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Laohathai S, Sadad Z, Suvarnakich K, Pathonsamit C, Tantraworasin A. Efficacy of the Enhanced Recovery After Surgery program for thoracic surgery in a developing country. Indian J Thorac Cardiovasc Surg 2023; 39:476-483. [PMID: 37609619 PMCID: PMC10441865 DOI: 10.1007/s12055-023-01518-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2022] [Revised: 04/06/2023] [Accepted: 04/11/2023] [Indexed: 08/24/2023] Open
Abstract
Purpose Enhanced Recovery After Surgery (ERAS) is a strategy used to improve perioperative outcomes and reduce complications. However, data on the efficacy of ERAS in thoracic surgery in developing countries are limited. The current study aimed to validate the benefits of ERAS among patients at a single institution. Methods This was a retrospective study of patients who underwent pulmonary resection at Vajira Hospital, Bangkok, Thailand, between 2016 and 2020. To compare outcomes, patients were divided into the pre-ERAS group (2016-2018) and the post-ERAS group (2019-2020) using propensity score matching (1:2) with the year 2019 as the cutoff for introducing ERAS protocols at our institution. Results In total, 321 patients were included in the analysis (pre-ERAS group, n = 74; post-ERAS group, n = 247). After propensity score matching, 56 and 112 patients were classified under the pre- and post-ERAS groups, respectively. The post-ERAS group had significantly lower pain scores than the pre-ERAS group on postoperative days 1, 2, and 3, and a lower volume of intraoperative blood loss. In the multivariable analysis, the post-ERAS group had a shorter chest tube duration (mean difference = -1.62 days, 95% confidence interval = -2.65 to -0.31) and length of hospital stay (mean difference = -2.40 days, 95% confidence interval = -4.45 to -0.65) than the pre-ERAS group. Conclusion The use of ERAS guidelines in pulmonary resection is beneficial. Although no significant differences were observed in postoperative complication rate, intensive care unit stay, and additional cost burden between the two groups, patients in the post-ERAS group had a shorter postoperative chest tube duration, shorter hospital stays, shorter operative time, lower postoperative pain score, and lower volume of intraoperative blood loss.
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Affiliation(s)
- Sira Laohathai
- Cardiothoracic Surgery Unit, Department of Surgery, Faculty of Medicine, Vajira Hospital, Navamindradhiraj University, Bangkok, Thailand
| | - Zarina Sadad
- Cardiothoracic Surgery Unit, Department of Surgery, Faculty of Medicine, Vajira Hospital, Navamindradhiraj University, Bangkok, Thailand
| | - Kanok Suvarnakich
- Cardiothoracic Surgery Unit, Department of Surgery, Faculty of Medicine, Vajira Hospital, Navamindradhiraj University, Bangkok, Thailand
| | - Chompunoot Pathonsamit
- Department of Anaesthesia, Faculty of Medicine, Vajira Hospital, Navamindradhiraj University, Bangkok, Thailand
| | - Apichat Tantraworasin
- Clinical Surgical Research Centre, Faculty of Medicine, Chiang Mai University, 110 Intrawaroros Road, Chiang Mai, Thailand
- Thoracic Surgery Unit, Department of Surgery, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
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Thompson C, Mattice AMS, Al Lawati Y, Seyednejad N, Lee A, Maziak DE, Gilbert S, Sundaresan S, Villeneuve J, Shamji F, Brehaut J, Ramsay T, Seely AJE. The longitudinal impact of division-wide implementation of an enhanced recovery after thoracic surgery programme. Eur J Cardiothorac Surg 2021; 61:1223-1229. [PMID: 34849684 DOI: 10.1093/ejcts/ezab492] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2021] [Revised: 10/13/2021] [Accepted: 10/18/2021] [Indexed: 01/03/2023] Open
Abstract
OBJECTIVES Data regarding enhanced recovery after thoracic surgery (ERATS) are sparse and inconsistent. This study aims to evaluate the effects of implementing an enhanced ERATS programme on postoperative outcomes, patient experience and quality of life (QOL). METHODS We conducted a prospective, longitudinal study evaluating 9 months before (pre-ERATS) and 9 months after (post-ERATS) a 3-month implementation of an ERATS programme in a single academic tertiary care centre. All patients undergoing major thoracic surgeries were included. The primary outcomes included length of stay (LOS), adverse events (AEs), 6-min walk test scores at 4 weeks, 30-day emergency room visits (without admission) and 30-day readmissions. The process-of-care outcomes included time to 'out-of-bed', independent ambulation, successful fluid intake, last chest tube removal and removal of urinary catheter. Perioperative anaesthesia-related outcomes were examined as well as patient experience and QOL scores. RESULTS The pre-ERATS group (n = 352 patients) and post-ERATS group (n = 352) demonstrated no differences in demographics. Post-ERATS patients had improved LOS (4.7 vs 6.2 days, P < 0.02), 6-min walk test scores (402 vs 371 m, P < 0.05) and 30-day emergency room visits (13.7% vs 21.6%, P = 0.03) with no differences in AEs and 30-day readmissions. Patients experienced shorter mean time to 'out-of-bed', independent ambulation, successful fluid intake, last chest tube removal and urinary catheter removal. There were no differences in postoperative analgesia administration, patient satisfaction and QOL scores. CONCLUSIONS ERATS implementation was associated with improved LOS, expedited feeding, ambulation and chest tube removal, without increasing AEs or readmissions, while maintaining a high level of patient satisfaction and QOL.
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Affiliation(s)
- Calvin Thompson
- Dept. of Anesthesiology and Pain Medicine, The Ottawa Hospital, Ottawa, ON, Canada
| | - Amanda M S Mattice
- Ottawa Hospital Research Institute, University of Ottawa, Ottawa, ON, Canada
| | - Yaseen Al Lawati
- Division of Thoracic Surgery, The Ottawa Hospital, Ottawa, ON, Canada
| | - Nazgol Seyednejad
- Division of Thoracic Surgery, The Ottawa Hospital, Ottawa, ON, Canada
| | - Alex Lee
- Ottawa Hospital Research Institute, University of Ottawa, Ottawa, ON, Canada
| | - Donna E Maziak
- Division of Thoracic Surgery, The Ottawa Hospital, Ottawa, ON, Canada
| | - Sebastian Gilbert
- Division of Thoracic Surgery, The Ottawa Hospital, Ottawa, ON, Canada
| | - Sudhir Sundaresan
- Division of Thoracic Surgery, The Ottawa Hospital, Ottawa, ON, Canada
| | - James Villeneuve
- Division of Thoracic Surgery, The Ottawa Hospital, Ottawa, ON, Canada
| | - Farid Shamji
- Division of Thoracic Surgery, The Ottawa Hospital, Ottawa, ON, Canada
| | - Jamie Brehaut
- Ottawa Hospital Research Institute, University of Ottawa, Ottawa, ON, Canada.,School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada
| | - Tim Ramsay
- Ottawa Hospital Research Institute, University of Ottawa, Ottawa, ON, Canada
| | - Andrew J E Seely
- Ottawa Hospital Research Institute, University of Ottawa, Ottawa, ON, Canada.,Division of Thoracic Surgery, The Ottawa Hospital, Ottawa, ON, Canada
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Abrão FC, Araujo de França S, de Abreu IRLB, das Neves Pereira JC, Del Massa EC, Oliver A, Cavalcante MGC. Enhanced recovery after surgery (ERAS ®) protocol adapted to the Brazilian reality: a prospective cohort study for thoracic patients. J Thorac Dis 2021; 13:5439-5447. [PMID: 34659810 PMCID: PMC8482344 DOI: 10.21037/jtd-21-920] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2021] [Accepted: 08/06/2021] [Indexed: 11/28/2022]
Abstract
Background In Low-Middle Income Countries (LMICs), resource optimization and infrastructure availability are recurrently in debate. In order to assist the development and implementation of guidelines, LMICs often exemplify from High-Income Countries protocols. At the final, it will be: content adaption is often needed. In this study, we demonstrated the preliminary analysis of the Brazilian experience by adapting the ERAS® Protocol for thoracic surgery patients (PROSM). Methods Patients’ data were extracted from the surgical group database that operated in the city of Sao Paulo. Patients’ data were organized for analysis after the institution’s ethics committee gave their approval. Patients’ variables were analyzed and compared to a control group. Subgroup analysis included patients without ICU Admission. Results PROSM patients had reduced ICU length of stay (LOS) (Mean of 0.3±0.58 days, 1.2±1.65 days, P=0.001), Hospital LOS (Mean of 1.6±1.32 days, 3.9±3.25 days, P=0.001) and Chest Drain duration (Median 1.0±1.00 days, 3.0±3.00 days, P=0.001). Analyses of patients that were not admitted to the ICU demonstrated reduced Hospital LOS and Chest drain duration. Cost analysis, such as procedure, daily, and post-surgical costs were also significantly lower towards PROSM group. Conclusions This study revealed important aspects for improvement of the delivered care quality and opportunity for expenditure management. We expect to assist more countries to improve knowledge under the implementation of enhanced protocols.
