BackgroundThere has been a rise in popularity in Enhanced Recovery After Surgery (ERAS) programmes in developed countries, but uptake has been varied, and inter-protocol consistency sketchy at best.1 A major challenge in the implementation of a multimodal care pathway is adequate resourcing, particularly in context of the current healthcare environment which dictates the provision of financial justification prior to the adoption of any new intervention.Cost-analyses of ERAS protocols in colorectal surgery have been limited to early clinical pathway studies,2,3 one study focussing solely on ileal-pouch anal anastomoses,4 and a study incorporating a very heterogeneous group of patients, some of whom were part of a unrelated international trial.5 None of these studies addressed the set-up costs of an ERAS protocol nor provided a detailed breakdown of where cost savings were achieved in the postoperative recovery phase.In December 2005, an ERAS programme was implemented for elective colonic resections at the Manukau Surgical Centre in Auckland, New Zealand.6 This programme emphasises structured nursing care pathways within an environment focusing on early recovery, and incorporates a number of perioperative strategies within the ERAS framework. We have previously published data outlining a significant reduction in intravenous fluid requirement, total day-stay and postoperative complications,7 as well as improved patient functional recovery8 as a direct result of instituting this programme.A considerable investment was required in order to setup this programme and ensure its success. The aim of this paper is to evaluate whether the costs saved by reduced postoperative resource utilisation would offset the financial burden of setting up and maintaining an ERAS programme in elective colonic surgery.Methods ERAS Protocol—The ERAS programme was developed in a multidisciplinary fashion and received appropriate institutional approval for implementation. A consultant surgeon, a ward charge nurse, and a colorectal nurse specialist visited an institution in Denmark with an established ERAS programme, and an equivalent programme tailored to the Manukau Surgical Centre was developed. A full-time ward-based junior doctor was then employed as a research fellow in enhanced recovery, to be responsible for the overall running of the programme as well as prospective auditing of safety and effectiveness. The ERAS protocol used in our institution is outlined in Table 1. All elective colonic resections in patients >15 years old were included in the ERAS programme. Exclusion criteria were: patients requiring a stoma, ASA (American Society of Anaesthesiologists) score ≥IV, significant cognitive impairment, inability to communicate in English, and patients declining consent. Cost analysis—A cost-effectiveness analysis from a healthcare provider perspective was performed comparing a study group of ERAS patients with a historical group of case-matched controls. Total cost of protocol development, as well as the cost of ward stay at the Manukau Surgical Centre, outpatient clinic time, and patient booklet production was obtained from hospital management budget records. The research fellow yearly salary was obtained from the University of Auckland (Auckland, New Zealand). Costs of oral supplements, non-steroidal anti-inflammatory medications, and intravenous fluids were obtained from the hospital pharmacy, and epidural costs from the hospital anaesthetic department. Costs of readmission and estimates of specific costs associated with postoperative complications were supplied by a hospital clinical analyst (complication costs were determined by calculating the cost of index hospital stay with and without a given complication, excluding cost of day stay and readmission) Patient groups—The study (ERAS) group consisted of consecutive patients enrolled in the ERAS programme for elective colonic surgery at Manukau Surgical Centre between December 2005 and March 2007. Data for this group were collected prospectively. The control group consisted of a comparable, consecutive series of patients identified through a hospital electronic database search from September 2004 to September 2005 (before the start of the ERAS programme). Control patients were individually matched with those in the study group with respect to the operation performed, BMI (Body Mass Index), ASA score, and Cr-POSSUM score (Colorectal Physiological and Operative Severity Score for the enumeration of Mortality).9 Furthermore, these patients all met the inclusion criteria used for the ERAS group and their operations were performed by the same specialist surgeons. Patients in the control group received conventional, non-structured perioperative care. Discharge was left to the discretion of the senior members of the surgical team with no specified discharge criteria in place. Data for this group were collected retrospectively. Table 1. Enhanced Recovery After Surgery (ERAS) protocol Timing Intervention Preadmission Preoperative assessment in a dedicated outpatient session. Programme information given, including specific daily milestones. Social issues are identified and addressed. Preoperative ward visit and orientation. Preop Preoperative carbohydrate loading (PreOP®, Nutricia; Numico, Zoetermeer, Netherlands). 4 drinks day before surgery, and 2 drinks 2 hours before surgery. Patients admitted to hospital on the morning of their surgery. Left-sided operations receive a phosphate enema on arrival at the hospital. Mechanical bowel preparation is avoided. Intraop Thoracic epidural inserted and bupivacaine epidural infusion started (Polybag®, AstraZeneca Theatre Pack®, AstraZenenca Ltd, Auckland, NZ). Limited intraop intravenous fluids (1-2L crystalloids / colloids). Transverse incisions for right-sided open surgery if appropriate. Prophylactic nasogastric tubes not used. Intra-abdominal drains not used. Calf stockings applied at the end of surgery. Recovery room Vasopressor agents in preference to intravenous fluids to treat epidural-related hypotension. Intravenous morphine / fentanyl PCA initiated. Day of surgery Patients are mobilised to a chair. Oral intake of fluids is started, aiming for > 800 ml of oral intake on the day of surgery. Pre-emptive regular antiemetics (5-HT3 antagonists as first line). Subcutanous low molecular weight heparin started for thrombo-prophylaxis (Clexane® 20mg once daily until discharge, Sanofi-aventis Ltd, Auckland, NZ). Day 1 Urinary catheter removed. Full solid oral diet. Resource supplement drinks (2-3 per day until discharge). Active mobilisation with nursing and physiotherapy input. Day 2 Epidural infusion is stopped, and epidural catheter removed. Regular oral non-steroidal anti-inflammatory drugs (Tenoxicam 20mg orally twice daily until discharge, Tilcotil tabs®, Roche, Auckland, NZ). Oral opiates for break-through pain only. Day 3 Discharged home if fulfill following criteria: Tolerating full oral diet Passing flatus Adequate analgesia on oral medication Ambulating independently Satisfactory support at home After discharge Patient given a phone number for contacting the ward if required. Nursing staff contact the patients three days after discharge for a phone interview. Follow up outpatient clinic appointment within 7 days of discharge. Preop: Preoperative; Intraop: Intraoperative Data collection—Data were collected from patient records including physical and electronic clinical, radiology, and laboratory records. Data included patient demographics, ASA score, Cr-POSSUM score, surgical indication, operating surgeon, operation performed, epidural use, intravenous fluid use, cancer staging, postoperative day stay, total day stay, complications and readmission. To ensure that recorded complications were comparable in both groups, specific complications were documented according to previously defined and published criteria.7 All patients were followed for 30 days after surgery. Results Data were available for 50 patients in each group. During the recruitment period, ten patients had been excluded from the ERAS programme; two had significant renal impairment, two had significant cardiac comorbidity, two were cognitively impaired, two could not speak sufficient English, and two declined consent. Eight patients treated from September 2004 to September 2005 were excluded from the conventional treatment control group; two patients had significant renal impairment, two had dementia, one had Addison’s disease, and three had hematologic disorders. Baseline characteristics—The ERAS and conventional groups were comparable with respect to sex, BMI, ASA score, Cr-POSSUM score, operation performed, and indication for surgery (Table 2). The ERAS group was marginally younger than the conventional group (65.6 vs 70.7 years, p=0.021). Table 2. Baseline characteristics