Evaluation of the Implementation of Multiple Enhanced Recovery After Surgery Pathways Across a Provincial Health Care System in Alberta, Canada
Authors: Gregg Nelson, Xiaoming Wang, Alison Nelson, Peter Faris, Laura Lagendyk, Tracy Wasylak, Oliver F. Bathe, David Bigam, Erin Bruce, W. Donald Buie, Michael Chong, Adrian Fairey, M. Eric Hyndman, Anthony MacLean, Michael McCall, Sophia Pin, Haili Wang, Leah Gramlich
Journal: JAMA Network Open (2021)

<h3>Importance</h3> Engaging multidisciplinary care teams in surgical practice is important for the improvement of surgical outcomes. <h3>Objective</h3> To evaluate the association of multiple Enhanced Recovery After Surgery (ERAS) pathways with ERAS guideline adherence and outcomes. <h3>Design, Setting, and Participants</h3> This quality improvement study compared a pre-ERAS cohort (2013-2017) with a post-ERAS cohort (2014-2018). All patients were from Alberta Health Services in Alberta, Canada, and had available ERAS and up to 1-year postsurgery administrative data. Data collected included age, sex, body mass index, tobacco and alcohol use, diabetes, comorbidity index, and surgical characteristics. Data analysis was performed from May 7, 2020, to February 1, 2021. <h3>Interventions</h3> Implementation of 5 ERAS pathways (colorectal, liver, pancreas, gynecologic oncology, and radical cystectomy) across 9 sites. <h3>Main Outcomes and Measures</h3> Adherence to ERAS guidelines was measured by the percentage of patients whose care met the common ERAS pathway care element criteria. Surgical procedures were grouped by complexity; complications were classified by severity. Outcome measures for the pre-post–ERAS cohorts included length of stay (LOS), readmission, complications, and mortality. <h3>Results</h3> A total of 7757 patients participated in the study, including 984 in the pre-ERAS cohort (median [interquartile range] age, 62 [53-71] years; 526 [53.5%] female) and 6773 in the post-ERAS cohort (median [interquartile range] age, 62 [53-71] years; 3470 [51.2%] male). In the total cohort, care-element adherence improved from 52% to 76% (<i>P</i> &lt; .001), no significant differences were found in serious complications (from 6.2% to 4.9%;<i>P</i> = .08) or 30-day mortality (from 0.71% to 0.93%;<i>P</i> = .50), 1-year mortality decreased from 7.1% to 4.6% (<i>P</i> &lt; .001), mean (SD) LOS decreased from 9.4 (7.0) to 7.8 (5.0) days (<i>P</i> &lt; .001), and 30-day readmission rates were unchanged (from 13.4% to 11.7%;<i>P</i> = .12). After adjustment for patient characteristics, the LOS mean difference decreased 0.71 days (95% CI, −1.13 to −0.29 days;<i>P</i> &lt; .001), with no significant differences in adjusted 30-day readmission (−3.5%; 95% CI, −22.7% to 20.4%;<i>P</i> = .75), serious complications (1.3%; 95% CI, −26.2% to 39.0%;<i>P</i> = .94), or mortality (30-day mortality: 42% [95% CI, −35.4% to 212.3%];<i>P</i>= .38; 1-year mortality: 8% [95% CI, −20.5% to 46.8%];<i>P</i>= .62). The adjusted 1-year readmission rate was −15.6% (95% CI, −27.7% to −1.5%;<i>P</i> = .03) in favor of ERAS, and readmission LOS was shorter by 1.7 days (95% CI, −3.3 to −0.1 days;<i>P</i> = .04). <h3>Conclusions and Relevance</h3> The results of this quality improvement study suggest that implementation of ERAS across multiple pathways may improve health care practitioner adherence to ERAS guidelines, LOS, and readmission rates at a system level.