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Enhanced Recovery After Surgery Program Implementation in 2 Surgical Populations in an Integrated Health Care Delivery System.
JAMA Surg 2017; 152(7):e171032JS

Abstract

Importance

Novel approaches to perioperative surgical care focus on optimizing nutrition, mobility, and pain management to minimize adverse events after surgical procedures.

Objective

To evaluate the outcomes of an enhanced recovery after surgery (ERAS) program among 2 target populations: patients undergoing elective colorectal resection and patients undergoing emergency hip fracture repair.

Design, Setting, and Participants

A pre-post difference-in-differences study before and after ERAS implementation in the target populations compared with contemporaneous surgical comparator groups (patients undergoing elective gastrointestinal surgery and emergency orthopedic surgery). Implementation began in February and March 2014 and concluded by the end of 2014 at 20 medical centers within the Kaiser Permanente Northern California integrated health care delivery system.

Exposures

A multifaceted ERAS program designed with a particular focus on perioperative pain management, mobility, nutrition, and patient engagement.

Main Outcomes and Measures

The primary outcome was hospital length of stay. Secondary outcomes included hospital mortality, home discharge, 30-day readmission rates, and complication rates.

Results

The study included a total of 3768 patients undergoing elective colorectal resection (mean [SD] age, 62.7 [14.1] years; 1812 [48.1%] male) and 5002 patients undergoing emergency hip fracture repair (mean [SD] age, 79.5 [11.8] years; 1586 [31.7%] male). Comparator surgical patients included 5556 patients undergoing elective gastrointestinal surgery and 1523 patients undergoing emergency orthopedic surgery. Most process metrics had significantly greater changes in the ERAS target populations after implementation compared with comparator surgical populations, including those for ambulation, nutrition, and opioid use. Hospital length of stay and postoperative complication rates were also significantly lower among ERAS target populations after implementation. The rate ratios for postoperative complications were 0.68 (95% CI, 0.46-0.99; P = .04) for patients undergoing colorectal resection and 0.67 (95% CI, 0.45-0.99, P = .05) for patients with hip fracture. Among patients undergoing colorectal resection, ERAS implementation was associated with decreased rates of hospital mortality (0.17; 95% CI, 0.03-0.86; P = .03), whereas among patients with hip fracture, implementation was associated with increased rates of home discharge (1.24; 95% CI, 1.06-1.44; P = .007).

Conclusions and Relevance

Multicenter implementation of an ERAS program among patients undergoing elective colorectal resection and patients undergoing emergency hip fracture repair successfully altered processes of care and was associated with significant absolute and relative decreases in hospital length of stay and postoperative complication rates. Rapid, large-scale implementation of a multidisciplinary ERAS program is feasible and effective in improving surgical outcomes.

Authors+Show Affiliations

Division of Research, Kaiser Permanente, Oakland, California2The Permanente Medical Group, Oakland, California.The Permanente Medical Group, Oakland, California.The Permanente Medical Group, Oakland, California.The Permanente Medical Group, Oakland, California.Kaiser Foundation Hospitals and Health Plan, Oakland, California.Kaiser Foundation Hospitals and Health Plan, Oakland, California.The Permanente Medical Group, Oakland, California.The Permanente Medical Group, Oakland, California.The Permanente Medical Group, Oakland, California.Kaiser Foundation Hospitals and Health Plan, Oakland, California.The Permanente Medical Group, Oakland, California.

Pub Type(s)

Journal Article
Multicenter Study
Research Support, N.I.H., Extramural
Research Support, Non-U.S. Gov't

