New York, NY—March 1, 2019
In recent years, hospitals in North America have increased implementation of procedures for Enhanced Recovery After Surgery (ERAS). While this should be a good thing, if these procedures are implemented without an appropriate evidence base and without focus on true measures of patient recovery such as complications, readmissions, or quality of life, ERAS may ultimately end up as yet another non-evidence based practice enacted solely to reduce costs, suggests Stavros Memtsoudis, MD, PhD, MBA, anesthesiologist at HSS, published in JAMA1.
While some components of ERAS have long been a part of medical practice in the United States, such as early oral intake or goal-directed fluid management, the concepts underlying ERAS originally began in Europe. The goal of these comprehensive patient care movements was to treat undesirable perioperative pathophysiologic processes in a way that would accelerate patient recovery.
Initially, protocols were developed specifically for various diseases and surgeries after rigorous study of the ways in which metabolic injury and physical interventions affect recovery, and after scientific evaluation of how effective certain measures are at hastening patient recovery.
Most of the available ERAS data involve gastrointestinal surgery, while, due to significant lag time between publication of evidence and adoption into practice, there is a lack of quality research on adopting these principles in other surgeries.
"Surgeries vary vastly in terms of invasiveness, resulting metabolic injury, and the organ systems affected," explained Dr. Memtsoudis. "Therefore, ERAS recommendations for one surgery are not necessarily applicable to others."
While it is certainly encouraging that ERAS measures in Europe have significantly reduced hospital length of stay (LOS) to durations similar to those seen in the United States, there is financial pressure in the United States to reduce LOS, both from managed care programs and due to the shift towards performing minor procedures in ambulatory settings. This means that the push to enact ERAS procedures in the United States is often driven not by measures of patient recovery such as complications, readmissions, or quality of life, but on a desire to reduce cost.
This has resulted in the formation of international ERAS specialty societies, whose protocols and alleged successes have been published and applied to various surgical settings. While these procedures are often extrapolated from those previously published in other settings and incorporate aspects supported by literature, the majority of these publications lack scientific rigor: for example, they may use data from cohort studies instead of clinical trials, include components of ERAS with minor effectiveness, or include small numbers of highly selected patient populations that often lack or only have limited external validity.
ERAS procedures created in this way may also have other problems, including adding interventions with only the assumption that they will provide benefit, resulting in unwieldy protocols including as many as 20 components;2 being unable to determine the incremental effects or benefits of drugs added to protocols, which may be unsafe because it is impossible to determine potential drug interactions or the effects of various interventions; and that because it is likely that a ceiling effect exists in which outcomes cannot be meaningfully improved further, patients are exposed to unnecessary risks and healthcare systems are left with increased cost from ineffective interventions.
The focus on LOS may also be misguided in its ability to actually reduce costs. A recent study showed that total joint arthroplasties with a decreased LOS coincided with increased spending post-discharge.3 And while most patients may prefer shorter hospital stays, focusing on LOS ignores the reality that much of rehabilitation occurs not in hospitals, but in other acute care settings such as skilled nursing facilities.
"ERAS was founded as an evidence-based science whose outcomes were patient-centered. It should not be replaced with the empiric addition of poorly-studied interventions and medications whose success is measured with outcomes that are primarily economic in nature," Dr. Memtsoudis said.
"To curb this issue, more high-quality research evaluating the individual and cumulative benefit of various aspects of ERAS protocols for specific patient populations needs to be conducted. Additionally, frequent re-evaluation is needed to replace components that may become either obsolete or can be replaced with better or more cost effective alternatives," he concluded.
1Memtsoudis S. Enhanced Recovery After Surgery in the United States: From Evidence-Based Practice to Uncertain Science? JAMA. 2019. doi: 10.1001/jama.2019.1070
2ERAS Society. List of Guidelines. http://erassociety.org/guidelines/list-of-guidelines/. Accessed December 4, 2018.
3Bozic KJ, Ward L, Vail TP, Maze M. Bundled payments in total joint arthroplasty: targeting opportunities for quality improvement and cost reduction. Clin Orthop Relat Res. 2014;472(1):188-193. doi: 10.1007/s11999-013-3034-3