Variation in care for surgical patients with colorectal cancer: protocol adherence in 12 European hospitals
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Surgical care for patients with colorectal cancer has become increasingly standardized. The Enhanced Recovery After Surgery (ERAS) protocol is a widely accepted structured care method to improve postoperative outcomes of patients after surgery. Despite growing evidence of effectiveness, adherence to the protocol remains challenging in practice. This study was designed to assess the adherence rate in daily practice and examine the relationship between the importance of interventions and adherence rate.
This international observational, cross-sectional multicenter study was performed in 12 hospitals in four European countries. Patients were included from January 1, 2014. Data was retrospectively collected from the patient record by the local study coordinator.
A total of 230 patients were included in the study. Protocol adherence was analyzed for both the individual interventions and on patient level. The interventions with the highest adherence were antibiotic prophylaxis (95%), thromboprophylaxis (87%), and measuring body weight at admission (87%). Interventions with the lowest adherence were early mobilization—walking and sitting (9 and 6%, respectively). The adherence ranged between 16 and 75%, with an average of 44%.
Our results show that the average protocol adherence in clinical practice is 44%. The variation on patient and hospital level is considerable. Only in one patient the adherence rate was >70%. In total, 30% of patients received 50% or more of the key interventions. A solid implementation strategy seems to be needed to improve the uptake of the ERAS pathway. The importance-performance matrix can help in prioritizing the areas for improvement.
KeywordsERAS Colorectal surgery Care pathways Protocol adherence Importance-performance analysis
Research made possible by an unconditional educational grant by Baxter SA, Baxter Belgium, Baxter France, Baxter Germany, and Baxter The Netherlands to the European Pathway Association. Baxter had no influence on the study. We would like to thank the teams in the participating hospitals for their commitment. The participating hospitals are as follows: Belgium: AZ Groeninge, Kortrijk (Dr. D. Devriendt/Mrs. K. Vandendriessche & Mrs. D. Verhelst), Institute Bordet, Brussels (Dr. G. Liberale), University Hospital Leuven (Dr. A. De Buck van Overstraeten/Mr. D. Michiels & Mr. K. Op de Beeck); France: American Hospital of Paris/Institute Hospitalier Franco-Britannique, Paris/Clinique Hartmann – Ambroise Parre, Paris (Dr. A. Toledano/Mr. P. Ihout); Germany: Kreisklinikum Ebersberg (Dr. D. Plecity), Städtischen Klinikum Frankfurt Höechst (Dr. M. Ferschke & Dr. J. Reusch), Klinikum St. Georg, Leipzig (Prof. Dr. A. Weimann/Dr. M. Braunert/Dr. M. Wobith); The Netherlands: Groene Hart Hospital, Gouda (Dr. L. Tseng/Mrs. J. Verkerk), Onze Lieve Vrouwe Hospital, Amsterdam (Mrs. H. Hiemstra), Wilhelmina Hospital Assen (Dr. W. Bleeker/Mrs. G. Boekeloo & Mrs. H. Bouwman).
Compliance with ethical standards
Ethical approval for this study was obtained with the ethical committee of the University Hospital Leuven (S57152 (ML11311)). Based on the study protocol, all hospitals provided written agreement of the local study coordinator and approval of the local ethical committee.
This study was funded with an unconditional educational grant by Baxter SA to the European Pathway Association. Baxter SA had no influence on the study.
Conflict of interest
AW has received lecturers’ honoraria from Baxter, B.Braun, Berlin-Chemie, Fresenius Gabi, Lilly, Medtronic, Nestlé, and Nutricia, and has received research grants from Baxter and Danone. The other authors declare that they have no conflict of interest.