Language

eng

PubMed ID

28492816

Citation

Liu, Vincent X., et al. "Enhanced Recovery After Surgery Program Implementation in 2 Surgical Populations in an Integrated Health Care Delivery System." JAMA Surgery, vol. 152, no. 7, 2017, pp. e171032.
Liu VX, Rosas E, Hwang J, et al. Enhanced Recovery After Surgery Program Implementation in 2 Surgical Populations in an Integrated Health Care Delivery System. JAMA Surg. 2017;152(7):e171032.
Liu, V. X., Rosas, E., Hwang, J., Cain, E., Foss-Durant, A., Clopp, M., ... Parodi, S. (2017). Enhanced Recovery After Surgery Program Implementation in 2 Surgical Populations in an Integrated Health Care Delivery System. JAMA Surgery, 152(7), pp. e171032. doi:10.1001/jamasurg.2017.1032.
Liu VX, et al. Enhanced Recovery After Surgery Program Implementation in 2 Surgical Populations in an Integrated Health Care Delivery System. JAMA Surg. 2017 07 19;152(7):e171032. PubMed PMID: 28492816.
* Article titles in AMA citation format should be in sentence-case
TY - JOUR T1 - Enhanced Recovery After Surgery Program Implementation in 2 Surgical Populations in an Integrated Health Care Delivery System. AU - Liu,Vincent X, AU - Rosas,Efren, AU - Hwang,Judith, AU - Cain,Eric, AU - Foss-Durant,Anne, AU - Clopp,Molly, AU - Huang,Mengfei, AU - Lee,Derrick C, AU - Mustille,Alex, AU - Kipnis,Patricia, AU - Parodi,Stephen, Y1 - 2017/07/19/ PY - 2017/5/12/pubmed PY - 2017/8/24/medline PY - 2017/5/12/entrez SP - e171032 EP - e171032 JF - JAMA surgery JO - JAMA Surg VL - 152 IS - 7 N2 - Importance: Novel approaches to perioperative surgical care focus on optimizing nutrition, mobility, and pain management to minimize adverse events after surgical procedures. Objective: To evaluate the outcomes of an enhanced recovery after surgery (ERAS) program among 2 target populations: patients undergoing elective colorectal resection and patients undergoing emergency hip fracture repair. Design, Setting, and Participants: A pre-post difference-in-differences study before and after ERAS implementation in the target populations compared with contemporaneous surgical comparator groups (patients undergoing elective gastrointestinal surgery and emergency orthopedic surgery). Implementation began in February and March 2014 and concluded by the end of 2014 at 20 medical centers within the Kaiser Permanente Northern California integrated health care delivery system. Exposures: A multifaceted ERAS program designed with a particular focus on perioperative pain management, mobility, nutrition, and patient engagement. Main Outcomes and Measures: The primary outcome was hospital length of stay. Secondary outcomes included hospital mortality, home discharge, 30-day readmission rates, and complication rates. Results: The study included a total of 3768 patients undergoing elective colorectal resection (mean [SD] age, 62.7 [14.1] years; 1812 [48.1%] male) and 5002 patients undergoing emergency hip fracture repair (mean [SD] age, 79.5 [11.8] years; 1586 [31.7%] male). Comparator surgical patients included 5556 patients undergoing elective gastrointestinal surgery and 1523 patients undergoing emergency orthopedic surgery. Most process metrics had significantly greater changes in the ERAS target populations after implementation compared with comparator surgical populations, including those for ambulation, nutrition, and opioid use. Hospital length of stay and postoperative complication rates were also significantly lower among ERAS target populations after implementation. The rate ratios for postoperative complications were 0.68 (95% CI, 0.46-0.99; P = .04) for patients undergoing colorectal resection and 0.67 (95% CI, 0.45-0.99, P = .05) for patients with hip fracture. Among patients undergoing colorectal resection, ERAS implementation was associated with decreased rates of hospital mortality (0.17; 95% CI, 0.03-0.86; P = .03), whereas among patients with hip fracture, implementation was associated with increased rates of home discharge (1.24; 95% CI, 1.06-1.44; P = .007). Conclusions and Relevance: Multicenter implementation of an ERAS program among patients undergoing elective colorectal resection and patients undergoing emergency hip fracture repair successfully altered processes of care and was associated with significant absolute and relative decreases in hospital length of stay and postoperative complication rates. Rapid, large-scale implementation of a multidisciplinary ERAS program is feasible and effective in improving surgical outcomes. SN - 2168-6262 UR - https://www.unboundmedicine.com/medline/citation/28492816/Enhanced_Recovery_After_Surgery_Program_Implementation_in_2_Surgical_Populations_in_an_Integrated_Health_Care_Delivery_System_ L2 - https://jamanetwork.com/journals/jamasurgery/fullarticle/10.1001/jamasurg.2017.1032 DB - PRIME DP - Unbound Medicine ER -