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Surgical Endoscopy
Published in: Surgical Endoscopy 7/2019

01-07-2019

An enhanced recovery program in colorectal surgery is associated with decreased organ level rates of complications: a difference-in-differences analysis

Authors: Alexander T. Hawkins, Timothy M. Geiger, Adam B. King, Jonathan P. Wanderer, Vikram Tiwari, Roberta L. Muldoon, Molly M. Ford, Roger R. Dmochowski, Warren S. Sandberg, Barbara Martin, M. Benjamin Hopkins, Matthew D. McEvoy

Published in: Surgical Endoscopy | Issue 7/2019

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Abstract

Background

Perioperative care has lacked coordination and standardization. Enhanced recovery programs (ERPs) have been shown to decrease aggregate complications across surgical specialties. We hypothesize that the sustained implementation of an ERP will be associated with a decrease in a broad range of complications at the organ system level.

Study design

Adult patients undergoing elective colorectal procedures between 1/2011 and 10/2016 were included. Patients were stratified based on exposure to a sustained ERP (7/2014–10/2016) after an 18-month wash-in period in a pre-post analysis. The primary outcome was 30-day complication rate by organ category as collected by National Surgical Quality Improvement Program (NSQIP) abstractors. Demographic and other patient level data were collected. Complication rates were compared using multivariable regression employing a differences-in-differences (DiD) approach using the national NSQIP PUF file to account for secular trends.

Results

A total of 1182 patients were included in this study, with 47% treated in an ERP. The two groups were similar in age, gender, race, BMI, comorbidity index, and procedure type. In a multivariable DiD analysis, significant reductions were seen in surgical site infection (OR 0.30; 95% CI 0.20–0.43), postoperative pulmonary complications (OR 0.46; 95% CI 0.24–0.90), transfusion (OR 0.27; 95% CI 0.15–0.51), urinary tract infections (OR 0.34; 95% CI 0.18–0.66), sepsis (OR 0.35; 95% CI 0.20–0.61), and cardiac complications (OR 0.10; 95% CI 0.01–0.84). A reduction in return to the operating room and 30-day readmission was also observed. Median length of stay (LOS) decreased from 5.2 to 3.5 days (p < 0.001). No significant changes occurred for acute kidney injury and hematologic complications.

Conclusion

An ERP was associated with reduced complication rates across a wide range of organ categories and > 1.5-day reduction in LOS in a colorectal surgery population.
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Metadata
Title
An enhanced recovery program in colorectal surgery is associated with decreased organ level rates of complications: a difference-in-differences analysis
Authors
Alexander T. Hawkins
Timothy M. Geiger
Adam B. King
Jonathan P. Wanderer
Vikram Tiwari
Roberta L. Muldoon
Molly M. Ford
Roger R. Dmochowski
Warren S. Sandberg
Barbara Martin
M. Benjamin Hopkins
Matthew D. McEvoy
Publication date
01-07-2019
Publisher
Springer US
Published in
Surgical Endoscopy / Issue 7/2019
Print ISSN: 0930-2794
Electronic ISSN: 1432-2218
DOI
https://doi.org/10.1007/s00464-018-6508-2

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