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Hong M, Ghajar M, Allen W, Jasti S, Alvarez-Downing MM. Evaluating Implementation Costs of an Enhanced Recovery After Surgery (ERAS) Protocol in Colorectal Surgery: A Systematic Review. World J Surg 2023; 47:1589-1596. [PMID: 37149554 DOI: 10.1007/s00268-023-07024-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/26/2023] [Indexed: 05/08/2023]
Abstract
BACKGROUND Enhanced recovery after surgery (ERAS) protocols have been well documented in the current literature to improve healthcare outcomes by decreasing length of stay, resource utilization, and morbidity without increasing readmission rates or complications. This subsequently leads to a net decrease in hospital costs. However, the initial costs of implementing such a program have not been well described, which is crucial information for hospitals with less resources. The aim of this study was to provide a cohesive review of the current literature for the costs of implementing a colorectal surgery ERAS protocol. METHODS A comprehensive review was conducted on five databases (Google Scholar, Web of Science, PROSPERO, PubMed, and Cochrane) with the assistance of a professional librarian. All relevant English articles published between 1995 and June 2021 were screened for eligibility prior to inclusion in the review. Cost data were converted to US dollars based on the exchange rate at the end time of the study period for standardization. RESULTS Seven studies were included for review. The studies evaluated a range of 50-1295 patients through their respective ERAS programs, which were followed for 5 to 22 months. ERAS implementation costs ranged from $57 to $1536 per patient. Components for each ERAS program varied for each study, but ultimately, the greatest costs were attributed to personnel. CONCLUSIONS Despite data heterogeneity and inconsistencies between cost breakdowns, a majority of the implementation cost was found to be secondary to personnel. This review demonstrates the need for a more standardized approach for reporting ERAS implementation costs through an open database as well as a potential streamlining of the ERAS protocol to facilitate implementation in institutions with less financial resources.
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Affiliation(s)
- Minki Hong
- Rutgers New Jersey Medical School, Newark, NJ, USA
| | - Mina Ghajar
- Rutgers University, George F. Smith Library of the Health Sciences, Newark, NJ, USA
| | | | | | - Melissa M Alvarez-Downing
- Department of Surgery, Division of Colorectal Surgery, Rutgers New Jersey Medical School, 185 South Orange Avenue, Medical Science Building, G-514, Newark, NJ, 07103, USA.
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Frankel L, Maurente D, Ardeljan AD, Divesh M, Rashid AM, Takabe K, Rashid OM. Improving Gastrointestinal Cancer Care by Enhanced Recovery Protocol Implementation. World J Oncol 2023; 14:135-144. [PMID: 37188038 PMCID: PMC10181426 DOI: 10.14740/wjon1534] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2022] [Accepted: 02/24/2023] [Indexed: 05/17/2023] Open
Abstract
Background Enhanced recovery protocols (ERPs) have become the standard of care for patients undergoing elective small bowel surgeries but have not yet been adequately studied in community hospitals. In this study, a multidisciplinary ERP was developed and implemented at a community hospital to include minimal anesthesia, early ambulation and enteral alimentation, and multimodal analgesia. The aim of this study was to determine the effects of the ERP on postoperative length of stay (LOS), readmission (RA) rates following bowel surgery, and postoperative outcomes. Methods The study design was a retrospective review of patients undergoing major bowel resection at Holy Cross Hospital (HCH) from January 1, 2017 to December 31, 2017. Patient charts for diagnostic-related group (DRG) 329, 330, and 331 were retrospectively reviewed at HCH in 2017 to compare outcomes in ERP versus non-ERP cases. The Medicare claims database (CMS) was also retrospectively reviewed to compare HCH data to the national average LOS and RA for the same DRG codes. Mean values for LOS and RA were statistically compared to determine significant differences between ERP versus non-ERP patients at HCH and national CMS data versus HCH patients. Results LOS was analyzed for each DRG at HCH. At HCH, for DRG 329, the mean LOS for non-ERP was 13.0833 days (n = 12) versus 3.375 days (n = 8) (P ≤ 0.001) for ERP. For DRG 330, the mean LOS for non-ERP was 10.861 days (n = 36) versus 4.583 days (n = 24) (P ≤ 0.001) for ERP. For DRG 331, the mean LOS for non-ERP was 7.272 days (n = 11) versus 3.348 days (n = 23) (P = 0.004) for ERP. LOS was also compared to national CMS data. The LOS at HCH for DRG 329 improved from the 10th to 90th percentile (n = 238,907); DRG 330 improved from the 10th to the 72nd percentile (n = 285,423); DRG 331 improved from 10th to 54th percentile (n = 126,941) (P < 0.001). The RA at HCH in ERP and non-ERP cases was 3% at 30 and 90 days. CMS RA for DRG 329 was 25.1% at 90 days and 9.9% at 30 days; DRG 330 RA was 18.3% at 90 days and 6.6% at 30 days; DRG 331 RA was 11% at 90 days and 3.9% at 30 days. Conclusion Implementation of ERP following bowel surgery at HCH significantly improved outcomes, in comparison to non-ERP cases, national CMS data, and Humana data. Further research on ERP for other fields and its impact on outcomes in other community settings is recommended.