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Affiliation(s)
- Fernando C Abrão
- Thoracic Surgery Department, Hospital Santa Marcelina, São Paulo, Brazil.,Thoracic Department, Hospital Alemão Oswaldo Cruz, São Paulo, Brazil
| | - Sabrina Araujo de França
- IPSPAC Research Department - Instituto Paulista de Saúde para Alta Complexidade, Santo Andre, Brazil
| | - Igor R L B de Abreu
- Thoracic Surgery Department, Hospital Santa Marcelina, São Paulo, Brazil.,Thoracic Surgery Department, Hospital São Camilo, São Paulo, Brazil
| | | | | | - Andréa Oliver
- Physiotherapy Department, Hospital Santa Marcelina, São Paulo, Brazil
| | - Maria Gabriela C Cavalcante
- Thoracic Surgery Department, Hospital Santa Marcelina, São Paulo, Brazil.,Thoracic Surgery Department, Hospital São Camilo, São Paulo, Brazil
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Liu L, Zhang J, Wang G, Guo C, Chen Y, Huang C, Li S. Delayed Discharge after Thoracic Surgery under the Guidance of ERAS Protocols. Thorac Cardiovasc Surg 2021; 70:405-412. [PMID: 34176111 DOI: 10.1055/s-0041-1727232] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Enhanced recovery after surgery (ERAS) protocols have been applied in thoracic surgery and are beneficial to patients. However, some issues about ERAS are still pending. METHODS A total of 1,654 patients who underwent thoracic surgery under the guidance of ERAS protocols were enrolled in this study. We set the length of postoperative stay (LOPS) as our key research indicator. Patients were divided into routine discharge group and delayed discharge group based on LOPS. Causes of delayed discharge were analyzed to improve management of postoperative recovery. RESULTS Male, old age, underlying disease (coronary artery disease, chronic kidney disease, old cerebral infarction, chronic obstructive pulmonary disease, and arrhythmia), intensive care unit (ICU) stay, type of insurance, and lower forced expiratory volume in one second (FEV1) are the independent impact factors causing delayed discharge. Increased nonchylous drainage (INCD) and prolonged air leakage were the two leading causes for delayed discharge. CONCLUSION Patients should have personalized recovery goal under the same ERAS protocols. We should accept that patients in poor general condition have a prolonged LOPS. More stringent ICU stay indications should be developed to increase postoperative patients' ERAS protocols compliance. Further research on chest tube management will make a contribution to ERAS protocols.
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Affiliation(s)
- Lei Liu
- Department of Thoracic Surgery, Peking Union Medical College Hospital, Dongcheng-qu, Beijing, People's Republic of China
| | - Jiaqi Zhang
- Department of Thoracic Surgery, Peking Union Medical College Hospital, Dongcheng-qu, Beijing, People's Republic of China
| | - Guige Wang
- Department of Thoracic Surgery, Peking Union Medical College Hospital, Dongcheng-qu, Beijing, People's Republic of China
| | - Chao Guo
- Department of Thoracic Surgery, Peking Union Medical College Hospital, Dongcheng-qu, Beijing, People's Republic of China
| | - Yeye Chen
- Department of Thoracic Surgery, Peking Union Medical College Hospital, Dongcheng-qu, Beijing, People's Republic of China
| | - Cheng Huang
- Department of Thoracic Surgery, Peking Union Medical College Hospital, Dongcheng-qu, Beijing, People's Republic of China
| | - Shanqing Li
- Department of Thoracic Surgery, Peking Union Medical College Hospital, Dongcheng-qu, Beijing, People's Republic of China
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Li R, Wang K, Qu C, Qi W, Fang T, Yue W, Tian H. The effect of the enhanced recovery after surgery program on lung cancer surgery: a systematic review and meta-analysis. J Thorac Dis 2021; 13:3566-3586. [PMID: 34277051 PMCID: PMC8264698 DOI: 10.21037/jtd-21-433] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2021] [Accepted: 05/14/2021] [Indexed: 12/25/2022]
Abstract
Background Lung cancer is one of the most common causes of cancer-related death worldwide. The enhanced recovery after surgery (ERAS) program is an effective evidence-based multidisciplinary protocol of perioperative care. However, the roles of ERAS in lung cancer surgery remain unclear. This systematic review and meta-analysis aimed to investigate the short-term impact of the ERAS program on lung resection surgery, especially in relation to postoperative complications. Methods A systematic literature search of PubMed, EMBASE, and the Cochrane Library databases until October 2020 was performed to identify the studies that implemented an ERAS program in lung cancer surgery. The studies were selected and subjected to data extraction by 2 reviewers independently, which was followed by quality assessment. A random effects model was used to calculate overall effect sizes. Risk ratio (RR), risk difference (RD), and standardized mean difference (SMD) with 95% confidence interval (CI) served as the summary statistics for meta-analysis. Subgroup analysis and sensitivity analysis were subsequently performed. Results A total of 21 studies with 6,480 patients were included. The meta-analysis indicated that patients in the ERAS group had a significantly reduced risk of postoperative complications (RR =0.64; 95% CI: 0.52 to 0.78) and shortened postoperative length of stay (SMD=-1.58; 95% CI: -2.38 to -0.79) with a significant heterogeneity. Subgroup analysis showed that the risks of pulmonary (RR =0.58; 95% CI: 0.45 to 0.75), cardiovascular (RR =0.73; 95% CI: 0.59 to 0.89), urinary (RR =0.53; 95% CI: 0.32 to 0.88), and surgical complications (RR =0.64; 95% CI: 0.42 to 0.97) were significantly lower in the ERAS group. No significant reduction was found in the in-hospital mortality (RD =0.00; 95% CI: -0.01 to 0.00) and readmission rate (RR =1.00; 95% CI: 0.76 to 1.32). In the qualitative review, most of the evidence reported significantly decreased hospitalization costs in the ERAS group. Conclusions The implementation of an ERAS program for surgery of lung cancer can effectively reduce risks of postoperative complications, length of stay, and costs of patients who have undergone lung cancer surgery without compromising their safety.