Variables ERAS group (n=50) Control group (n=50) P value Age (mean, range) 65.6 (39-92) 70.7 (40-85) 0.021 Sex Male Female 26 24 28 22 0.688‡ 0.688‡ ASA score I II III 8 29 13 8 31 11 1.00‡ 0.683‡ 0.640‡ BMI 28.6 27.4 0.588† CR-POSSUM Physiologic Operative 10.3 9.2 9.7 8.3 0.524† 0.061† Operation Open R hemicolectomy Open L hemicolectomy Lap L hemicolectomy Open Total colectomy 26 19 4 1 29 14 7 0 0.546‡ 0.288‡ 0.525‡ 1.000‡ Diagnosis Diverticulosis IBD Adenoma Dukes A Dukes B Dukes C Dukes D 2 1 4 6 15 19 3 4 1 2 5 8 21 9 0.674‡ 1.000‡ 0.674‡ 0.749‡ 0.096‡ 0.683‡ 0.124‡ ASA: American Society of Anesthesiologists; BMI: Body mass index; CR-POSSUM: Colorectal Physiologic and Operative Severity Score for the enUmeration of Mortality; ERAS: Enhanced Recovery After Surgery; IBD: Inflammatory bowel disease; R: Right, L: Left, Lap: Laparoscopic. †Mann-Whitney U test, ‡Chi-squared test. Postoperative recovery—As we have previously shown7 there was a significant reduction in postoperative hospital stay, total hospital stay, intravenous fluid use (both intraoperative and day 1 to day 3 postoperative), and duration of epidural use in the ERAS group compared to the control group (Table 3). There was also a one day reduction in the median time to first full solid meal and passage of flatus, and patients mobilised a median of 2 days earlier. Table 3. Postoperative recovery data. Variables ERAS Group (n=50) Control Group (n=50) P Value Intravenous fluids Intraoperative First 3 days 2 (1-8) 2 (1-10) 3 (1-7.5) 6.5 (1-12) <0.0001† <0.0001† Epidural analgesia No. of patients Duration of use (days) 44 (89%) 2 (0-3) 38 (76%) 3 (0-4) 0.223‡ <0.0001† Recovery Days to 1st full meal Days to passage of flatus Days to independent mobilisation 1 (1-3) 2 (0-8) 1 (1-3) 2 (1-15) 3 (0-18) 3 (1-7) <0.0001† <0.0001† <0.0001† Complications No. of patients with > 1 complication Breakdown of complication events Death Reoperation Anastomotic leak Intra-abdominal collection Ileus Wound complication Urinary tract infection Urinary retention Cardiopulmonary 27 0 4 4 1 5 6 2 5 11 33 2 4 3 1 18 10 12 3 21 0.221‡ 0.495‡ 1.000‡ 1.000‡ 1.000‡ 0.005‡ 0.275‡ 0.008‡ 0.715‡ 0.032‡ Day stay No. admitted > 1 day before surgery\r

BackgroundThere has been a rise in popularity in Enhanced Recovery After Surgery (ERAS) programmes in developed countries, but uptake has been varied, and inter-protocol consistency sketchy at best.1 A major challenge in the implementation of a multimodal care pathway is adequate resourcing, particularly in context of the current healthcare environment which dictates the provision of financial justification prior to the adoption of any new intervention.Cost-analyses of ERAS protocols in colorectal surgery have been limited to early clinical pathway studies,2,3 one study focussing solely on ileal-pouch anal anastomoses,4 and a study incorporating a very heterogeneous group of patients, some of whom were part of a unrelated international trial.5 None of these studies addressed the set-up costs of an ERAS protocol nor provided a detailed breakdown of where cost savings were achieved in the postoperative recovery phase.In December 2005, an ERAS programme was implemented for elective colonic resections at the Manukau Surgical Centre in Auckland, New Zealand.6 This programme emphasises structured nursing care pathways within an environment focusing on early recovery, and incorporates a number of perioperative strategies within the ERAS framework. We have previously published data outlining a significant reduction in intravenous fluid requirement, total day-stay and postoperative complications,7 as well as improved patient functional recovery8 as a direct result of instituting this programme.A considerable investment was required in order to setup this programme and ensure its success. The aim of this paper is to evaluate whether the costs saved by reduced postoperative resource utilisation would offset the financial burden of setting up and maintaining an ERAS programme in elective colonic surgery.Methods ERAS Protocol—The ERAS programme was developed in a multidisciplinary fashion and received appropriate institutional approval for implementation. A consultant surgeon, a ward charge nurse, and a colorectal nurse specialist visited an institution in Denmark with an established ERAS programme, and an equivalent programme tailored to the Manukau Surgical Centre was developed. A full-time