Association of Enhanced Recovery After Surgery Implementation and Comparative Outcomes Improvement at an Academic Medical Center.

Abstract

Enhanced recovery after surgery (ERAS) has been hypothesized to improve surgical outcomes following colorectal surgery; however, the long-term sustainability of improvement remains unclear. A comprehensive ERAS program was implemented for patients undergoing colorectal surgery at Johns Hopkins Hospital (JHH) in 2014. This study investigated inpatient elective colorectal surgery outcomes at JHH during three two-year postimplementation periods (2014-19) relative to a two-year baseline (2012-2013) via pre-post analyses and using difference-in-differences (DID) regression comparing JHH with a national sample of > 700 hospitals participating in the National Surgical Quality Improvement Program (NSQIP). Length of stay (LOS) was evaluated using multivariable zero-truncated negative binomial regression, whereas Surgical Site Infections (SSIs) and readmission rates were analyzed using multivariable logistic regression. Analyses controlled for ASA score, procedure type, age, sex, race, and surgical approach. The study included 1851 patients at JHH and 303,175 patients from the national sample. In pre-post analyses comparing JHH from baseline (2012-2013) to the final period (2018-2019), statistically significant improvements were seen for SSIs with a 4.4% reduction (OR 0.54 and 95% CI 0.35-0.86) and for readmissions with a 5.6% reduction (OR 0.57 and 95% CI 0.39-0.85), while LOS was statistically unchanged (0.41 days reduction; IRR 0.93 and 95% CI 0.85-1.01). DID analyses showed statistical equivalence for SSIs (OR 0.80 and 95% CI 0.51-1.26), greater improvement for readmission rates at JHH (OR 0.62 and 95% CI 0.42-0.92), and lower improvement for LOS at JHH (IRR 1.17 and 95% CI 1.07-1.27). ERAS implementation at JHH was associated with sustained improvement that was comparable (SSIs) or superior (readmissions) to national improvement trends over a period of 6 years (postimplementation), suggesting ERAS adoption in colorectal surgery is warranted for long-term outcomes improvement. Results were suggestive of a tradeoff between readmission rates and LOS.