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Affiliation(s)
- Rongyang Li
- Department of Thoracic Surgery, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan, China.,Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Kun Wang
- Department of Thoracic Surgery, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan, China.,Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Chenghao Qu
- Department of Thoracic Surgery, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan, China.,Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Weifeng Qi
- Department of Thoracic Surgery, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan, China.,Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Tao Fang
- Department of Thoracic Surgery, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan, China.,Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Weiming Yue
- Department of Thoracic Surgery, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan, China.,Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Hui Tian
- Department of Thoracic Surgery, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan, China.,Cheeloo College of Medicine, Shandong University, Jinan, China
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Berna P, Quesnel C, Assouad J, Bagan P, Etienne H, Fourdrain A, Le Guen M, Leone M, Lorne E, Nguyen YNL, Pages PB, Roz H, Garnier M. Guidelines on enhanced recovery after pulmonary lobectomy. Anaesth Crit Care Pain Med 2021; 40:100791. [PMID: 33451912 DOI: 10.1016/j.accpm.2020.100791] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
OBJECTIVE To establish recommendations for optimisation of the management of patients undergoing pulmonary lobectomy, particularly Enhanced Recovery After Surgery (ERAS). DESIGN A consensus committee of 13 experts from the French Society of Anaesthesia and Intensive Care Medicine (Soci,t, franOaise d'anesth,sie et de r,animation, SFAR) and the French Society of Thoracic and Cardiovascular Surgery (Soci,t, franOaise de chirurgie thoracique et cardiovasculaire, SFCTCV) was convened. A formal conflict-of-interest policy was developed at the onset of the process and enforced throughout. The entire guidelines process was conducted independently of any industry funding. The authors were advised to follow the principles of the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system to guide assessment of quality of evidence. METHODS Five domains were defined: 1) patient pathway and patient information; 2) preoperative management and rehabilitation; 3) anaesthesia and analgesia for lobectomy; 4) surgical strategy for lobectomy; and 5) enhanced recovery after surgery. For each domain, the objective of the recommendations was to address a number of questions formulated according to the PICO model (Population, Intervention, Comparison, Outcome). An extensive literature search on these questions was carried out and analysed using the GRADE® methodology. Recommendations were formulated according to the GRADE® methodology, and were then voted by all experts according to the GRADE grid method. RESULTS The SFAR/SFCTCV guideline panel provided 32 recommendations on the management of patients undergoing pulmonary lobectomy. After two voting rounds and several amendments, a strong consensus was reached for 31 of the 32 recommendations and a moderate consensus was reached for the last recommendation. Seven of these recommendations present a high level of evidence (GRADE 1+), 23 have a moderate level of evidence (18 GRADE 2+ and 5 GRADE 2-), and 2 correspond to expert opinions. Finally, no recommendation was provided for 2 of the questions. CONCLUSIONS A strong consensus was expressed by the experts to provide recommendations to optimise the whole perioperative management of patients undergoing pulmonary lobectomy.
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Affiliation(s)
- Pascal Berna
- Department of Thoracic Surgery, Amiens University Hospital, 80000 Amiens, France
| | - Christophe Quesnel
- Sorbonne Universit,, APHP, DMU DREAM, Service d'Anesth,sie-R,animation et M,decine P,riop,ratoire, H"pital Tenon, 75020 Paris, France
| | - Jalal Assouad
- Department of Thoracic Surgery, Tenon University Hospital, Sorbonne Universit,, 75020 Paris, France
| | - Patrick Bagan
- Department of Thoracic and Vascular Surgery, Victor Dupouy Hospital, 95100 Argenteuil, France
| | - Harry Etienne
- Department of Thoracic Surgery, Tenon University Hospital, Sorbonne Universit,, 75020 Paris, France
| | - Alex Fourdrain
- Department of Thoracic Surgery, Amiens University Hospital, 80000 Amiens, France
| | - Morgan Le Guen
- D,partement d'Anesth,sie, H"pital Foch, Universit, Versailles Saint Quentin, 92150 Suresnes, France; INRA UMR 892 VIM, 78350 Jouy-en-Josas, France
| | - Marc Leone
- Aix Marseille Universit, - Assistance Publique H"pitaux de Marseille - Service d'Anesth,sie et de R,animation - H"pital Nord - 13005 Marseille, France
| | - Emmanuel Lorne
- Departement d'Anesth,sie-R,animation, Clinique du Mill,naire, 34000 Montpellier, France
| | - Y N-Lan Nguyen
- Anaesthesiology and Critical Care Department, APHP Centre, Paris University, 75000 Paris, France
| | - Pierre-Benoit Pages
- Department of Thoracic Surgery, Dijon Burgundy University Hospital, 21000 Dijon, France; INSERM UMR 1231, Dijon Burgundy University Hospital, University of Burgundy, 21000 Dijon, France
| | - Hadrien Roz
- Unit, d'Anesth,sie R,animation Thoracique, H"pital Haut Leveque, CHU de Bordeaux, 33000 Bordeaux, France
| | - Marc Garnier
- Sorbonne Universit,, APHP, DMU DREAM, Service d'Anesth,sie-R,animation et M,decine P,riop,ratoire, H"pital Tenon, 75020 Paris, France.
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Haywood N, Nickel I, Zhang A, Byler M, Scott E, Julliard W, Blank RS, Martin LW. Enhanced Recovery After Thoracic Surgery. Thorac Surg Clin 2020; 30:259-267. [DOI: 10.1016/j.thorsurg.2020.04.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
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Tahiri M, Goudie E, Jouquan A, Martin J, Ferraro P, Liberman M. Enhanced recovery after video-assisted thoracoscopic surgery lobectomy: a prospective, historically controlled, propensity-matched clinical study. Can J Surg 2020; 63:E233-E240. [PMID: 32386474 DOI: 10.1503/cjs.001919] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023] Open
Abstract
Background Enhanced recovery pathways or fast-tracking following surgery can decrease the rate of postoperative complications and hospital length of stay. The objectives of this study were to implement an enhanced recovery after surgery (ERAS) pathway for patients undergoing a video-assisted thoracoscopic surgery (VATS) lobectomy, to assess the safety and efficiency of this protocol by measuring associated postoperative outcomes, and to compare the outcomes for patients in the ERAS group with the outcomes for patients in a propensity-matched control group. Methods The study was a prospective clinical trial. Patients who were scheduled to undergo VATS lobectomy at the Centre hospitalier de l'Université de Montréal in Montréal, Quebec, Canada, were enrolled between November 2015 and October 2016. The ERAS pathway was used for all enrolled patients. The primary outcome was the number and severity of complications measured by the Comprehensive Complication Index. Secondary outcomes included length of stay, readmission and recovery. Recovery of patients was measured using EQ-5D-5L preoperatively and at 1 week, 1 month and 4 months after surgery. Prospectively enrolled patients were propensity matched to historical controls. Results Ninety-eight patients (36 men and 62 women) in the ERAS group and 98 patients in the control group (29 men and 69 women) were included in the analysis. The mean age was 65.2 ± 9.3 years, the mean body mass index (BMI) was 26.9 ± 5.9 kg/m2 and the median Charlson Comorbidity Index score was 2 (interquartile range [IQR] 2-3) in the ERAS group. In the control group, the mean age was 66.2 ± 9.4 years, the mean BMI was 27.4 ± 5.6 kg/m2 and the median Charlson Comorbidity Index score was 3 (IQR 2-3). A total of 23 patients (23.4%) in the ERAS group and 28 (28.6%) in the control group experienced 1 or more postoperative complications. The mean Comprehensive Complication Index score was 7.4 ± 16.8 in the ERAS group compared with 8.0 ± 14.3 in the control group (p = 0.79). The median postoperative length of stay was 3 days in the ERAS group and 5 days in the control group (p < 0.001). Five patients in the ERAS group and 4 patients in the control group were readmitted. The protocol adherence rate was 64.3%. Conclusion It is feasible to implement an enhanced recovery protocol after VATS lobectomy. Although the pathway is still early in its development in Canada, implementation of an ERAS pathway after VATS lobectomy was associated with decreased length of stay, with no observable increase in complication or readmission rates.