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Affiliation(s)
- Lexi Frankel
- Nova Southeastern University, Dr. Kiran C. Patel College of Allopathic Medicine, Fort Lauderdale, FL, USA
| | - Diego Maurente
- Michael and Dianne Biennes Comprehensive Cancer Center, Holy Cross Health, Fort Lauderdale, FL, USA
| | - Amalia D. Ardeljan
- Michael and Dianne Biennes Comprehensive Cancer Center, Holy Cross Health, Fort Lauderdale, FL, USA
| | - Manjani Divesh
- Michael and Dianne Biennes Comprehensive Cancer Center, Holy Cross Health, Fort Lauderdale, FL, USA
| | - Ali M. Rashid
- Michael and Dianne Biennes Comprehensive Cancer Center, Holy Cross Health, Fort Lauderdale, FL, USA
| | - Kazuaki Takabe
- Department of Surgical Oncology, Roswell Park Comprehensive Cancer Center, Buffalo, NY, USA
- Department of Surgery, University at Buffalo Jacobs School of Medicine and Biomedical Sciences, the State University of New York, Buffalo, NY, USA
| | - Omar M. Rashid
- Nova Southeastern University, Dr. Kiran C. Patel College of Allopathic Medicine, Fort Lauderdale, FL, USA
- Michael and Dianne Biennes Comprehensive Cancer Center, Holy Cross Health, Fort Lauderdale, FL, USA
- University of Miami, Leonard Miami School of Medicine, Miami, FL, USA
- Massachusetts General Hospital, Boston, MA, USA
- Broward Health, Fort Lauderdale, FL, USA
- TopLine MD Alliance, Fort Lauderdale, FL, USA
- Memorial Health, Pembroke Pines, FL, USA
- Delray Medical Center, Delray, FL, USA
- Corresponding Author: Omar M. Rashid, Complex General Surgical Oncology, General & Robotic Surgery, TopLine MD Alliance, Fort Lauderdale, FL 33308, USA.
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Shao C, Tsai S, Woo R, Dream S. Becoming a Sustainable Academic Surgeon. J Surg Res 2023; 283:606-610. [PMID: 36442260 DOI: 10.1016/j.jss.2022.10.091] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2022] [Revised: 09/30/2022] [Accepted: 10/17/2022] [Indexed: 11/27/2022]
Abstract
INTRODUCTION Health care facilities represent a significant source of pollution, contributing to the growing problems associated with global warming. The resulting climate change impacts our health through worsening air and water quality, diminished access to nutritious food, and safe shelter. METHODS We outline here the not only the role of the surgeon in contributing to climate change, but also ways in which to minimize one's carbon footprint. RESULTS Surgeons are leaders within healthcare systems. Adopting environmentally conscious practices can reduce solid waste, energy usage, and carbon emissions. Practices outside of the clinical setting can also incorporate sustainability, including the use of virtual recruitment and educational programs, as well as thoughtful and conscientious travel practices. CONCLUSIONS Academic surgery combines clinical practice with an element of leadership, at all levels. Our recognition and action to reduce wasteful practices can help leave a better earth for generations to come.
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Affiliation(s)
- Connie Shao
- Department of Surgery, University of Alabama at Birmingham, Birmingham, Alabama
| | - Susan Tsai
- Division of Surgical Oncology, Department of Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Russell Woo
- Department of Surgery, University of Hawai'I, John A. Burns School of Medicine, Honolulu, Hawaii
| | - Sophie Dream
- Division of Surgical Oncology, Department of Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin.
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Abstract
OBJECTIVE Although value-based healthcare (VBHC) views accurate cost information to be crucial in the pursuit of value, little is known about how the costs of care should be measured. The aim of this review is to identify how costs are currently measured in VBHC, and which cost measurement methods can facilitate VBHC or value-based decision making. DESIGN Two reviewers systematically search the PubMed/MEDLINE, Embase, EBSCOhost and Web of Science databases for publications up to 1 January 2022 and follow Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines to identify relevant studies for further analysis. ELIGIBILITY CRITERIA Studies should measure the costs of an intervention, treatment or care path and label the study as 'value based'. An inductive qualitative approach was used to identify studies that adopted management accounting techniques to identify if or how cost information facilitated VBHC by aiding decision-making. RESULTS We identified 1930 studies, of which 215 measured costs in a VBHC setting. Half of these studies measured hospital costs (110, 51.2%) and the rest relied on reimbursement amounts. Sophisticated costing methods that allocate both direct and indirect costs to care paths were seen as able to provide valuable managerial information by facilitating care path adjustments (39), benchmarking (38), the identification of cost drivers (47) and the measurement of total costs or cost savings (26). We found three best practices that were key to success in cost measurement: process mapping (33), expert input (17) and observations (24). CONCLUSIONS Cost information can facilitate VBHC. Time-driven activity-based costing (TDABC) is viewed as the best method although its ability to inform decision-making depends on how it is implemented. While costing short, or partial, care paths and surgical episodes produces accurate cost information, it provides only limited decision-making information. Practitioners are advised to focus on costing full care cycles and to consider both direct and indirect costs through TDABC.
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Affiliation(s)
- Maura Leusder
- Erasmus School of Health Policy & Management, Department Health Services Management & Organization, Erasmus University Rotterdam, Rotterdam, The Netherlands
| | - Petra Porte
- Erasmus School of Health Policy & Management, Department Health Services Management & Organization, Erasmus University Rotterdam, Rotterdam, The Netherlands
| | - Kees Ahaus
- Erasmus School of Health Policy & Management, Department Health Services Management & Organization, Erasmus University Rotterdam, Rotterdam, The Netherlands
| | - Hilco van Elten
- Erasmus School of Health Policy & Management, Department Health Services Management & Organization, Erasmus University Rotterdam, Rotterdam, The Netherlands
- Center for Corporate Reporting, Finance & Tax, Nyenrode Business Universiteit, Breukelen, The Netherlands
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