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



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.


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.


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.


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


Compliance with ethical standards


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.


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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

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