- 1.Gustafsson UO, Scott MJ, Schwenk W, Demartines N, Roulin D, Francis N, McNaught CE, Macfie J, Liberman AS, Soop M, Hill A, Kennedy RH, Lobo DN, Fearon K, Ljungqvist O (2013) Guidelines for perioperative care in elective colonic surgery: Enhanced Recovery After Surgery (ERAS®) Society recommendations. World J Surg 37(2):259–284. doi: 10.1007/s00268-012-1772-0 CrossRefPubMedGoogle Scholar
- 2.Aarts MA, Okrainec A, Glicksman A, Pearsall E, Victor JC, McLeod RS (2012) Adoption of enhanced recovery after surgery (ERAS) strategies for colorectal surgery at academic teaching hospitals and impact on total length of hospital stay. Surg Endosc 26(2):442–450. doi: 10.1007/s00464-011-1897-5 CrossRefPubMedGoogle Scholar
- 3.Gonzalez-Ayora S, Pastor C, Guadalajara H, Ramirez JM, Royo P, Redondo E, Arroyo A, Moya P, Garcia-Olmo D (2016) Enhanced recovery care after colorectal surgery in elderly patients. Compliance and outcomes of a multicenter study from the Spanish working group on ERAS. Int J Color Dis 31(9):1625–1631. doi: 10.1007/s00384-016-2621-7 CrossRefGoogle Scholar
- 5.Pedziwiatr M, Kisialeuski M, Wierdak M, Stanek M, Natkaniec M, Matlok M, Major P, Malczak P, Budzynski A (2015) Early implementation of Enhanced Recovery After Surgery (ERAS®) protocol—compliance improves outcomes: a prospective cohort study. Int J Surg (London, England) 21:75-81. doi: 10.1016/j.ijsu.2015.06.087
- 6.Alcantara-Moral M, Serra-Aracil X, Gil-Egea MJ, Frasson M, Flor-Lorente B, Garcia-Granero E (2014) Observational cross-sectional study of compliance with the fast track protocol in elective surgery for colon cancer in Spain. Int J Color Dis 29(4):477–483. doi: 10.1007/s00384-013-1825-3 CrossRefGoogle Scholar
- 9.Pisarska M, Pedziwiatr M, Malczak P, Major P, Ochenduszko S, Zub-Pokrowiecka A, Kulawik J, Budzynski A (2016) Do we really need the full compliance with ERAS protocol in laparoscopic colorectal surgery? A prospective cohort study. Int J Surg (London, England) 36 (Pt A):377-382. doi: 10.1016/j.ijsu.2016.11.088
- 10.Cwikel JG (2006) Social epidemiology: strategies for public health activism. Columbia University Press, New YorkGoogle Scholar
- 11.van Zelm R, Janssen I, Vanhaecht K, de Buck van Overstraeten A, Panella M, Sermeus W, Coeckelberghs E (2017) Development of a model care pathway for adults undergoing colorectal cancer surgery: evidence-based key interventions and indicators. J Eval Clin Pract. doi: 10.1111/jep.12700
- 12.Seys D, Bruyneel L, Decramer M, Lodewijckx C, Panella M, Sermeus W, Boto P, Vanhaecht K (2016) An international study of adherence to guidelines for patients hospitalised with a COPD exacerbation. Copd:1–8. doi: 10.1080/15412555.2016.1257599
- 15.ICHOM (2016) ICHOM standard set for colorectal cancer. ICHOM, Cambridge MAGoogle Scholar
- 16.ICHOM (2016) Colorectal cancer reference guide. ICHOM, Cambrigde MAGoogle Scholar
- 19.Vanhaecht K, Sermeus W, Peers J, Lodewijckx C, Deneckere S, Leigheb F, Decramer M, Panella M (2010) The impact of care pathways for exacerbation of chronic obstructive pulmonary disease: rationale and design of a cluster randomized controlled trial. Trials 11:111. doi: 10.1186/1745-6215-11-111 CrossRefPubMedPubMedCentralGoogle Scholar
- 20.Vanhaecht K, Sermeus W, Peers J, Lodewijckx C, Deneckere S, Leigheb F, Boonen S, Sermon A, Boto P, Mendes RV, Panella M (2012) The impact of care pathways for patients with proximal femur fracture: rationale and design of a cluster-randomized controlled trial. BMC Health Serv Res 12:124. doi: 10.1186/1472-6963-12-124 CrossRefPubMedPubMedCentralGoogle Scholar
- 21.Vanhaecht K, Van Gerven E, Deneckere S, Lodewijckx C, Janssen I, Van Zelm R, Boto P, Mendes R, Panella M, Biringer E, Sermeus W (2012) The 7-phase method to design, implement and evaluate care pathways. International Journal of Person Centered Care 2(3):341–351Google Scholar