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Affiliation(s)
- Mehdi Tahiri
- From the Division of Thoracic Surgery, Université de Montréal, Montreal, Que. (Tahiri, Goudie, Jouquan, Thiffault, Martin, Ferraro, Liberman); and the CHUM Endoscopic Tracheobronchial and Oesophageal Centre (CETOC), Montreal, Que. (Tahiri, Goudie, Jouquan, Thiffault, Martin, Ferraro, Liberman)
| | - Eric Goudie
- From the Division of Thoracic Surgery, Université de Montréal, Montreal, Que. (Tahiri, Goudie, Jouquan, Thiffault, Martin, Ferraro, Liberman); and the CHUM Endoscopic Tracheobronchial and Oesophageal Centre (CETOC), Montreal, Que. (Tahiri, Goudie, Jouquan, Thiffault, Martin, Ferraro, Liberman)
| | - Adeline Jouquan
- From the Division of Thoracic Surgery, Université de Montréal, Montreal, Que. (Tahiri, Goudie, Jouquan, Thiffault, Martin, Ferraro, Liberman); and the CHUM Endoscopic Tracheobronchial and Oesophageal Centre (CETOC), Montreal, Que. (Tahiri, Goudie, Jouquan, Thiffault, Martin, Ferraro, Liberman)
| | - Jocelyne Martin
- From the Division of Thoracic Surgery, Université de Montréal, Montreal, Que. (Tahiri, Goudie, Jouquan, Thiffault, Martin, Ferraro, Liberman); and the CHUM Endoscopic Tracheobronchial and Oesophageal Centre (CETOC), Montreal, Que. (Tahiri, Goudie, Jouquan, Thiffault, Martin, Ferraro, Liberman)
| | - Pasquale Ferraro
- From the Division of Thoracic Surgery, Université de Montréal, Montreal, Que. (Tahiri, Goudie, Jouquan, Thiffault, Martin, Ferraro, Liberman); and the CHUM Endoscopic Tracheobronchial and Oesophageal Centre (CETOC), Montreal, Que. (Tahiri, Goudie, Jouquan, Thiffault, Martin, Ferraro, Liberman)
| | - Moishe Liberman
- From the Division of Thoracic Surgery, Université de Montréal, Montreal, Que. (Tahiri, Goudie, Jouquan, Thiffault, Martin, Ferraro, Liberman); and the CHUM Endoscopic Tracheobronchial and Oesophageal Centre (CETOC), Montreal, Que. (Tahiri, Goudie, Jouquan, Thiffault, Martin, Ferraro, Liberman)
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Nunns M, Shaw L, Briscoe S, Thompson Coon J, Hemsley A, McGrath JS, Lovegrove CJ, Thomas D, Anderson R. Multicomponent hospital-led interventions to reduce hospital stay for older adults following elective surgery: a systematic review. Health Serv Deliv Res 2019. [DOI: 10.3310/hsdr07400] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
BackgroundElective older adult inpatient admissions are increasingly common. Older adults are at an elevated risk of adverse events in hospital, potentially increasing with lengthier hospital stay. Hospital-led organisational strategies may optimise hospital stay for elective older adult inpatients.ObjectivesTo evaluate the effectiveness and cost-effectiveness of hospital-led multicomponent interventions to reduce hospital stay for older adults undergoing elective hospital admissions.Data sourcesSeven bibliographic databases (MEDLINE, MEDLINE In-Process & Other Non-Indexed Citations, EMBASE, Health Management Information Consortium, Cochrane Central Register of Controlled Trials, Cumulative Index to Nursing and Allied Health Literature and Allied and Complementary Medicine Database) were searched from inception to date of search (August 2017), alongside carrying out of web searches, citation searching, inspecting relevant reviews, consulting stakeholders and contacting authors. This search was duplicated, with an additional cost-filter, to identify cost-effectiveness evidence.Review methodsComparative studies were sought that evaluated the effectiveness or cost-effectiveness of relevant interventions in elective inpatients with a mean or median age of ≥ 60 years. Study selection, data extraction and quality assessment were completed independently by two reviewers. The main outcome was length of stay, but all outcomes were considered. Studies were sorted by procedure, intervention and outcome categories. Where possible, standardised mean differences or odds ratios were calculated. Meta-analysis was performed when multiple randomised controlled trials had the same intervention, treatment procedure, comparator and outcome. Findings were explored using narrative synthesis.FindingsA total of 218 articles were included, with 80 articles from 73 effectiveness studies (n = 26,365 patients) prioritised for synthesis, including 34 randomised controlled trials conducted outside the UK and 39 studies from the UK, of which 12 were randomised controlled trials. Fifteen studies included cost-effectiveness data. The evidence was dominated by enhanced recovery protocols and prehabilitation, implemented to improve recovery from either colorectal surgery or lower limb arthroplasty. Six other surgical categories and four other intervention types were identified. Meta-analysis found that enhanced recovery protocols were associated with 1.5 days’ reduction in hospital stay among patients undergoing colorectal surgery (Cohen’sd = –0.51, 95% confidence interval –0.78 to –0.24;p < 0.001) and with 5 days’ reduction among those undergoing upper abdominal surgery (Cohen’sd = –1.04, 95% confidence interval –1.55 to –0.53;p < 0.001). Evidence from the UK was not pooled (owing to mixed study designs), but it echoed findings from the international literature. Length of stay usually was reduced with intervention or was no different. Other clinical outcomes also improved or were no worse with intervention. Patient-reported outcomes were not frequently reported. Cost and cost-effectiveness evidence came from 15 highly heterogeneous studies and was less conclusive.LimitationsStudies were usually of moderate or weak quality. Some intervention or treatment types were under-reported or absent. The reporting of variance data often precluded secondary analysis.ConclusionsEnhanced recovery and prehabilitation interventions were associated with reduced hospital stay without detriment to other clinical outcomes, particularly for patients undergoing colorectal surgery, lower limb arthroplasty or upper abdominal surgery. The impacts on patient-reported outcomes, health-care costs or additional service use are not well known.Future workFurther studies evaluating of the effectiveness of new enhanced recovery pathways are not required in colorectal surgery or lower limb arthroplasty. However, the applicability of these pathways to other procedures is uncertain. Future studies should evaluate the implementation of interventions to reduce service variation, in-hospital patient-reported outcomes, impacts on health and social care service use, and longer-term patient-reported outcomes.Study registrationThis study is registered as PROSPERO CRD42017080637.FundingThe National Institute for Health Research Health Services and Delivery Research programme.
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Affiliation(s)
- Michael Nunns
- Exeter Health Services and Delivery Research Evidence Synthesis Centre, Institute of Health Research, University of Exeter Medical School, University of Exeter, Exeter, UK
| | - Liz Shaw
- Exeter Health Services and Delivery Research Evidence Synthesis Centre, Institute of Health Research, University of Exeter Medical School, University of Exeter, Exeter, UK
| | - Simon Briscoe
- Exeter Health Services and Delivery Research Evidence Synthesis Centre, Institute of Health Research, University of Exeter Medical School, University of Exeter, Exeter, UK
| | - Jo Thompson Coon
- Exeter Health Services and Delivery Research Evidence Synthesis Centre, Institute of Health Research, University of Exeter Medical School, University of Exeter, Exeter, UK
| | - Anthony Hemsley
- Department of Healthcare for Older People, Royal Devon & Exeter NHS Foundation Trust, Exeter, UK
| | - John S McGrath
- Exeter Health Services and Delivery Research Evidence Synthesis Centre, Institute of Health Research, University of Exeter Medical School, University of Exeter, Exeter, UK
- Royal Devon & Exeter NHS Foundation Trust, Exeter, UK
| | - Christopher J Lovegrove
- Royal Devon & Exeter NHS Foundation Trust, Exeter, UK
- School of Health Professions, Faculty of Health & Human Sciences, University of Plymouth, Plymouth, UK
| | - David Thomas
- Royal Devon & Exeter NHS Foundation Trust, Exeter, UK
| | - Rob Anderson
- Exeter Health Services and Delivery Research Evidence Synthesis Centre, Institute of Health Research, University of Exeter Medical School, University of Exeter, Exeter, UK
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Ishikawa M, Sato Y, Kitagawa N, Shichita T, Isshiki Y, Kawata D, Matsumura K. Effectiveness of a clinical pathway for complete denture adjustment. J Oral Sci 2019; 61:483-490. [PMID: 31631093 DOI: 10.2334/josnusd.17-0216] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
This study was performed to evaluate the usefulness of a developed clinical pathway (CP) to determine the sequence of dental treatment in patients who are edentulous and use maxillary and mandibular complete dentures. Sixty-two edentulous patients with maxillary and mandibular complete dentures were randomly allocated either to with (31 subjects) or without (31 subjects) a CP. The main categories of the CP were the examination, instructions, practice, idle time, evaluation sheet, preparation, and other steps. The subcategories were made with respect to the main categories. The participants were categorized as dentists, assistants, or patients. There was no significant difference in mean chair time between with a CP (27.5 min) and without a CP (28.0 min). The CP led to a significant reduction in idle time (waiting in the chair or no treatment) of dentists, assistants, and patients. In contrast, the instances of medical examination, patients' instructions, and the number of patients reporting improvement of symptoms significantly increased. These results indicated that there is an opportunity to improve the complete denture treatment with a CP.
