Recovery-conscious Program Improves Surgical Recovery, Costs

FEBRUARY 09, 2018
Kevin Kunzmann
Ian Paquette, MD, FACSIan Paquette, MD, FACS
Clinical outcomes and hospital costs can be significantly improved with a standardized colorectal operation protocol, according to a novel study.

The study, an investigatory look into the association between enhanced recovery pathway for colorectal patients, and hospital costs, found that the enhanced protocol improves patients’ recovery time, narcotic medication use, and spending on care.

Led by Ian Paquette, MD, FACS, associate professor of surgery at the University of Cincinnati College of Medicine, the study considered the merits of standardizing surgical patient management with an enhanced recovery approach that is popularly used in Europe. The investigated program, the Agency for Healthcare Research and Quality (AHRQ) Safety Program for Improving Surgical Care and Recovery (ISCR), was founded last year by the American College of Surgeons (ACS) and Johns Hopkins Medicine Armstrong Institute for Patient Safety and Quality.

The University of Cincinnati researchers' work was in response to previous studies which shows that similar protocols for surgery patients improved the rate of complications, length of hospital stay, and patient satisfaction. However, these studies did not give consideration to patient costs in a non-estimated format.

Researchers compared the outcomes and costs for 2 patient groups — 160 patients to have gone through colorectal procedures a year prior to the enhanced recovery program, and 146 patients to have undergone the procedure following the protocol's adoption in 2016. The observed patients underwent procedures to treat diverticulitis, colon polyp removal, cancer, inflammatory bowel disease, or prolapse. 

Patients' preoperative bowel preparation, fluid management, pain control, early ambulation, and return to a normal diet are intended to be standardized through the enhanced protocol.

Patients in the enhanced protocol system recorded a mean hospital stay length 2 days shorter than the other patient group, while also having a fewer rate of lacking normal bowel function (6%, versus 20%). Enhanced protocol system patients also required 212 morphine equivalent units, versus the other group's 720 morphine equivalent units. Enhanced protocol system patients discontinued pain medication 1 day following their procedure, on average; the other patient group discontinued pain medication a mean 3 days follwowing procedure.

As result, enhanced protocol patients had $1,717 less total direct hospital costs versus the other patient group. The researchers translated the costs to equate to savings of greater than $250,000 annually. Total pharmacy costs were another $325 less per patient in the enhanced recovery group.

Parquette noted that surgeons frequently wait "as long as possible" to feed patients following colorectal surgery due to concern for the intestinal tract. Despite this, the researchers had found literature that led them to believe it's safe to feed patients immediately after the procedure.

"By restricting fluids, changing the pain management regimen, mobilizing the patient sooner, and putting all these steps together as an organized pathway, we're seeing that the return of normal gastrointestinal function is faster and patients get out of the hospital sooner," Parquette said in a statement.

Though it's become prominent in regions outside of the US, enhanced recovery programs have been universally accepted due to the perception that they heavily involve high-cost pharmaceutical therapies. Parquette argued that narcotics — the therapy most commonly used in post-procedure pain management, is very inexpensive.

"Medications recommended in enhanced recovery protocols, such as intravenous acetaminophen, ibuprofen, and alvimopan, are expensive and increase daily pharmacy costs," Parquette said. "Our study showed that the enhanced recovery pathway decreased total pharmacy cost as well as the total cost of hospitalization."

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