The Impact of the Implementation of the Enhanced Recovery After Surgery (ERAS®) Program in an Entire Health System: A Natural Experiment in Alberta, Canada
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.
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.
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).
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.
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.
Compliance with ethical standards
Conflict of interest
None of the authors have any conflict of interest relating to this study.
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