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Affiliation(s)
- Mariko Ishikawa
- Department of Geriatric Dentistry, Showa University School of Dentistry
| | - Yuji Sato
- Department of Geriatric Dentistry, Showa University School of Dentistry
| | - Noboru Kitagawa
- Department of Geriatric Dentistry, Showa University School of Dentistry
| | | | - Yukari Isshiki
- Department of Geriatric Dentistry, Showa University School of Dentistry
| | - Daisuke Kawata
- Department of Geriatric Dentistry, Showa University School of Dentistry
| | - Keisuke Matsumura
- Department of Geriatric Dentistry, Showa University School of Dentistry
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Chevrollier GS, Nemecz AK, Devin C, Go KV, Yi M, Keith SW, Cowan SW, Evans NR. Early Discharge Does Not Increase Readmission Rates After Minimally Invasive Anatomic Lung Resection. Innovations�(Phila) 2019; 14:218-226. [DOI: 10.1177/1556984519836821] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Objective Enhanced recovery pathways reduce length of stay and costs following lung resection. However, many fear that early discharge may lead to increased hospital readmissions. In this study, we aimed to determine whether early discharge was associated with increased readmission following anatomic lung resection. Methods Using the lung resection database approved by our institutional review board, we identified all patients undergoing minimally invasive lobectomy and segmentectomy between January 2010 and March 2017 at our institution, where an enhanced recovery pathway is well established. Thirty-day readmissions were compared between patients with short- and average length of stay, defined as 1 to 2 days and 3 to 5 days, respectively. Multivariable logistic regression analysis of patients matched by propensity scores was performed to determine odds of 30-day readmission for each group. Significance was set at P < 0.05. Results A total of 296 patients met inclusion criteria. Unadjusted analysis revealed a 3-fold increased rate of readmission in the group with average length of stay (9%, n = 12) versus the group with short length of stay (3%, n = 5; P < 0.01). At baseline, patients with average length of stay had increased rates of preoperative chemotherapy (13%, n = 18 vs. 4%, n = 6; P < 0.01) and radiation (12%, n = 16 vs. 3%, n = 5). Patients with average length of stay also had higher rates of lobectomy (95%, n = 127 vs. 86%, n = 140; P = 0.02) and postoperative complications (31%, n = 41 vs. 4%, n = 7; P < 0.01). On multivariable analysis, patients with average length of stay had a 2.3-fold greater odds of readmission, which was not statistically significant (OR = 2.33; 95% CI, 0.60 to 9.02; P = 0.22). Conclusions Early discharge following minimally invasive anatomic lung resection does not increase the risk of hospital readmission in patients treated within an enhanced recovery pathway.
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Affiliation(s)
- Guillaume S. Chevrollier
- Department of Surgery, Sidney Kimmel Medical College of Thomas Jefferson University, Philadelphia, PA, USA
| | - Amanda K. Nemecz
- Department of Surgery, Sidney Kimmel Medical College of Thomas Jefferson University, Philadelphia, PA, USA
| | - Courtney Devin
- Department of Surgery, Sidney Kimmel Medical College of Thomas Jefferson University, Philadelphia, PA, USA
| | - Kendrick V. Go
- Department of Surgery, Sidney Kimmel Medical College of Thomas Jefferson University, Philadelphia, PA, USA
| | - Misung Yi
- Department of Pharmacology and Experimental Therapeutics, Sidney Kimmel Medical College of Thomas Jefferson University, Philadelphia, PA, USA
| | - Scott W. Keith
- Department of Pharmacology and Experimental Therapeutics, Sidney Kimmel Medical College of Thomas Jefferson University, Philadelphia, PA, USA
| | - Scott W. Cowan
- Department of Surgery, Sidney Kimmel Medical College of Thomas Jefferson University, Philadelphia, PA, USA
| | - Nathaniel R. Evans
- Department of Surgery, Sidney Kimmel Medical College of Thomas Jefferson University, Philadelphia, PA, USA
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12
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Comacchio GM, Monaci N, Verderi E, Schiavon M, Rea F. Enhanced recovery after elective surgery for lung cancer patients: analysis of current pathways and perspectives. J Thorac Dis 2019; 11:S515-S522. [PMID: 31032070 DOI: 10.21037/jtd.2019.01.99] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
The concept of enhanced recovery after surgery (ERAS), initially introduced in the field of colorectal surgery, has been developed in order to optimize the postoperative course. In recent years the number of authors analyzing the role of ERAS in lung cancer surgery is increasing, highlighting several interventions with positive effects on the postoperative course. Yet it is still difficult to draw definite conclusions and specific guidelines, as most of these studies largely differ for their methodological aspects and study populations. Herein we focus on the key elements of each single intervention, trying to identify what we can apply in a common pathway, and which aspects are still to be evaluated for the validation of an ERAS program.
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Affiliation(s)
- Giovanni Maria Comacchio
- Thoracic Surgery Unit, Department of Cardiac, Thoracic and Vascular Sciences, University of Padova, Padova, Italy
| | - Nicola Monaci
- Thoracic Surgery Unit, Department of Cardiac, Thoracic and Vascular Sciences, University of Padova, Padova, Italy
| | - Enrico Verderi
- Thoracic Surgery Unit, Department of Cardiac, Thoracic and Vascular Sciences, University of Padova, Padova, Italy
| | - Marco Schiavon
- Thoracic Surgery Unit, Department of Cardiac, Thoracic and Vascular Sciences, University of Padova, Padova, Italy
| | - Federico Rea
- Thoracic Surgery Unit, Department of Cardiac, Thoracic and Vascular Sciences, University of Padova, Padova, Italy
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Abstract
PURPOSE OF REVIEW Both surgical workload and the age of those patients being considered for radial pulmonary resection are increasing. Enhanced recovery programmes are now well established in most surgical disciplines and are increasingly reported in thoracic procedures. This review will discuss the relevant principles of these programmes as applied to an increasing elderly population. RECENT FINDINGS Elderly patients undergoing less radial surgical resections without lymphadenectomy have comparable outcomes to those undergoing classical curative treatment. Patients require careful assessment and self-reported quality of life metrics or function may be a better marker of outcome than static measures such as lung function. Hypotension, low values for bispectral index and low anaesthetic gas mean alveolar concentration values are common and independent predictors of mortality in the elderly. Paravertebral blockade is preferred to epidural anaesthesia because of a more favourable side-effect profile and comparable efficacy. As yet no robust work has examined the efficacy of an integrated enhanced recovery programme in thoracic surgery. SUMMARY Elderly patients are suitable for enhanced recovery programmes but these must be tailored to individual circumstance. Further work is required to comprehensively assess their value in a modern healthcare setting.
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Martin LW, Sarosiek BM, Harrison MA, Hedrick T, Isbell JM, Krupnick AS, Lau CL, Mehaffey JH, Thiele RH, Walters DM, Blank RS. Implementing a Thoracic Enhanced Recovery Program: Lessons Learned in the First Year. Ann Thorac Surg 2018; 105:1597-1604. [DOI: 10.1016/j.athoracsur.2018.01.080] [Citation(s) in RCA: 79] [Impact Index Per Article: 13.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2017] [Revised: 01/24/2018] [Accepted: 01/26/2018] [Indexed: 01/23/2023]
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15
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van Hoeve JC, Vernooij RWM, Lawal AK, Fiander M, Nieboer P, Siesling S, Rotter T. Effects of oncological care pathways in primary and secondary care on patient, professional, and health systems outcomes: protocol for a systematic review and meta-analysis. Syst Rev 2018; 7:49. [PMID: 29580293 PMCID: PMC5870525 DOI: 10.1186/s13643-018-0693-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2017] [Accepted: 01/25/2018] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND The high impact of a cancer diagnosis on patients and their families and the increasing costs of cancer treatment call for optimal and efficient oncological care. To improve the quality of care and to minimize healthcare costs and its economic burden, many healthcare organizations introduce care pathways to improve efficiency across the continuum of cancer care. However, there is limited research on the effects of cancer care pathways in different settings. METHODS The aim of this systematic review and meta-analysis described in this protocol is to synthesize existing literature on the effects of oncological care pathways. We will conduct a systematic search strategy to identify all relevant literature in several biomedical databases, including Cochrane library, MEDLINE, Embase, and CINAHL. We will follow the methodology of Cochrane Effective Practice and Organisation of Care (EPOC), and we will include randomized trials, non-randomized trials, controlled before-after studies, and interrupted time series studies. In addition, we will include full economic evaluations (cost-effectiveness analyses, cost-utility analyses, and cost-benefit analyses), cost analyses, and comparative resource utilization studies, if available. Two reviewers will independently screen all studies and evaluate those included for risk of bias. From these studies, we will extract data regarding patient, professional, and health systems outcomes. Our systematic review will follow the PRISMA set of items for reporting in systematic reviews and meta-analyses. DISCUSSION Following the protocol outlined in this article, we aim to identify, assess, and synthesize all available evidence in order to provide an evidence base on the effects of oncological care pathways as reported in the literature. SYSTEMATIC REVIEW REGISTRATION PROSPERO CRD42017057592 .
