Enhanced Recovery Pathway for Colorectal Surgery Improves Outcomes in Private and Safety-Net Settings

BACKGROUND: Although it is known that Enhanced Recovery Pathways (ERP) decrease length of stay (LOS) and improve outcomes in colorectal surgery, these studies predominantly represent the private health care setting. There is a paucity of information regarding the effectiveness of ERP in the public arena, comprised of the under and uninsured who may have different social determinants of health. This study aims to compare the effect of an ERP on LOS and readmission for colorectal surgery across the private and safety-net settings in a large urban academic medical center. METHODS: A multidisciplinary panel of experts utilized professionally recognized standards and evidence-based best practice to create a comprehensive ERP for elective colorectal surgery. The ERP included standardization of patient education, optimization of co-morbidities, multimodal analgesia, carbohydrate loading, intraoperative goal-directed fluid therapy, minimization of opioids, and early ambulation, removal of urinary catheter, and resumption of diet. There were no social interventions. The ERP was implemented in the safety-net hospital (SNH) in September 2014 and the private hospital (PH) in December 2014. Process and outcome metrics from 100 consecutive patients having surgery in the 18 months prior to ERP at each institution were compared to a similar group post ERP. Surgeons and discharge criteria remained constant. Primary endpoints were LOS and readmissions. RESULTS: Patients in the post-ERP cohorts at both facilities were significantly older than pre-ERP (p=0.047, 0.034), with no significant difference in gender and BMI. The rate of open versus minimally invasive was similar at SNH (p=0.067), while more post-ERP patients at PH underwent open surgery (p=0.002). 96% of PH patients were funded through private insurance or Medicare, verses only 6% at the SNH. ERP implementation reduced total LOS at both facilities, while readmission and reoperation remained constant. LOS at PH fell from 8.1 to 5.9 days (p=0.028), and at SNH from 7.0 to 5.1 days (p=0.004). 30-day all-cause readmission and return to surgery were stable (PH p=0.634; SNH p=1) and (PH p=0.610; SNH p=0.066) respectively. Surgical site infection rate was unchanged at PH (p=0.485) and significantly reduced at SNH (p=0.021, OR 0.39). Mean time to ambulation and mean time to first bowel movement were reduced at SNH (p=0.002, 0.001). Mean time to resumption of solids was reduced at both PH and SNH (p<0.001). CONCLUSIONS: Implementation of ERP is similarly effective across private and safety net settings, without interventions to address social determinants of health. Both cohorts experienced reduced LOS without increasing readmission or reoperation. The data suggest ERP may have a more dramatic impact on outcomes in the safety net setting, perhaps through standardization in a group with more varied baseline health status. Utilization of ERP appears to be advantageous for all populations regardless of funding.