Enhanced recovery protocols for pediatric colorectal surgery demonstrate cost-effectiveness: An economic analysis to support programmatic development

William Luo; Ursula Adams; Elizabeth Tracy; Clint Cappiello; Cathleen Mooney; Adesola C Akinkuotu; Sean E McLean; Anthony G Charles; Michael R Phillips

doi:10.1016/j.jpedsurg.2026.163135

Enhanced recovery protocols for pediatric colorectal surgery demonstrate cost-effectiveness: An economic analysis to support programmatic development

J Pediatr Surg. 2026 Apr 9;61(7):163135. doi: 10.1016/j.jpedsurg.2026.163135. Online ahead of print.

Authors

William Luo¹, Ursula Adams², Elizabeth Tracy², Clint Cappiello², Cathleen Mooney², Adesola C Akinkuotu², Sean E McLean², Anthony G Charles³, Michael R Phillips⁴

Affiliations

¹ The University of North Carolina at Chapel Hill School of Medicine, Department of Surgery, 4001 Burnett-Womack Building CB #7050 Chapel Hill, NC 27599-7050 USA; WakeMed Health and Hospitals, 3000 New Bern Ave, Raleigh, NC 27610, USA.
² The University of North Carolina at Chapel Hill School of Medicine, Department of Surgery, 4001 Burnett-Womack Building CB #7050 Chapel Hill, NC 27599-7050 USA.
³ Department of Surgery, The University of Vermont Larner College of Medicine, 463 Fletcher 4, 111 Colchester Avenue, Mail Stop 320FL4, Burlington, VT 05401, USA.
⁴ The University of North Carolina at Chapel Hill School of Medicine, Department of Surgery, 4001 Burnett-Womack Building CB #7050 Chapel Hill, NC 27599-7050 USA. Electronic address: miphilli@med.unc.edu.

PMID: 41966323
DOI: 10.1016/j.jpedsurg.2026.163135

Abstract

Background: Enhanced recovery pathways (ERPs) after pediatric colorectal surgery have been shown to improve patient experience without compromising outcomes. ERPs for this population are also associated with reduced admission costs, but their economic impact in large populations is unclear. We present the first formal cost-effectiveness analysis of a pediatric colorectal surgery ERP from the payer perspective.

Methods: We compared the cost-effectiveness of an ERP versus standard care in a pediatric patient requiring colorectal surgery without additional comorbid conditions, using a Markov microsimulation model to estimate the incremental cost-effectiveness ratio for each intervention. We sourced costs and health utilities from the peer-reviewed literature and transition-state probabilities from institutional primary data. We modeled our analysis from a US payer perspective over a 30-day time horizon and a willingness-to-pay ratio of $100,000/quality-adjusted life-year (QALY) gained by either intervention.

Results: We simulated individual patient outcomes using published clinical outcomes for patients managed with and without an ERP (microsimulation). The statistical software evaluates the variability across 10,000 microsimulations and repeats the modeling 1,000 times (iterations). The software then reports the most likely outcome based on the summarized results. We found that our ERP was a cost-effective alternative to standard care in over 86% of iterations. On average, an admission with ERP costs $5,625 less and provides a health utility benefit of 0.002 QALY over 30 days compared to standard care. Our model was sensitive to the costs of acute-care hospital stays, celecoxib costs, and time to solid oral (PO) intake.

Conclusions: In a first-of-its-kind cost-effectiveness analysis of ERPs for pediatric surgery, ERPs were both less costly and better for quality of life than standard care. These findings support the continued development and implementation of ERPs for pediatric patients requiring colorectal surgery, as well as the referral of such patients to centers with ERP programs.

Keywords: Cost-effectiveness; Enhanced recovery pathways; Pediatric colorectal surgery; Quality.