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Affiliation(s)
- Jolanda C. van Hoeve
- Department Health Technology and Services Research (HTSR), University of Twente, P.O. Box 217, 7500 AE Enschede, the Netherlands
- Netherlands Comprehensive Cancer Organisation (IKNL), P.O. Box 19079, 3501 DB Utrecht, the Netherlands
| | - Robin W. M. Vernooij
- Netherlands Comprehensive Cancer Organisation (IKNL), P.O. Box 19079, 3501 DB Utrecht, the Netherlands
| | - Adegboyega K. Lawal
- College of Pharmacy and Nutrition, University of Saskatchewan, Saskatoon, Canada
| | - Michelle Fiander
- College of Pharmacy, Department of Pharmacology, University of Utah, Salt Lake City, USA
| | | | - Sabine Siesling
- Department Health Technology and Services Research (HTSR), University of Twente, P.O. Box 217, 7500 AE Enschede, the Netherlands
- Netherlands Comprehensive Cancer Organisation (IKNL), P.O. Box 19079, 3501 DB Utrecht, the Netherlands
| | - Thomas Rotter
- Healthcare Quality Programs, School of Nursing, Queen’s University, Kingston, Ontario Canada
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Affiliation(s)
- Rajat Kumar
- Division of Cardiothoracic Surgery, University of Alabama at Birmingham School of Medicine, Birmingham, AL, USA
| | - James M Donahue
- Division of Cardiothoracic Surgery, University of Alabama at Birmingham School of Medicine, Birmingham, AL, USA
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Paci P, Madani A, Lee L, Mata J, Mulder DS, Spicer J, Ferri LE, Feldman LS. Economic Impact of an Enhanced Recovery Pathway for Lung Resection. Ann Thorac Surg 2017; 104:950-957. [PMID: 28778343 DOI: 10.1016/j.athoracsur.2017.05.085] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2017] [Revised: 05/24/2017] [Accepted: 05/30/2017] [Indexed: 10/19/2022]
Abstract
BACKGROUND Multimodal enhanced recovery pathways (ERP) improve clinical outcomes and hospital length of stay for patients undergoing lung resection. However, data supporting their economic impact is lacking. This study evaluated the effect of an ERP on costs of lung resection. METHODS Adult patients undergoing elective lung resection from August 2011 to August 2013 at a single university-affiliated institution were prospectively recruited. Pneumonectomies and extended resections were excluded. Beginning in September 2012, patients were enrolled in a multimodal ERP. Outcomes were recorded until 90 days after discharge. Total costs from institutional, health care system, and societal perspectives are reported in 2016 Canadian dollars, with uncertainty expressed as 95% confidence intervals derived using bootstrapped estimates (10,000 repetitions). RESULTS The study included 133 patients (conventional care: n = 58; ERP: n = 75). Patient and operative characteristics were similar between the groups. The ERP group had shorter median (interquartile range) length of stay (4 [3 to 6] days vs 6 [4 to 9] days, p < 0.01), decreased total complications (32% vs 52%, p = 0.02), and decreased pulmonary complications (16% vs 34%, p = 0.01), with no difference in readmissions. After discharge, there was a trend towards less caregiver burden for the ERP group (53 ± 90 hours vs 101 ± 252 hours, p = 0.17). Overall societal costs were lower in the ERP group (mean difference per patient: -$4,396 Canadian; 95% confidence interval -$8,674 to $618 Canadian). CONCLUSIONS A multidisciplinary ERP is associated with improved clinical outcomes and societal cost savings compared with conventional perioperative management for elective lung resection.
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Affiliation(s)
- Philippe Paci
- Department of Surgery, McGill University, Montreal, Quebec, Canada; Steinberg-Bernstein Centre for Minimally Invasive Surgery, McGill University, Montreal, Quebec, Canada
| | - Amin Madani
- Department of Surgery, McGill University, Montreal, Quebec, Canada; Steinberg-Bernstein Centre for Minimally Invasive Surgery, McGill University, Montreal, Quebec, Canada
| | - Lawrence Lee
- Department of Surgery, McGill University, Montreal, Quebec, Canada; Steinberg-Bernstein Centre for Minimally Invasive Surgery, McGill University, Montreal, Quebec, Canada
| | - Juan Mata
- Department of Surgery, McGill University, Montreal, Quebec, Canada; Steinberg-Bernstein Centre for Minimally Invasive Surgery, McGill University, Montreal, Quebec, Canada
| | - David S Mulder
- Department of Surgery, McGill University, Montreal, Quebec, Canada; Division of Thoracic Surgery, McGill University, Montreal, Quebec, Canada
| | - Jonathan Spicer
- Department of Surgery, McGill University, Montreal, Quebec, Canada; Division of Thoracic Surgery, McGill University, Montreal, Quebec, Canada
| | - Lorenzo E Ferri
- Department of Surgery, McGill University, Montreal, Quebec, Canada; Division of Thoracic Surgery, McGill University, Montreal, Quebec, Canada
| | - Liane S Feldman
- Department of Surgery, McGill University, Montreal, Quebec, Canada; Steinberg-Bernstein Centre for Minimally Invasive Surgery, McGill University, Montreal, Quebec, Canada.
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Brunelli A, Thomas C, Dinesh P, Lumb A. Enhanced recovery pathway versus standard care in patients undergoing video-assisted thoracoscopic lobectomy. J Thorac Cardiovasc Surg 2017; 154:2084-90. [PMID: 28728783 DOI: 10.1016/j.jtcvs.2017.06.037] [Citation(s) in RCA: 100] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2017] [Revised: 06/09/2017] [Accepted: 06/16/2017] [Indexed: 12/25/2022]
Abstract
OBJECTIVE The objective of this study was to compare outcomes after video-assisted thoracoscopic lobectomy or segmentectomy before and after introduction of an enhanced recovery program. METHODS Data from 600 patients undergoing video-assisted lobectomy or segmentectomy between April 2014 and January 2017 were analyzed. A comparative analysis was performed between patients undergoing operation before (365 patients) and after (235 patients) the start of the enhanced recovery program. The incidence of cardiopulmonary complications and 30-day and 90-day mortality, postoperative length of stay, and 30-day and 90-day hospital readmission rates were evaluated. Risk-adjusted cardiopulmonary morbidity and 30-day mortality were calculated for each group and compared. RESULTS The 2 groups had a similar postoperative length of stay (enhanced recovery pathway median 5 days vs pre-enhanced recovery pathway 4, P = .44), cardiopulmonary complication rates (enhanced recovery pathway 22.6% vs pre-enhanced recovery pathway 22.4%, P = .98), 30-day mortality rates (enhanced recovery pathway 3.8% vs pre-enhanced recovery pathway 2.2%, P = .31), and 90-day mortality rates (enhanced recovery pathway 4.7% vs pre-enhanced recovery pathway 3.0%, P = .37). No differences were noted in terms of 30-day (enhanced recovery pathway 7.2% vs pre-enhanced recovery pathway 7.4%, P = .94) or 90-day readmission rates (enhanced recovery pathway 9.8% vs pre-enhanced recovery pathway 12.3%, P = .34). The risk-adjusted cardiopulmonary morbidity rates were similar in the 2 periods (P = .76), whereas the risk-adjusted 30-day mortality was higher in the enhanced recovery pathway period compared with the pre-enhanced recovery pathway mortality (P = .0004). CONCLUSIONS We found no benefit conferred by the enhanced recovery program on outcomes such as cardiopulmonary complications, 30- and 90-day mortality, length of stay, and readmissions. Enhanced recovery program elements may be insufficiently different than previous standards of perioperative care to confer detectable benefits in our settings.
