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The Impact of the Implementation of the Enhanced Recovery After Surgery (ERAS®) Program in an Entire Health System: A Natural Experiment in Alberta, Canada

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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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References

  1. Ljungqvist O, Scott M, Fearon KC (2017) Enhanced recovery after surgery. A review. JAMA Surg 152:292–298

    Article  PubMed  Google Scholar 

  2. Liu VX, Rosas E, Hwang J, Cain E, Foss-Durant A, Clopp M et al (2017) Enhanced recovery after surgery program implementation in 2 surgical populations in an integrated health care delivery system. JAMA Surg 152:e171032

    Article  PubMed  PubMed Central  Google Scholar 

  3. ERAS Compliance Group (2015) The impact of enhanced recovery protocol compliance on elective colorectal cancer resection: results from an international registry. Ann Surg 261(6):1153–1159

    Article  Google Scholar 

  4. Gustafsson UO, Scott MJ, Schwenk W et al (2012) Guidelines for perioperative care in elective colonic surgery: enhanced recovery after surgery (ERAS®) society recommendations. Clin Nutr 31(6):783–800

    Article  PubMed  CAS  Google Scholar 

  5. Greco M, Capretti G, Beretta L, Gemma M, Pecorelli N, Braga M (2014) Enhanced recovery program in colorectal surgery: a meta-analysis of randomized controlled trials. World J Surg 38(6):1531–1541. https://doi.org/10.1007/s00268-013-2416-8

    Article  PubMed  Google Scholar 

  6. Gustafsson UO, Hausel J, Thorell A, Ljungqvist O, Soop M, Nygen J (2011) Adherence to the enhanced recovery after surgery protocol and outcomes after colorectal cancer surgery. Arch Surg 146(5):571–577

    Article  PubMed  Google Scholar 

  7. Albalawi Z, Laffin M, Gramlich L, Senior P, McAlister FA (2017) Enhanced recovery after surgery (ERAS(®)) in individuals with diabetes: a systematic review. World J Surg 41:1927–1934. https://doi.org/10.1007/s00268-017-3982-y

    Article  PubMed  Google Scholar 

  8. Quan H, Sundararajan V, Halfon P et al (2005) Coding algorithms for defining comorbidities in ICD-9-CM and ICD-10 administrative data. Med Care 43(11):1130–1139

    Article  PubMed  Google Scholar 

  9. Quan H, Li B, Saunders LD et al (2008) Assessing validity of ICD-9-CM and ICD-10 administrative data in recording clinical conditions in a unique dually coded database. Health Serv Res 43(4):1424–1441

    Article  PubMed  PubMed Central  Google Scholar 

  10. Charlson ME, Pompei P, Ales KL, MacKenzie CR (1987) A new method of classifying prognostic comorbidity in longitudinal studies: development and validation. J Chronic Dis 40(5):373–383

    Article  PubMed  CAS  Google Scholar 

  11. Aarts MJ, Lemmens VEPP, Louwman MWJ, Kunst AE, Coebergh JWW (2010) Socioeconomic status and changing inequalities in colorectal cancer? A review of the associations with risk, treatment and outcome. Eur J Cancer Oxf Engl 1990 46(15):2681–2695

    Google Scholar 

  12. Ma C, Crespin M, Proulx M-C et al (2012) Postoperative complications following colectomy for ulcerative colitis: a validation study. BMC Gastroenterol 12:39

    Article  PubMed  PubMed Central  Google Scholar 

  13. Dindo D, Demartines N, Clavien P-A (2004) Classification of surgical complications: a new proposal with evaluation in a cohort of 6336 patients and results of a survey. Ann Surg 240(2):205–213

    Article  PubMed  PubMed Central  Google Scholar 

  14. Rosenthal R, Hoffmann H, Clavien P-A, Bucher HC, Dell-Kuster S (2015) Definition and classification of intraoperative complications (CLASSIC): Delphi study and pilot evaluation. World J Surg 39(7):1663–1671. https://doi.org/10.1007/s00268-015-3003-y

