An economic evaluation of the Enhanced Recovery After Surgery (ERAS) multisite implementation program for colorectal surgery in Alberta

An economic evaluation of the Enhanced Recovery After Surgery (ERAS) multisite implementation program for colorectal surgery in Alberta

Can J Surg 2016;59(6):415-421 | PDF

Nguyen X. Thanh, MD, PhD; Anderson W. Chuck, PhD, MPH; Tracy Wasylak, MSc; Jeannette Lawrence, BScN, MBA; Peter Faris, PhD; Olle Ljungqvist, MD, PhD; Gregg Nelson, MD, PhD; Leah M. Gramlich, MD

Abstract

Background: In February 2013, Alberta Health Services established an Enhanced Recovery After Surgery (ERAS) implementation program for adopting the ERAS Society colorectal guidelines into 6 sites (initial phase) that perform more than 75% of all colorectal surgeries in the province. We conducted an economic evaluation of this initiative to not only determine its cost-effectiveness, but also to inform strategy for the spread and scale of ERAS to other surgical protocols and sites.

Methods: We assessed the impact of ERAS on patients’ health services utilization (HSU; length of stay [LOS], readmissions, emergency department visits, general practitioner and specialist visits) within 30 days of discharge by comparing pre- and post-ERAS groups using multilevel negative binomial regressions. We estimated the net health care costs/savings and the return on investment (ROI) associated with those impacts for post-ERAS patients using a decision analytic modelling technique.

Results: We included 331 pre- and 1295 post-ERAS patients in our analyses. ERAS was associated with a reduction in all HSU outcomes except visits to specialists. However, only the reduction in primary LOS was significant. The net health system savings were estimated at $2 290 000 (range $1 191 000–$3 391 000), or $1768 (range $920–$2619) per patient. The probability for the program to be cost-saving was 73%–83%. In terms of ROI, every $1 invested in ERAS would bring $3.8 (range $2.4–$5.1) in return.

Conclusion: The initial phase of ERAS implementation for colorectal surgery in Alberta is cost-saving. The total savings has the potential to be more substantial when ERAS is spread for other surgical protocols and across additional sites.

Résumé

Contexte : En février 2013, les Services de santé de l’Alberta ont mis en place le programme ERAS (Enhanced Recovery After Surgery — récupération postchirurgicale améliorée) dans le but de faire adopter les lignes directrices en matière d’interventions colorectales de la ERAS Society à 6 établissements (première phase) où sont pratiquées plus de 75 % des interventions chirurgicales colorectales de la province. Nous avons réalisé une évaluation économique du programme, non seulement pour en mesurer la rentabilité, mais aussi pour élaborer une stratégie visant à étendre le programme ERAS à d’autres protocoles chirurgicaux et services de chirurgie.

Méthodes : Nous avons mesuré les effets du programme ERAS sur l’utilisation des services de santé (durée de séjour, réadmissions, visites au service des urgences, visites d’un omnipraticien ou d’un spécialiste) dans les 30 jours suivant le congé en comparant les groupes pré- et post-ERAS à l’aide de régressions binomiales négatives multiniveaux. Nous avons évalué le coût net des soins de santé, les économies réalisées et le rendement sur investissement (RSI) associés aux mesures ci-dessus chez les patients post-ERAS à l’aide d’une technique de modélisation analytique décisionnelle.

Résultats : Nos analyses ont porté sur 331 patients pré-ERAS et 1295 patients post-ERAS. Nous avons observé une réduction de toutes les mesures de l’utilisation des services de santé étudiées, sauf les visites d’un spécialiste. Toutefois, seule la réduction de la durée du premier séjour était significative. Les économies nettes pour le système de santé ont été estimées à 2 290 000 $ (de 1 191 000 $ à 3 391 000 $), soit 1768 $ (de 920 $ à 2619 $) par patient. La probabilité que le programme soit économique était de 73 % à 83 %. En ce qui concerne le RSI, nous avons établi que chaque dollar investi dans le programme ERAS rapporterait 3,8 $ (de 2,4 $ à 5,1 $).

Conclusion : La première phase de la mise en oeuvre du programme ERAS en Alberta, appliqué à la chirurgie colorectale, a été économique. Les économies pour le système de santé pourraient être plus importantes si l’on étendait le programme à d’autres protocoles chirurgicaux et services de chirurgie.


Drs. Gramlich and Nelson share senior authorship.

Accepted July 12, 2016; Early-released Oct. 1, 2016

Acknowledgements: The authors acknowledge the work and contribution of the provincial implementation team in this work. Organizational partners: Alberta Health Services, Covenant Health. ERAS provincial implementation leadership: Diabetes, Obesity and Nutrition, Provincial Nutrition and Food Services, Dr. Tom Noseworthy and Dr. Alun Edwards. Implementation site partners and unit teams: Peter Lougheed Centre, Grey Nuns Community Hospital, Royal Alexandra Hospital, University of Alberta Hospital, Misericordia Community Hospital, Foothills Medical Centre. ERAS surgeon leadership: Drs. Douglas Hedden, John Kortbeek, John Heine, Michael Chatenay, Art Plewes, Haili Wang, Anna Borowiec, Tony MacLean, Don Buie, Dale Berg, Ron Brisebois and Cliff Sample. ERAS anesthesiology leadership: Drs. Marelise Kruger, Bart Godlewski, Dean Jordon, James Chin, Neil Klassen, Derek Dillane, Bernard Sowa and Michael Chong. Provincial site coordinator and data collection team: Melissa Mucenski, Kevin Connolly, Katrina Percival, Miranda Klein, Christine Garland, Danielle Stevenson, Shawna Gallagher. Data analysts: Edwin Rogers, Lawrence Kiyang. Research consultant: Kelvin Mok, Ellen Crumley.

Affiliations: From the Institute of Health Economics, Edmonton, Alta. (Thanh, Chuck); Alberta Health Services, Calgary, Alta. (Wasylak, Lawrence, Faris); the Faculty of Medicine and Health, School of Health and Medical Sciences, Department of Surgery, Örebro University, Örebro, Sweden (Ljungqvist); the Department of Oncology, University of Calgary, Calgary, Alta. (Nelson); the Department of Medicine, University of Alberta, Edmonton, Alta. (Gramlich).

Funding: This study was funded by Alberta Health Services and the Partnership for Research and Innovation in the Health System (PRIHS) Research Grant from Alberta Innovates Health Solutions.

Competing interests: T. Wasylak declares travel assistance from ERAS World Congress. O. Ljungqvist is the current Chairman of the ERAS Society. He founded and owns stock in Encare AB that runs the ERAS Society Interactive Audit System. He also declares speaker fees and travel assistance from Merck. No other competing interests declared.

Contributors: N. Thanh, A. Chuck, T. Wasylak, P. Faris, O. Ljungqvist, G. Nelson and L. Gramlich designed the study. N. Thanh, A. Chuck, T. Wasylak, J. Lawrence, P. Faris and G. Nelson acquired the data, which N. Thanh, A. Chuck, O. Ljungqvist and G. Nelson analyzed. N. Thanh, A. Chuck, T. Wasylak, J. Lawrence, O. Ljungqvist and G. Nelson wrote the article, which all authors reviewed and approved for publication.

DOI: 10.1503/cjs.006716

Correspondence to: N.X. Thanh, Institute of Health Economics, 1200 10405 Jasper Ave., Edmonton AB T5J 3N4 tnguyen@ihe.ca