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Numan RC, Berge MT, Burgers JA, Klomp HM, van Sandick JW, Baas P, Wouters MW. Peri- and postoperative management of stage I-III Non Small Cell Lung Cancer: Which quality of care indicators are evidence-based? Lung Cancer 2016; 101:129-136. [PMID: 27794401 DOI: 10.1016/j.lungcan.2016.06.007] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2016] [Revised: 05/30/2016] [Accepted: 06/11/2016] [Indexed: 10/21/2022]
Abstract
Quality of care (QoC) has a central role in our health care system. The aim of this review is to present a set of evidence-based quality indicators for the surgical treatment and postoperative management of lung cancer. A search was performed through PubMed, Embase and the Cochrane library database, including English literature, published between 1980 and 2012. Search terms regarding 'lung neoplasms', 'surgical treatment' and 'quality of care' were used. Potential QoC indicators were divided into structure, process or outcome measures and a final selection was made based upon the level of evidence. High hospital volume and surgery performed by a thoracic surgeon, were identified as important structure indicators. Sleeve resection instead of pneumonectomy and the importance of treatment within a clinical care path setting were identified as evidence-based process indicators. A symptom-based follow-up regime was identified as a new QoC indicator. These indicators can be used for registration, benchmarking and ultimately quality improvement in lung cancer surgery.
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Affiliation(s)
- Rachel C Numan
- Department of Surgical Oncology, Netherlands Cancer Institute/Antoni van Leeuwenhoek, Plesmanlaan 161, 1066CX Amsterdam, The Netherlands.
| | - Martijn Ten Berge
- Department of Surgical Oncology, Leids Universitair Medisch Centrum, Albinusdreef 2, 2333 ZA Leiden, The Netherlands
| | - Jacobus A Burgers
- Department of Thoracic Oncology, Netherlands Cancer Institute/Antoni van Leeuwenhoek, Plesmanlaan 161, 1066CX Amsterdam, The Netherlands
| | - Houke M Klomp
- Department of Surgical Oncology, Netherlands Cancer Institute/Antoni van Leeuwenhoek, Plesmanlaan 161, 1066CX Amsterdam, The Netherlands
| | - Johanna W van Sandick
- Department of Surgical Oncology, Netherlands Cancer Institute/Antoni van Leeuwenhoek, Plesmanlaan 161, 1066CX Amsterdam, The Netherlands
| | - Paul Baas
- Department of Thoracic Oncology, Netherlands Cancer Institute/Antoni van Leeuwenhoek, Plesmanlaan 161, 1066CX Amsterdam, The Netherlands
| | - Michel W Wouters
- Department of Surgical Oncology, Netherlands Cancer Institute/Antoni van Leeuwenhoek, Plesmanlaan 161, 1066CX Amsterdam, The Netherlands
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French DG, Dilena M, LaPlante S, Shamji F, Sundaresan S, Villeneuve J, Seely A, Maziak D, Gilbert S. Optimizing postoperative care protocols in thoracic surgery: best evidence and new technology. J Thorac Dis 2016; 8:S3-S11. [PMID: 26941968 DOI: 10.3978/j.issn.2072-1439.2015.10.67] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Postoperative clinical pathways have been shown to improve postoperative care and decrease length of stay in hospital. In thoracic surgery there is a need to develop chest tube management pathways. This paper considers four aspects of chest tube management: (I) appraising the role of chest X-rays in the management of lung resection patients with chest drains; (II) selecting of a fluid output threshold below which chest tubes can be removed safely; (III) deciding whether suction should be applied to chest tubes; (IV) and selecting the safest method for chest tube removal. There is evidence that routine use of chest X-rays does not influence the management of chest tubes. There is a lack of consensus on the highest fluid output threshold below which chest tubes can be safely removed. The optimal use of negative intra-pleural pressure has not yet been established despite multiple randomized controlled trials and meta-analyses. When attempting to improve efficiency in the management of chest tubes, evidence in support of drain removal without a trial of water seal should be considered. Inconsistencies in the interpretation of air leaks and in chest tube management are likely contributors to the conflicting results found in the literature. New digital pleural drainage systems, which provide a more objective air leak assessment and can record air leak trend over time, will likely contribute to the development of new evidence-based guidelines. Technology should be combined with continued efforts to standardize care, create clinical pathways, and analyze their impact on postoperative outcomes.
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Affiliation(s)
- Daniel G French
- Division of Thoracic Surgery, University of Ottawa, The Ottawa Hospital-General Campus, Ottawa, ON, Canada
| | - Michael Dilena
- Division of Thoracic Surgery, University of Ottawa, The Ottawa Hospital-General Campus, Ottawa, ON, Canada
| | - Simon LaPlante
- Division of Thoracic Surgery, University of Ottawa, The Ottawa Hospital-General Campus, Ottawa, ON, Canada
| | - Farid Shamji
- Division of Thoracic Surgery, University of Ottawa, The Ottawa Hospital-General Campus, Ottawa, ON, Canada
| | - Sudhir Sundaresan
- Division of Thoracic Surgery, University of Ottawa, The Ottawa Hospital-General Campus, Ottawa, ON, Canada
| | - James Villeneuve
- Division of Thoracic Surgery, University of Ottawa, The Ottawa Hospital-General Campus, Ottawa, ON, Canada
| | - Andrew Seely
- Division of Thoracic Surgery, University of Ottawa, The Ottawa Hospital-General Campus, Ottawa, ON, Canada
| | - Donna Maziak
- Division of Thoracic Surgery, University of Ottawa, The Ottawa Hospital-General Campus, Ottawa, ON, Canada
| | - Sebastien Gilbert
- Division of Thoracic Surgery, University of Ottawa, The Ottawa Hospital-General Campus, Ottawa, ON, Canada
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Fiore JF, Bejjani J, Conrad K, Niculiseanu P, Landry T, Lee L, Ferri LE, Feldman LS. Systematic review of the influence of enhanced recovery pathways in elective lung resection. J Thorac Cardiovasc Surg 2016; 151:708-715.e6. [DOI: 10.1016/j.jtcvs.2015.09.112] [Citation(s) in RCA: 85] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2015] [Revised: 09/01/2015] [Accepted: 09/28/2015] [Indexed: 11/29/2022]
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Madani A, Fiore JF, Wang Y, Bejjani J, Sivakumaran L, Mata J, Watson D, Carli F, Mulder DS, Sirois C, Ferri LE, Feldman LS. An enhanced recovery pathway reduces duration of stay and complications after open pulmonary lobectomy. Surgery 2015; 158:899-908; discussion 908-10. [PMID: 26189953 DOI: 10.1016/j.surg.2015.04.046] [Citation(s) in RCA: 117] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2015] [Revised: 03/31/2015] [Accepted: 04/05/2015] [Indexed: 01/31/2023]
Abstract
BACKGROUND Few studies have investigated the effectiveness of enhanced recovery pathways (ERP) for lung resection. This study estimates the impact of an ERP for lobectomy on duration of stay, complications, and readmissions. METHODS Patients undergoing open lobectomy were identified from an OR database between 2011 and 2013. Beginning September 2012, all patients were managed according to a 4-day multidisciplinary ERP with written daily patient education treatment plans, multimodal analgesia, early diet, structured mobilization and standardized drain management. Pre-pathway (PRE) and post-pathway (POST) patients were compared in terms of duration of stay, complications, and readmissions. RESULTS We identified 234 patients (PRE, 127; POST, 107). Groups were similar with respect to age, gender, American Society of Anesthesiologists score, and baseline pulmonary function. Compared with the PRE group, the POST group had decreased duration of stay (median, 6 [interquartile range (IQR), 5-7] vs 7 [6-10] days; P < .05), total complications (40 [37%] vs 64 [50%]; P < .05), urinary tract infections (3 [3%] vs 15 [12%]; P < .05), and chest tube duration (median, 4 [IQR, 3-6] vs 5 [4-7] days; P < .05), with no difference in readmissions (7 [7%] vs 6 [5%]; P < .05) or chest tube reinsertion (4 [4%] vs 6 [5%]; P < .05). Decreased duration of stay was driven by patients without complications (median, 5 [IQR, 4-6] vs 6 [5-7] days; P < .05). CONCLUSION Implementation of a multimodal ERP for lobectomy was associated with decreased duration of stay and complications with no difference in readmissions.
