Abstract
Background
The Enhanced Recovery After Surgery (ERAS) program has been shown to reduce length of stay (LOS) in colorectal surgical patients in randomized trials. The impact outside of trial settings, or in subgroups of patients excluded from trials such as individuals with diabetes, is uncertain. We conducted this study to evaluate the impact of ERAS implementation in Alberta, Canada.
Methods
This is a retrospective cohort study and interrupted time series analysis using linked administrative data to examine LOS and postoperative outcomes in the 12 months pre- and post-implementation of ERAS in 2013 for all adults undergoing elective colorectal surgery.
Results
Of 2714 patients (mean age 60.4 years, 55% men) with similar demographics and comorbidity profiles in the pre/post-ERAS time periods, LOS was significantly shorter post-ERAS (8.5 vs. 9.5 days, p = 0.01; − 0.84 days [95% CI − 0.04 to − 1.64 days] after adjustment for age, sex, Charlson comorbidity score, procedure type, surgical approach, and hospital). However, interrupted time series demonstrated no significant level change (p = 0.30) or change in slope (p = 0.63) with ERAS implementation, consistent with continuation of an underlying secular trend of reductions in LOS over time. There were no significant differences (in multivariate analysis or ITS) in risk of 30-day death/readmission (14.3% post vs. 13.5% pre-ERAS, aOR 1.12, 95% CI 0.89–1.40), 30-day death/ED visit (27.2% post vs. 30.0% pre, aOR 0.93, 95% CI 0.78–1.10), or 30-day death/readmission/ED visit (27.8% post vs. 30.6% pre, aOR 0.93, 95% CI 0.78–1.10). The 428 patients with diabetes had longer LOS but exhibited no significant difference post- versus pre-ERAS (10.7 vs. 11.6 days, p = 0.53; p = 0.56 for level change and p = 0.66 for slope change on ITS).
Conclusion
Although there was a secular trend toward decreasing LOS over time in Alberta, ERAS implementation was not associated with statistically significant changes in LOS or postoperative outcomes for all colorectal surgery patients or for those with diabetes. Our study highlights the importance of evaluating system changes (for both uptake and outcomes) rather than assuming trial benefits will translate directly into practice. Interventions to improve LOS and postoperative outcomes for patients with diabetes undergoing colorectal surgery are still needed even in the ERAS era.
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Acknowledgements
This work was supported by the Alberta Strategy for Patient Oriented Research Support Unit Data Platform. The authors thank Mr. Edwin Rogers, M.A. (Senior Analyst, Clinical Analytics, Alberta Health Services) for assistance with colorectal surgery case definitions and logic, as well as access to the patient lists maintained by the ERAS team for cross-validation with our administrative data. They also extend their thanks to Jeff Bakal, Ph.D., P.Stat (Alberta SPOR Support Unit, University of Alberta) for assistance with study design and statistical methods and Peter Faris, Ph.D. (Director, Research Facilitation, Analytics, DIMR, Alberta Health Services) for statistical review. Zaina Albalawi and Erik Youngson had full access to all the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.
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Appendix
Appendix
ICD-10 codes used to define index hospitalization complications [13]
Category | Complications | ICD-10 |
---|---|---|
Gastrointestinal | Small bowel obstruction, anastomotic stricture (include peritoneal adhesions), pouch leak pouch failure, bowel perforation, ileus, ischemic bowel, GI bleeding (also include other hemorrhage and hemorrhagic conditions), ileostomy/colostomy complication or malfunction, digestive organ disorders (include acute hepatic failure and acute pancreatitis), other GI complications (include pneumatosis) | K22.8, K25.0, K25.2, K25.4, K25.6, K26.0, K26.1, K26.2, K26.4, K26.5, K26.6, K27.0, K27.2, K27.4, K27.6, K28.0, K28.2, K28.4, K28.6, K29.0, K55.0, K55.9, K56.0, K56.5, K56.6, K56.7, K62.5, K63.1, K63.8, K66.0, K65.5, K65.6, K72.0, K72.9, K85, K91.3, K91.4, K91.8, K91.9, K92, T79.2, T81.0, T88.8 |
Wounds | Fistula, hematoma/seroma, wound dehiscence and delayed wound healing, Iatrogenic injuries (include foreign body accidentally left during procedure) and pressure ulcer. | K60.3, K60.4, K60.5, K63.2, K82.9, K83.2, L89, N36.0, N82.4, T81.2, T81.3, T81.5, T81.8, 1.OT.52.DA, 1.OT.56.DA, 1.OT.70.LA,1.OW.80, 2.OT.70.LA |
Infections | Sepsis and bacteremia, abscess, wound infection, urinary tract infection, pneumonia and empyema, other infections (include peritonitis, and bacterial skin and subcutaneous tissue infection). | A40, A41, A49, B95, B96, J10.0, J11.0, J12, J13, J14, J15, J16, J17, J18, J69.0, J85, J86, K61, K63.0, K65, L03, L04, N10, N12, N15.1, N15.9, N30.0, N30.9, N39.0, R78.8, T79.3, T80.2, T81.4, T81.6, T82.7, T83.6, T85.7 |
Renal and endocrine | Acute renal failure, fluid and electrolyte disorders (include hypokalemia), severe endocrine disorders (include adrenal disorders and hypoglycemic coma), retention of urine (include atony of bladder), other urinary complication (include urinary obstruction) | E15, E272, E86, E87, N13.9, N17, N19, N31.2, N99.0, N99.9, R33 |
Cardiovascular disorders | Thrombosis/embolism, myocardial infarction, cardiac arrest, hypotension or shock, cardiac arrhythmias (exclude tachycardia), heart failure, other cardiovascular complication (include atherosclerotic heart disease, and angina) | I21, I26, I46, I48, I49, I50, I74, I80, I81, I82, I95.0, I95.2, I95.9, I97.8, I97.9, R57, T79.0, T80.0, T80.1, T81.1, T81.7, T88.2 |
Pulmonary | Acute respiratory failure, hypoxia, pleural effusion and pulmonary edema, pneumothorax and atelectasis, other pulmonary complications (include asthma, extubation failure, and difficulty breathing) | J80, J81, J90, J91, J93, J95.5, J95.8, J95.9, J96.0, J96.9, J98.1, R09 |
Neurological disorders | Cerebrovascular disease, neurological disorders (psychoses/delirium/seizure), disorders/complications of nervous system (include neuropathies) | F05, F13, F15, F19, G45, G46, G81, G82, G83, G93.1, G93.6, G97.0, G97.1, G97.8, G97.9, I63, I65 |
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AlBalawi, Z., Gramlich, L., Nelson, G. et al. The Impact of the Implementation of the Enhanced Recovery After Surgery (ERAS®) Program in an Entire Health System: A Natural Experiment in Alberta, Canada. World J Surg 42, 2691–2700 (2018). https://doi.org/10.1007/s00268-018-4559-0
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DOI: https://doi.org/10.1007/s00268-018-4559-0