery programs versus traditional care for colorectal surgery: a meta-analysis of randomized controlled trials. Dis Colon Rectum 56(5):667–678CrossRefGoogle Scholar
  10. 10.
    Greco M, Capretti G, Beretta L et al (2014) Enhanced recovery program in colorectal surgery: a meta-analysis of randomized controlled trials. World J Surg 38(6):1531–1541CrossRefGoogle Scholar
  11. 11.
    Group EC (2015) The impact of enhanced recovery protocol compliance on elective colorectal cancer resection: results from an international registry. Ann Surg 261(6):1153–1159CrossRefGoogle Scholar
  12. 12.
    Ljungqvist O, Scott M, Fearon KC (2017) Enhanced recovery after surgery: a review. JAMA Surg 152(3):292–298CrossRefGoogle Scholar
  13. 13.
    Thiele RH, Rea KM, Turrentine FE et al (2015) Standardization of care: impact of an enhanced recovery protocol on length of stay, complications, and direct costs after colorectal surgery. J Am Coll Surg 220(4):430–443CrossRefGoogle Scholar
  14. 14.
    Okrainec A, Aarts MA, Conn LG et al (2017) Compliance with urinary catheter removal guidelines leads to improved outcome in enhanced recovery after surgery patients. J Gastrointest Surg 21(8):1309–1317CrossRefGoogle Scholar
  15. 15.
    Eskicioglu C, Forbes SS, Aarts MA et al (2009) Enhanced recovery after surgery (ERAS) programs for patients having colorectal surgery: a meta-analysis of randomized trials. J Gastrointest Surg 13(12):2321–2329CrossRefGoogle Scholar
  16. 16.
    Liu VX, Rosas E, Hwang J et al (2017) Enhanced recovery after surgery program implementation in 2 surgical populations in an integrated health care delivery system. JAMA Surg 152(7):e171032CrossRefGoogle Scholar
  17. 17.
    Vlug MS, Wind J, Hollmann MW et al (2011) Laparoscopy in combination with fast track multimodal management is the best perioperative strategy in patients undergoing colonic surgery: a randomized clinical trial (LAFA-study). Ann Surg 254(6):868–875CrossRefGoogle Scholar
  18. 18.
    Wood T, Aarts MA, Okrainec A et al (2018) Emergency room visits and readmissions following implementation of an enhanced recovery after surgery (iERAS) program. J Gastrointest Surg 22(2):259–266CrossRefGoogle Scholar
  19. 19.
    McEvoy MD, Wanderer JP, King AB et al (2016) A perioperative consult service results in reduction in cost and length of stay for colorectal surgical patients: evidence from a healthcare redesign project. Perioper Med 5:3CrossRefGoogle Scholar
  20. 20.
    Charlson ME, Pompei P, Ales KL et al (1987) A new method of classifying prognostic comorbidity in longitudinal studies: development and validation. J Chronic Dis 40(5):373–383CrossRefGoogle Scholar
  21. 21.
    Wickstrom G, Bendix T (2000) The “Hawthorne effect"—what did the original Hawthorne studies actually show? Scand J Work Environ Health 26(4):363–367CrossRefGoogle Scholar
  22. 22.
    Program ACoSNSQI (2016) ACS NSQIP® semiannual report. American College of Surgeons, ChicagoGoogle Scholar
  23. 23.
    Program ACoSNSQI (2016) User guide for the 2015 ACS NSQIp participant use data file. https://www.facs.org/~/media/files/quality%20programs/nsqip/nsqip_puf_user_guide_2015.ashx. Accessed 5 Jul 2017
  24. 24.
    Colla CH, Wennberg DE, Meara E et al (2012) Spending differences associated with the medicare physician group practice demonstration. JAMA 308(10):1015–1023CrossRefGoogle Scholar
  25. 25.
    Dimick JB, Ryan AM (2014) Methods for evaluating changes in health care policy: the difference-in-differences approach. JAMA 312(22):2401–2402CrossRefGoogle Scholar
  26. 26.
    Volpp KG, Rosen AK, Rosenbaum PR et al (2007) Mortality among hospitalized medicare beneficiaries in the first 2 years following ACGME resident duty hour reform. JAMA 298(9):975–983CrossRefGoogle Scholar
  27. 27.
