Enhanced Recovery After Surgery (ERAS) in gynecologic oncology: System-wide implementation and audit leads to improved value and patient outcomes

Gynecol Oncol. 2018 Oct;151(1):117-123. doi: 10.1016/j.ygyno.2018.08.007. Epub 2018 Aug 9.

Abstract

Objective: Enhanced recovery pathways have been shown to reduce length of stay without increasing readmission or complications in numerous areas of surgery. Uptake of gynecologic oncology ERAS guidelines has been limited. We describe the effect of ERAS guideline implementation in gynecologic oncology on length of stay, patient outcomes, and economic impact for a province-wide single-payer system.

Methods: We compared pre- and post-guideline implementation outcomes in consecutive staging and debulking patients at two centers that provide the majority of surgical gynecologic oncology care in Alberta, Canada between March 2016 and April 2017. Clinical outcomes and compliance were obtained using the ERAS Interactive Audit System. Patients were followed until 30 days after discharge. Negative binomial regression was employed to adjust for patient characteristics.

Results: We assessed 152 pre-ERAS and 367 post-ERAS implementation patients. Mean compliance with ERAS care elements increased from 56% to 77.0% after implementation (p < 0.0001). Median length of stay for all surgeries decreased from 4.0 days to 3.0 days post-ERAS (p < 0.0001), which translated to an adjusted LOS decrease of 31.4% (95% CI = [21.7% - 39.9%], p < 0.0001). In medium/high complexity surgery median LOS was reduced by 2.0 days (p = 0.0005). Complications prior to discharge decreased from 53.3% to 36.2% post-ERAS (p = 0.0003). There was no significant difference in readmission (p = 0.6159), complications up to 30 days (p = 0.6274), or mortality (p = 0.3618) between the cohorts. The net cost savings per patient was $956 (95%CI: $162 to $1636).

Conclusions: Systematic implementation of ERAS gynecologic oncology guidelines across a healthcare system improves patient outcomes and saves resources.

Keywords: Clinical outcomes; Cost savings; ERAS; Gynecologic oncology.

Publication types

  • Comparative Study

MeSH terms

  • Aged
  • Cost Savings
  • Cytoreduction Surgical Procedures / adverse effects
  • Cytoreduction Surgical Procedures / economics
  • Cytoreduction Surgical Procedures / methods
  • Female
  • Genital Neoplasms, Female / economics
  • Genital Neoplasms, Female / surgery*
  • Guideline Adherence / statistics & numerical data*
  • Gynecologic Surgical Procedures / adverse effects*
  • Gynecologic Surgical Procedures / economics
  • Gynecologic Surgical Procedures / methods
  • Humans
  • Length of Stay / economics
  • Length of Stay / statistics & numerical data
  • Medical Audit
  • Middle Aged
  • Patient Discharge / statistics & numerical data
  • Patient Readmission / economics
  • Patient Readmission / statistics & numerical data
  • Perioperative Care / economics
  • Perioperative Care / methods
  • Perioperative Care / standards*
  • Postoperative Complications / epidemiology*
  • Practice Guidelines as Topic
  • Program Evaluation