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Affiliation(s)
- Amin Madani
- Department of Surgery, McGill University, Montreal, Quebec, Canada; Steinberg-Bernstein Centre for Minimally Invasive Surgery and Innovation, McGill University, Montreal, Quebec, Canada
| | - Julio F Fiore
- Steinberg-Bernstein Centre for Minimally Invasive Surgery and Innovation, McGill University, Montreal, Quebec, Canada
| | - Yifan Wang
- Steinberg-Bernstein Centre for Minimally Invasive Surgery and Innovation, McGill University, Montreal, Quebec, Canada
| | - Jimmy Bejjani
- Steinberg-Bernstein Centre for Minimally Invasive Surgery and Innovation, McGill University, Montreal, Quebec, Canada
| | - Lojan Sivakumaran
- Steinberg-Bernstein Centre for Minimally Invasive Surgery and Innovation, McGill University, Montreal, Quebec, Canada
| | - Juan Mata
- Steinberg-Bernstein Centre for Minimally Invasive Surgery and Innovation, McGill University, Montreal, Quebec, Canada
| | - Debbie Watson
- Department of Surgery, McGill University, Montreal, Quebec, Canada
| | - Franco Carli
- Department of Anaesthesia, McGill University, Montreal, Quebec, Canada
| | - David S Mulder
- Department of Surgery, McGill University, Montreal, Quebec, Canada
| | - Christian Sirois
- Department of Surgery, McGill University, Montreal, Quebec, Canada
| | - Lorenzo E Ferri
- Department of Surgery, McGill University, Montreal, Quebec, Canada; Steinberg-Bernstein Centre for Minimally Invasive Surgery and Innovation, McGill University, Montreal, Quebec, Canada
| | - Liane S Feldman
- Department of Surgery, McGill University, Montreal, Quebec, Canada; Steinberg-Bernstein Centre for Minimally Invasive Surgery and Innovation, McGill University, Montreal, Quebec, Canada.
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Shoji F, Yano T, Haro A, Yoshida T, Ito K, Morodomi Y, Wakata Y, Maehara Y. Assessing a clinical pathway to improve the quality of care in pulmonary resections. Surg Today 2011; 41:787-90. [PMID: 21626323 DOI: 10.1007/s00595-010-4483-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2010] [Accepted: 10/12/2010] [Indexed: 11/29/2022]
Abstract
PURPOSE To evaluate the efficacy of the current clinical pathway for pulmonary resections. METHODS This study examined variances from expected clinical pathway outcomes for pulmonary resections performed between 2005 and 2009. Data on a total of 383 patients were retrospectively analyzed. RESULTS The median length of hospital stay (LOS) using the clinical pathway was 12 days (range: 1-188 days); the mean LOS was 15.5 days. The cost per day with use of the clinical pathway was 102 726 yen. Poor control of pain from intercostal neuralgia was the most frequently observed variance from expected outcomes. It affected 119 of 168 electronic clinical pathway patients (70.8%). The clinical pathway was terminated in 3.9% of patients (15/383) due to serious or life-threatening complications. CONCLUSIONS This study showed the single institutional experience of the clinical pathway for pulmonary resections. These findings indicate a need to revise certain aspects of the pathway, based on data from our analysis of variances.
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Affiliation(s)
- Fumihiro Shoji
- Department of Surgery and Science, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka, 812-8582, Japan
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Schwarzbach M, Rössner E, Schattenberg T, Post S, Hohenberger P, Ronellenfitsch U. Effects of a clinical pathway of pulmonary lobectomy and bilobectomy on quality and cost of care. Langenbecks Arch Surg 2010; 395:1139-46. [DOI: 10.1007/s00423-010-0600-y] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2009] [Accepted: 01/20/2010] [Indexed: 10/19/2022]
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Ronellenfitsch U, Vargas Hein O, Uerlich M, Dahmen A, Tuschy S, Schwarzbach M. Klinische Pfade als Instrument zur Qualitätsverbesserung in der perioperativen Medizin. ACTA ACUST UNITED AC 2009; 1:164-72. [DOI: 10.1016/j.periop.2009.06.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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Schwarzbach MHM, Ronellenfitsch U, Wang Q, Rössner ED, Denz C, Post S, Hohenberger P. Effects of a clinical pathway for video-assisted thoracoscopic surgery (VATS) on quality and cost of care. Langenbecks Arch Surg 2009; 395:333-40. [PMID: 19513745 DOI: 10.1007/s00423-009-0507-7] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2009] [Accepted: 05/20/2009] [Indexed: 11/27/2022]
Abstract
PURPOSE The purpose of this study was to evaluate effects of a clinical pathway (CP) for video-assisted thoracoscopic surgery (VATS) on process quality, outcome quality, and hospital costs. MATERIALS AND METHODS We implemented a CP for VATS and compared 34 patients treated with CP to 77 patients treated without CP. Indicators for process quality were duration of catheter placement, pain intensity, respiratory exercising, and mobilization. Outcome quality was measured through morbidity, mortality, reoperations, and readmissions. Cost of hospital stay was calculated using an imputed daily rate. RESULTS Foley catheters were removed significantly earlier after CP implementation. All patients on CP were mobilized and received pulmonary exercising on the operation day. Pain levels were low after CP implementation. Median hospital stay significantly reduced by 5 days. Perioperative outcome quality remained unchanged. Costs significantly diminished by 1,510 Euro per stay. CONCLUSIONS CP implementation had positive effects on process quality. Specifically, catheter management was improved and a good pain control achieved. Patients benefited from shortened stay and were treated at lower cost. A clear effect on outcome quality was not found. CPs are a promising tool for quality improvement and cost containment in thoracic surgery.
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Affiliation(s)
- Matthias H M Schwarzbach
- Department of Surgery, Division of Surgical Oncology and Thoracic Surgery, University Medical Centre Mannheim, Medical Faculty Mannheim, Heidelberg University, Theodor-Kutzer-Ufer 1-3, 68135, Mannheim, Germany.
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Okita A, Yamashita M, Abe K, Nagai C, Matsumoto A, Akehi M, Yamashita R, Ishida N, Seike M, Yokota S, Umekawa N, Matsumoto Y, Kishimoto Y, Okazaki A, Komori E, Sawada S, Takashima S. Variance analysis of a clinical pathway of video-assisted single lobectomy for lung cancer. Surg Today 2009; 39:104-9. [PMID: 19198986 DOI: 10.1007/s00595-008-3821-8] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2008] [Accepted: 05/12/2008] [Indexed: 10/21/2022]
Abstract
PURPOSE Clinical pathways have contributed to standardized postoperative management, but analyzing variance is also important to maintain quality control. To evaluate the validity of our own clinical pathway for managing video-assisted lobectomy for lung cancer, we analyzed the variances influencing postoperative recovery. METHODS Between April 2003 and April 2004, 62 consecutive patients with lung cancer underwent video-assisted single anatomic lobectomy with lymph node dissection. We evaluated 61 of these patients after the exclusion of one, who deviated from the clinical pathway management immediately as a result of serious complications. RESULTS There were 29 men and 32 women, with an average age of 65.7 years. Complications developed in 29 patients, but there was no operative mortality. The occurrence of variance ranged from 1.6% to 34.4% for each activity and included prolonged supplemental oxygen therapy, out-of routine examination, prolonged epidural anesthesia, and delayed bathing frequently. Complications and an abnormal body mass index were significant and independent clinical factors affecting the increase in variance. CONCLUSIONS Our original clinical pathway management was tolerable for lung cancer patients undergoing a video-assisted lobectomy. Complications and an abnormal body mass index were significant predictive factors for an increase in variance of our clinical pathway.
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Ronellenfitsch U, Rössner E, Jakob J, Post S, Hohenberger P, Schwarzbach M. Clinical Pathways in surgery—should we introduce them into clinical routine? A review article. Langenbecks Arch Surg 2008; 393:449-57. [DOI: 10.1007/s00423-008-0303-9] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2007] [Accepted: 01/31/2008] [Indexed: 10/22/2022]
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