    Donald SGKL (2007) Inference with difference-in-differences and other panel data. Rev Econ Stat 89(2):221–233CrossRefGoogle Scholar
  28. 28.
    Ryan AM (2009) Effects of the premier hospital quality incentive demonstration on medicare patient mortality and cost. Health Serv Res 44(3):821–842CrossRefGoogle Scholar
  29. 29.
    Kang CY, Chaudhry OO, Halabi WJ et al (2012) Outcomes of laparoscopic colorectal surgery: data from the nationwide inpatient sample 2009. Am J Surg 204(6):952–957CrossRefGoogle Scholar
  30. 30.
    Gillissen F, Ament SM, Maessen JM et al (2015) Sustainability of an enhanced recovery after surgery program (ERAS) in colonic surgery. World J Surg 39(2):526–533CrossRefGoogle Scholar
  31. 31.
    Hammond JS, Humphries S, Simson N et al (2014) Adherence to enhanced recovery after surgery protocols across a high-volume gastrointestinal surgical service. Dig Surg 31(2):117–122CrossRefGoogle Scholar
  32. 32.
    Huang J (2014) Enhanced recovery after surgery. AANA J 82(4):259–261Google Scholar
  33. 33.
    Maessen J, Dejong CH, Hausel J et al (2007) A protocol is not enough to implement an enhanced recovery programme for colorectal resection. Br J Surg 94(2):224–231CrossRefGoogle Scholar
  34. 34.
    Paton F, Chambers D, Wilson P et al (2014) Effectiveness and implementation of enhanced recovery after surgery programmes: a rapid evidence synthesis. BMJ Open 4(7):e005015CrossRefGoogle Scholar
  35. 35.
    Shah PM, Johnston L, Sarosiek B et al (2017) Reducing readmissions while shortening length of stay: the positive impact of an enhanced recovery protocol in colorectal surgery. Dis Colon Rectum 60(2):219–227CrossRefGoogle Scholar
  36. 36.
    Geltzeiler CB, Rotramel A, Wilson C et al (2014) Prospective study of colorectal enhanced recovery after surgery in a community hospital. JAMA Surg 149(9):955–961CrossRefGoogle Scholar
  37. 37.
    Stowers MD, Lemanu DP, Hill AG (2015) Health economics in enhanced recovery after surgery programs. Can J Anaesth 62(2):219–230CrossRefGoogle Scholar
  38. 38.
    Medicine IoMURoE-B (2010) The healthcare imperative: lowering costs and improving outcomes: workshop series summary. National Academies Press (US), Washington, DCGoogle Scholar
  39. 39.
    Thacker JK, Mountford WK, Ernst FR et al (2016) Perioperative fluid utilization variability and association with outcomes: considerations for enhanced recovery efforts in sample us surgical populations. Ann Surg 263(3):502–510CrossRefGoogle Scholar
  40. 40.
    Kiran RP, El-Gazzaz GH, Vogel JD et al (2010) Laparoscopic approach significantly reduces surgical site infections after colorectal surgery: data from national surgical quality improvement program. J Am Coll Surg 211(2):232–238CrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC, part of Springer Nature 2018

Authors and Affiliations

  • Alexander T. Hawkins
    • 1
    Email author
  • Timothy M. Geiger
    • 1
  • Adam B. King
    • 2
  • Jonathan P. Wanderer
    • 3
  • Vikram Tiwari
    • 3
  • Roberta L. Muldoon
    • 1
  • Molly M. Ford
    • 1
  • Roger R. Dmochowski
    • 4
  • Warren S. Sandberg
    • 3
  • Barbara Martin
    • 5
  • M. Benjamin Hopkins
    • 1
  • Matthew D. McEvoy
    • 3
  1. 1.Section of Colon & Rectal Surgery, Division of General SurgeryVanderbilt University Medical CenterNashvilleUSA
  2. 2.Department of AnesthesiologyVanderbilt University Medical CenterNashvilleUSA
  3. 3.Departments of Anesthesiology and Biomedical InformaticsVanderbilt University Medical CenterNashvilleUSA
  4. 4.Section of Surgical Sciences, Department of UrologyVanderbilt University Medical CenterNashvilleUSA
  5. 5.Department of Quality, Safety and Risk PreventionVanderbilt University Medical CenterNashvilleUSA

Personalised recommendations