ward-based junior doctor was then employed as a research fellow in enhanced recovery, to be responsible for the overall running of the programme as well as prospective auditing of safety and effectiveness. The ERAS protocol used in our institution is outlined in Table 1. All elective colonic resections in patients >15 years old were included in the ERAS programme. Exclusion criteria were: patients requiring a stoma, ASA (American Society of Anaesthesiologists) score ≥IV, significant cognitive impairment, inability to communicate in English, and patients declining consent. Cost analysis—A cost-effectiveness analysis from a healthcare provider perspective was performed comparing a study group of ERAS patients with a historical group of case-matched controls. Total cost of protocol development, as well as the cost of ward stay at the Manukau Surgical Centre, outpatient clinic time, and patient booklet production was obtained from hospital management budget records. The research fellow yearly salary was obtained from the University of Auckland (Auckland, New Zealand). Costs of oral supplements, non-steroidal anti-inflammatory medications, and intravenous fluids were obtained from the hospital pharmacy, and epidural costs from the hospital anaesthetic department. Costs of readmission and estimates of specific costs associated with postoperative complications were supplied by a hospital clinical analyst (complication costs were determined by calculating the cost of index hospital stay with and without a given complication, excluding cost of day stay and readmission) Patient groups—The study (ERAS) group consisted of consecutive patients enrolled in the ERAS programme for elective colonic surgery at Manukau Surgical Centre between December 2005 and March 2007. Data for this group were collected prospectively. The control group consisted of a comparable, consecutive series of patients identified through a hospital electronic database search from September 2004 to September 2005 (before the start of the ERAS programme). Control patients were individually matched with those in the study group with respect to the operation performed, BMI (Body Mass Index), ASA score, and Cr-POSSUM score (Colorectal Physiological and Operative Severity Score for the enumeration of Mortality).9 Furthermore, these patients all met the inclusion criteria used for the ERAS group and their operations were performed by the same specialist surgeons. Patients in the control group received conventional, non-structured perioperative care. Discharge was left to the discretion of the senior members of the surgical team with no specified discharge criteria in place. Data for this group were collected retrospectively. Table 1. Enhanced Recovery After Surgery (ERAS) protocol Timing Intervention Preadmission Preoperative assessment in a dedicated outpatient session. Programme information given, including specific daily milestones. Social issues are identified and addressed. Preoperative ward visit and orientation. Preop Preoperative carbohydrate loading (PreOP®, Nutricia; Numico, Zoetermeer, Netherlands). 4 drinks day before surgery, and 2 drinks 2 hours before surgery. Patients admitted to hospital on the morning of their surgery. Left-sided operations receive a phosphate enema on arrival at the hospital. Mechanical bowel preparation is avoided. Intraop Thoracic epidural inserted and bupivacaine epidural infusion started (Polybag®, AstraZeneca Theatre Pack®, AstraZenenca Ltd, Auckland, NZ). Limited intraop intravenous fluids (1-2L crystalloids / colloids). Transverse incisions for right-sided open surgery if appropriate. Prophylactic nasogastric tubes not used. Intra-abdominal drains not used. Calf stockings applied at the end of surgery. Recovery room Vasopressor agents in preference to intravenous fluids to treat epidural-related hypotension. Intravenous morphine / fentanyl PCA initiated. Day of surgery Patients are mobilised to a chair. Oral intake of fluids is started, aiming for > 800 ml of oral intake on the day of surgery. Pre-emptive regular antiemetics (5-HT3 antagonists as first line). Subcutanous low molecular weight heparin started for thrombo-prophylaxis (Clexane® 20mg once daily until discharge, Sanofi-aventis Ltd, Auckland, NZ). Day 1 Urinary catheter removed. Full solid oral diet. Resource supplement drinks (2-3 per day until discharge). Active mobilisation with nursing and physiotherapy