Association of Enhanced Recovery Pathway Compliance With Patient Outcomes

Enhanced recovery pathways (ERPs) have emerged as one of the most effective strategies to improve clinical outcomes and reduce health care utilization in elective colorectal surgery. However, ERP implementation alone does not result in improvement without high pathway component compliance.^1,2 Hospital collaboratives have been used to accelerate quality improvement across clinical areas, including ERP adoption.^3-5 Despite collaborative participation, hospitals are frequently hindered by barriers related to local culture, agreement over ERP components, and resources.

The question remains if patients can achieve equally efficacious outcomes regardless of local hospital culture. We sought to determine the association of high ERP compliance with patient outcomes in the setting of variation in hospital-level performance in a national ERP collaborative.

A nationwide US ERP collaborative was launched in 2017.⁶ During participation, hospitals implemented and optimized ERPs throughout 18 months and audited compliance with 8 ERP components (preoperative bowel prepation, preoperative oral antibiotics, regional anesthesia use, multimodal pain control, early Foley catheter removal, postoperative venous thromboembolism [VTE] prophylaxis, early mobilization, and early feeding) and 5 outcomes (surgical site infection [SSI; superficial, deep, and organ space], postoperative VTE, 30-day unplanned readmission, ileus, and prolonged length of stay [7 days, defined as >75th percentile of all registry patients]) were monitored using standardized data definitions. Data were collected from July 2017 to December 2020. This study was approved by Chesapeake IRB, on behalf of the American College of Surgeons. All participating hospitals provided written consent for data sharing in this project.

Association of full ERP adherence (8 of 8 ERP components) compared with partial adherence (≤7 of 8 ERP components) with 30-day surgical outcomes was examined with multivariable logistic regression. In the full adherence population, hospitals that performed better or worse than expected (low and high outliers) for each surgical outcome were identified using hierarchical logistic regression models with hospital as a random effect (subject to empirical bayes smoothing) and risk adjustment for demographics, comorbidity, procedure type, surgical complexity, and hospital teaching status. Intraclass correlation was used to determine percent of model variance attributable to hospital-level association. Analysis was performed in SAS statistical software version 9.4 (SAS Institute). Analysis took place from September to December 2020.

A total of 39 482 patients underwent elective colorectal surgery (3736 [48.2%] female; mean [SD] age, 60.3 [14.3] years), and 7751 patients (20%) had full ERP adherence. Of 288 hospitals, 199 (69%) had at least 1 patient with full adherence (range, 1-358 patients) and 89 (31%) did not. Full ERP adherence was associated with significantly lower rates of all clinical outcomes except VTE compared with patients with partial adherence (7 or fewer ERP components) (Table).

Hospital-level variation in outcomes was largely obviated when exclusively examining full–ERP adherence patients. High-outlier hospitals (worse than expected performance) were identified in outcomes of SSI (n = 1), ileus (n = 6), and prolonged length of stay (n = 7) in the cohort of patients with perfect ERP compliance (Figure). No hospital outliers were identified for VTE or readmission. Outcome variation attributable to hospital-level factors rather than patient-level risk factors in outcomes with outliers was low (intraclass correlation: SSI, 0.037; ileus, 0.128; prolonged length of stay, 0.073).

In this study, patients with full adherence to core ERP components had lower rates of postoperative complications than patients with only partial ERP adherence. In full-adherence patients, there was little variation in clinical outcomes of VTE, SSI, readmission, and prolonged length of stay attributable to the hospital environment. Postoperative ileus demonstrated the greatest variation attributable to hospital-factors, an outcome that may be multifactorial in nature and more susceptible to influence of the local environment.

Our results in a collaborative of hospitals with diverse settings and geographic spread suggest that low postoperative outcome occurrence is achievable regardless of hospital environment, and full ERP adherence may be an equalizing factor across diverse environments. However, despite wide popularization of ERPs in elective colorectal surgery, full adherence to 8 core ERP components was only 20%, with 31% of hospitals failing to achieve perfect adherence for any of their patients undergoing elective colorectal surgery. Although patient factors may contribute to nonadherence, surgeons should consider initiating small-scale ERPs while striving for higher compliance across all patients, likely requiring widespread stakeholder buy-in, culture change, and patient optimization prior to surgery.

Corresponding Author: Chelsea P. Fischer, MD, MS, Division of Research and Optimal Patient Care, American College of Surgeons, 633 N St Clair St, 23nd Floor, Chicago, IL 60611 (cfischer@facs.org).

Accepted for Publication: May 4, 2021.

Published Online: July 21, 2021. doi:10.1001/jamasurg.2021.2866

Author Contributions: Dr Fischer had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: Fischer, Cohen, Wick.

Acquisition, analysis, or interpretation of data: All authors.

Drafting of the manuscript: Fischer, Cohen.

Critical revision of the manuscript for important intellectual content: Knapp, Cohen, Ko, Wick.

Statistical analysis: Fischer, Knapp, Cohen.

Obtained funding: Wick.

Administrative, technical, or material support: Fischer, Wick.

Supervision: Wick.

Conflict of Interest Disclosures: Drs Fischer, Ko, and Wick, and Ms Knapp reported salary support from the Agency for Healthcare Research and Quality during the conduct of the study. No other disclosures were reported.

Disclaimer: The findings and opinions in this article are those of the authors and do not reflect the official position of the Agency for Healthcare Research and Quality or the US Department of Health and Human Services.

Meeting Presentation: This work was accepted for presentation at the Pacific Coast Surgical Association annual meeting; February 2021; Monterey, California; however, the meeting was canceled owing to the COVID-19 pandemic.