    Article  PubMed  Google Scholar 

  15. McAlister FA, Bakal JA, Majumdar SR et al (2014) Safely and effectively reducing inpatient length of stay: a controlled study of the General Internal Medicine Care Transformation Initiative. BMJ Qual Saf 23(6):446–456

    Article  PubMed  Google Scholar 

  16. Lau CSM, Chamberlain RS (2017) Enhanced recovery after surgery programs improve patient outcomes and recovery: a meta-analysis. World J Surg 41:899–913. https://doi.org/10.1007/s00268-016-3807-4

    Article  PubMed  Google Scholar 

  17. Gillissen F, Hoff C, Maessen JMC et al (2013) Structured synchronous implementation of an enhanced recovery program in elective colonic surgery in 33 hospitals in The Netherlands. World J Surg 37(5):1082–1093. https://doi.org/10.1007/s00268-013-1938-4

    Article  PubMed  Google Scholar 

  18. Nelson G, Kiyang LN, Crumley ET et al (2016) Implementation of enhanced recovery after surgery (ERAS) across a provincial healthcare system: the ERAS Alberta Colorectal Surgery Experience. World J Surg 40(5):1092–1103. https://doi.org/10.1007/s00268-016-3472-7

    Article  PubMed  Google Scholar 

  19. Thiele RH, Rea KM, Turrentine FE, Friel CM, Hassinger TE, Goudreau BJ et al (2015) Standardization of care: IMpact of an Enhanced Recovery protocol on length of stay, complications, and direct costs after colorectal surgery. J Am Coll Surg 220:430–443

    Article  PubMed  Google Scholar 

  20. Schnüriger B, Barmparas G, Branco BC, Lustenberger T, Inaba K, Demetriades D (2011) Prevention of postoperative peritoneal adhesions: a review of the literature. Am J Surg 201(1):111–121

    Article  PubMed  Google Scholar 

  21. Okabayashi K, Ashrafian H, Zacharakis E et al (2014) Adhesions after abdominal surgery: a systematic review of the incidence, distribution and severity. Surg Today 44(3):405–420

    Article  PubMed  Google Scholar 

  22. Ramsay CR, Matowe L, Grilli R, Grimshaw JM, Thomas RE (2003) Interrupted time series designs in health technology assessment: lessons from two systematic reviews of behavior change strategies. Int J Technol Assess Health Care 19(4):613–623

    Article  PubMed  Google Scholar 

  23. Zhang F, Wagner AK, Ross-Degnan D (2011) Simulation-based power calculation for designing interrupted time series analyses of health policy interventions. J Clin Epidemiol 64(11):1252–1261

    Article  PubMed  Google Scholar 

  24. Bernal JL, Cummins S, Gasparrini A (2017) Interrupted time series regression for the evaluation of public health interventions: a tutorial. Int J Epidemiol 46(1):348–355

    PubMed  Google Scholar 

Download references

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.

Author information

Authors and Affiliations

  1. Division of Endocrinology, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Canada

    Zaina AlBalawi & Peter Senior

  2. Division of Gastroenterology, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Canada

    Leah Gramlich

  3. Surgical Lead, ERAS Alberta and Department of Oncology, Cumming School of Medicine, University of Calgary, Calgary, Canada

    Gregg Nelson

  4. Alberta SPOR Support Unit, University of Alberta, Edmonton, Canada

    Erik Youngson & Finlay A. McAlister

  5. 5-134C Clinical Sciences Building, Division of General Internal Medicine, Faculty of Medicine and Dentistry, University of Alberta, 11350 83 Avenue, Edmonton, AB, T6G 2G3, Canada

    Finlay A. McAlister

Authors
  1. Zaina AlBalawi
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  2. Leah Gramlich
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  3. Gregg Nelson
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  4. Peter Senior
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  5. Erik Youngson
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  6. Finlay A. McAlister
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Corresponding author

Correspondence to Finlay A. McAlister.

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Conflict of interest

None of the authors have any conflict of interest relating to this study.

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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