input. Day 2 Epidural infusion is stopped, and epidural catheter removed. Regular oral non-steroidal anti-inflammatory drugs (Tenoxicam 20mg orally twice daily until discharge, Tilcotil tabs®, Roche, Auckland, NZ). Oral opiates for break-through pain only. Day 3 Discharged home if fulfill following criteria: Tolerating full oral diet Passing flatus Adequate analgesia on oral medication Ambulating independently Satisfactory support at home After discharge Patient given a phone number for contacting the ward if required. Nursing staff contact the patients three days after discharge for a phone interview. Follow up outpatient clinic appointment within 7 days of discharge. Preop: Preoperative; Intraop: Intraoperative Data collection—Data were collected from patient records including physical and electronic clinical, radiology, and laboratory records. Data included patient demographics, ASA score, Cr-POSSUM score, surgical indication, operating surgeon, operation performed, epidural use, intravenous fluid use, cancer staging, postoperative day stay, total day stay, complications and readmission. To ensure that recorded complications were comparable in both groups, specific complications were documented according to previously defined and published criteria.7 All patients were followed for 30 days after surgery. Results Data were available for 50 patients in each group. During the recruitment period, ten patients had been excluded from the ERAS programme; two had significant renal impairment, two had significant cardiac comorbidity, two were cognitively impaired, two could not speak sufficient English, and two declined consent. Eight patients treated from September 2004 to September 2005 were excluded from the conventional treatment control group; two patients had significant renal impairment, two had dementia, one had Addison’s disease, and three had hematologic disorders. Baseline characteristics—The ERAS and conventional groups were comparable with respect to sex, BMI, ASA score, Cr-POSSUM score, operation performed, and indication for surgery (Table 2). The ERAS group was marginally younger than the conventional group (65.6 vs 70.7 years, p=0.021). Table 2. Baseline characteristics Variables ERAS group (n=50) Control group (n=50) P value Age (mean, range) 65.6 (39-92) 70.7 (40-85) 0.021 Sex Male Female 26 24 28 22 0.688‡ 0.688‡ ASA score I II III 8 29 13 8 31 11 1.00‡ 0.683‡ 0.640‡ BMI 28.6 27.4 0.588† CR-POSSUM Physiologic Operative 10.3 9.2 9.7 8.3 0.524† 0.061† Operation Open R hemicolectomy Open L hemicolectomy Lap L hemicolectomy Open Total colectomy 26 19 4 1 29 14 7 0 0.546‡ 0.288‡ 0.525‡ 1.000‡ Diagnosis Diverticulosis IBD Adenoma Dukes A Dukes B Dukes C Dukes D 2 1 4 6 15 19 3 4 1 2 5 8 21 9 0.674‡ 1.000‡ 0.674‡ 0.749‡ 0.096‡ 0.683‡ 0.124‡ ASA: American Society of Anesthesiologists; BMI: Body mass index; CR-POSSUM: Colorectal Physiologic and Operative Severity Score for the enUmeration of Mortality; ERAS: Enhanced Recovery After Surgery; IBD: Inflammatory bowel disease; R: Right, L: Left, Lap: Laparoscopic. †Mann-Whitney U test, ‡Chi-squared test. Postoperative recovery—As we have previously shown7 there was a significant reduction in postoperative hospital stay, total hospital stay, intravenous fluid use (both intraoperative and day 1 to day 3 postoperative), and duration of epidural use in the ERAS group compared to the control group (Table 3). There was also a one day reduction in the median time to first full solid meal and passage of flatus, and patients mobilised a median of 2 days earlier. Table 3. Postoperative recovery data. Variables ERAS Group (n=50) Control Group (n=50) P Value Intravenous fluids Intraoperative First 3 days 2 (1-8) 2 (1-10) 3 (1-7.5) 6.5 (1-12) <0.0001† <0.0001† Epidural analgesia No. of patients Duration of use (days) 44 (89%) 2 (0-3) 38 (76%) 3 (0-4) 0.223‡ <0.0001† Recovery Days to 1st full meal Days to passage of flatus Days to independent mobilisation 1 (1-3) 2 (0-8) 1 (1-3) 2 (1-15) 3 (0-18) 3 (1-7) <0.0001† <0.0001† <0.0001† Complications No. of patients with > 1 complication Breakdown of complication events Death Reoperation Anastomotic leak Intra-abdominal collection Ileus Wound complication Urinary tract infection Urinary retention Cardiopulmonary 27 0 4 4 1 5 6 2 5 11 33 2 4 3 1 18 10 12 3 21 0.221‡ 0.495‡ 1.000‡ 1.000‡ 1.000‡ 0.005‡ 0.275‡ 0.008‡ 0.715‡ 0.032‡ Day stay No. admitted > 1 day before surgery\r