Abstract
Background
Enhanced recovery after surgery (ERAS) protocols have been well documented in the current literature to improve healthcare outcomes by decreasing length of stay, resource utilization, and morbidity without increasing readmission rates or complications. This subsequently leads to a net decrease in hospital costs. However, the initial costs of implementing such a program have not been well described, which is crucial information for hospitals with less resources. The aim of this study was to provide a cohesive review of the current literature for the costs of implementing a colorectal surgery ERAS protocol.
Methods
A comprehensive review was conducted on five databases (Google Scholar, Web of Science, PROSPERO, PubMed, and Cochrane) with the assistance of a professional librarian. All relevant English articles published between 1995 and June 2021 were screened for eligibility prior to inclusion in the review. Cost data were converted to US dollars based on the exchange rate at the end time of the study period for standardization.
Results
Seven studies were included for review. The studies evaluated a range of 50–1295 patients through their respective ERAS programs, which were followed for 5 to 22 months. ERAS implementation costs ranged from $57 to $1536 per patient. Components for each ERAS program varied for each study, but ultimately, the greatest costs were attributed to personnel.
Conclusions
Despite data heterogeneity and inconsistencies between cost breakdowns, a majority of the implementation cost was found to be secondary to personnel. This review demonstrates the need for a more standardized approach for reporting ERAS implementation costs through an open database as well as a potential streamlining of the ERAS protocol to facilitate implementation in institutions with less financial resources.
Similar content being viewed by others
References
Kehlet H (1997) Multimodal approach to control postoperative pathophysiology and rehabilitation. Br J Anaesth 78:606–617
Fearon KC, Ljungqvist O, Von Meyenfeldt M et al (2005) Enhanced recovery after surgery: a consensus review of clinical care for patients undergoing colonic resection. Clin Nutr 24(3):466–477
Ljungqvist O, Scott M, Fearon KC (2017) Enhanced recovery after surgery: a review. JAMA Surg. https://doi.org/10.1001/jamasurg.2016.4952
Greenshields N, Mythen M (2020) Enhanced recovery after surgery. Curr Anesthesiol Rep 10:49–55
El-Shewy A, Abdalla W, Baghdadi M (2020) Enhanced recovery after surgery protocol in colorectal surgery. Egypt J Surg 1:94–101
Fierens J, Wolthuis AM, Penninckx F, D’Hoore A (2012) Enhanced recovery after surgery (ERAS) protocol: prospective study of outcome in colorectal surgery. Acta Chir Belg 112(5):355–358
Geltzeiler CB, Rotramel A, Wilson C, Deng L, Whiteford MH, Frankhouse J (2014) Prospective study of colorectal enhanced recovery after surgery in a community hospital. JAMA Surg 149(9):955–961
Jung AD, Dhar VK, Hoehn RS et al (2018) Enhanced recovery after colorectal surgery: can we afford not to use it? J Am Coll Surg 226(4):586–593
Persico M, Miller D, Way C et al (2018) Implementation of enhanced recovery after surgery in a community hospital: an evidence-based approach. J Perianesth Nurs 34(1):188–197
Schilling PL, Dimick JB, Birkmeyer JD (2008) Prioritizing quality improvement in general surgery. J Am Coll Surg 207(5):698–704
Alvarez A, Goudra BG, Singh PM (2017) Enhanced recovery after bariatric surgery. Curr Opin Anaesthesiol 30(1):133–139
Małczak P, Pisarska M, Piotr M et al (2016) Enhanced recovery after bariatric surgery: systematic review and meta-analysis. Obes Surg 27:226–235
Auyong DB, Allen CJ, Pahang JA et al (2015) Reduced length of hospitalization in primary total knee arthroplasty patients using an updated enhanced recovery after orthopedic surgery (ERAS) pathway. J Arthroplasty 30(1):1705–1709
Ayrian E, Sugeir SH, Arakelyan A et al (2021) Impact of a perioperative protocol on length of ICU and hospital stay in complex spine surgery. J Neurosurg Anesthesiol 33(1):65–72
Dietz N, Sharma M, Adams S et al (2019) Enhanced Recovery After Surgery (ERAS) for spine surgery: a systematic review. World Neurosurg 130:415–426
Bisch SP, Jago CA, Kalogera E, Ganshorn H, Meyer LA, Ramirez PT, Dowdy SC, Nelson G (2021) Outcomes of enhanced recovery after surgery (ERAS) in gynecologic oncology - a systematic review and meta-analysis. Gynecol Oncol 161(1):46–55
Glaser G, Dowdy SC, Peedicayil A (2018) Enhanced recovery after surgery in gynecologic oncology. Int J Gynaecol Obstet 143(Suppl 2):143–146
Brown JK, Singh K, Dumitru R et al (2018) The benefits of enhanced recovery after surgery programs and their application in cardiothoracic surgery. Methodist Debakey Cardiovasc J 14(2):77–88
Golder HJ, Papalois V (2021) Enhanced recovery after surgery: history, key advancements and developments in transplant surgery. J Clin Med 10(8):1634
Gao R, Yang H, Li Y, Meng L, Li Y, Sun B, Zhang G, Yue M, Guo F (2019) Enhanced recovery after surgery in pediatric gastrointestinal surgery. J Int Med Res 47(1):4815–4826
Kocián P, Whitley A, Prikryl P et al (2019) Enhanced recovery after colorectal surgery: the clinical and economic benefit in elderly patients. Eur Surg 51:183–188
Pirrera B, Lucchi A, Gabbianelli C et al (2017) E.R.A.S. pathway in colorectal surgery in elderly: our experience: a retrospective cohort study. Int J Surg 43:101–106
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):955–961
Norcross W, Miller TE, Huang S et al (2019) Implementation of a successful enhanced recovery after surgery program in a community hospital. Cureus 11(10):e6029
Khanijow AN, Wood LN, Xie R et al (2020) The impact of an enhanced recovery program (ERP) on the costs of colorectal surgery. Am J Surg 222(1):186–192
Singh S, Liverpool A, Romeiser JL et al (2021) Types of surgical patients enrolled in enhanced recovery after surgery (ERAS) programs in the USA. Perioper Med 10(12).
Page M, McKenzie J, Bossuyt P et al (2021) The PRISMA 2020 statement: an updated guideline for reporting systematic reviews. BMJ 372:n71
Nelson G, Kiyang LN, Chuck A et al (2016) Cost impact analysis of Enhanced Recovery After Surgery program implementation in Alberta colon cancer patients. Curr Oncol 23(3):e221-227
Roulin D, Donadini A, Gander S et al (2013) Cost-effectiveness of the implementation of an enhanced recovery protocol for colorectal surgery. Br J Surg 100(8):1108–1114
Stone AB, Grant MC, Pio Roda C et al (2016) Implementation costs of an enhanced recovery after surgery program in the United States: a financial model and sensitivity analysis based on experiences at a quaternary academic medical center. J Am Coll Surg 222(3):219–225
Portinari M, Ascanelli S, Targa S et al (2018) Impact of a colorectal enhanced recovery program implementation on clinical outcomes and institutional costs: a prospective cohort study with retrospective control. Int J Surg 53:206–213
Lee L, Mata J, Ghitulescu GA et al (2015) Cost-effectiveness of enhanced recovery versus conventional perioperative management for colorectal surgery. Ann Surg 262(6):1026–1033
Thanh NX, Chuck AW, Wasylak T et al (2016) An economic evaluation of the Enhanced Recovery After Surgery (ERAS) multisite implementation program for colorectal surgery in Alberta. Can J Surg 59(6):415–421
Sammour T, Zargar-Shoshtari K, Bhat A et al (2010) A programme of Enhanced Recovery After Surgery (ERAS) is a cost-effective intervention in elective colonic surgery. N Z Med J 123(1319):61–70
Nelson G, Kiyang LN, Crumley ET et al (2016) Implementation of an enhanced recovery after surgery (ERAS) across a provincial healthcare system: the ERAS Alberta Colorectal Surgery Experience. World J Surg 40:1092–1103
Gustafsson UO, Scott MJ, Hubner M et al (2019) Guidelines for perioperative care in elective colorectal surgery: enhanced recovery after surgery (ERAS®) Society recommendations: 2018. World J Surg 43(3):659–695
Stone AB, Grant MC, Wu CL et al (2019) Enhanced recovery after surgery for colorectal surgery: a review of the economic implications. Clin Colon Rectal Surg 32(2):129–213
Thanh NX, Nelson A, Wang X et al (2020) Return on investment of the Enhanced Recovery After Surgery (ERAS) multiguideline, multisite implementation in Alberta. Canada Can J Surg 63(6):E542–E550
Seif MA, Kruse BC, Keramati CA, et al (2022) Development and implementation of an institutional enhanced recovery program data process. Health Inf. Manag. J. 0(0). doi:https://doi.org/10.1177/18333583221095139
Cardell CF, Knapp L, Cohen ME et al (2021) Successful implementation of enhanced recovery in elective colorectal surgery is variable and dependent on the local environment. Ann Surg 274(4):605–612
Campbell DA Jr, Englesbe MJ, Kubus JJ et al (2010) Accelerating the pace of surgical quality improvement: the power of hospital collaboration. Arch Surg 145(10):985–991
Hedrick TL, Thiele RH, Hassinger TE et al (2019) Multicenter observational study examining the implementation of enhanced recovery within the virginia surgical quality collaborative in patients undergoing elective colectomy. J Am Coll Surg 229(4):374-382.e3
Smucker L, Victory J, Scribani M et al (2020) Rural context, single institution prospective outcomes after enhanced recovery colorectal surgery protocol implementation. BMC Health Serv Res 20(1):1120
Urias DS, Di Como J, Marley M et al (2019) Resident implementation of an enhanced recovery pathway for colorectal surgery in a rural community. Am Surg 85(12):E593–E595
Rona K, Choi J, Sigle G et al (2012) Enhanced recovery protocol: implementation at a county institution with limited resources. Am Surg 78(10):1041–1044
Ahmed J, Khan S, Gatt M et al (2010) Compliance with enhanced recovery programmes in elective colorectal surgery. Br J Surg 97(5):754–758
Author information
Authors and Affiliations
Corresponding author
Ethics declarations
Conflict of interest
All authors declare no conflicts of interest or financial support for the review.
Additional information
Publisher's Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
Supplementary Information
Below is the link to the electronic supplementary material.
Rights and permissions
Springer Nature or its licensor (e.g. a society or other partner) holds exclusive rights to this article under a publishing agreement with the author(s) or other rightsholder(s); author self-archiving of the accepted manuscript version of this article is solely governed by the terms of such publishing agreement and applicable law.
About this article
Cite this article
Hong, M., Ghajar, M., Allen, W. et al. Evaluating Implementation Costs of an Enhanced Recovery After Surgery (ERAS) Protocol in Colorectal Surgery: A Systematic Review. World J Surg 47, 1589–1596 (2023). https://doi.org/10.1007/s00268-023-07024-2
Accepted:
Published:
Issue Date:
DOI: https://doi.org/10.1007/s00268-023-07024-2