A. N. Khanijow1, M. S. Morris1, J. A. Cannon1, G. D. Kennedy1, J. S. Richman1, D. I. Chu1 1University Of Alabama at Birmingham,Department Of Surgery, Division Of Gastrointestinal Surgery,Birmingham, Alabama, USA
Introduction: The overall cost-effectiveness of enhanced recovery after surgery (ERAS) programs have been demonstrated across many institutions, but it is unclear if certain patients account for disproportionate shares of ERAS costs. The purpose of this study was to characterize the cost drivers and clinical features of the highest cost patients undergoing elective colorectal surgery before and after ERAS implementation.
Methods: ERAS was implemented at a tertiary-care single-institution in January 2015. Variable cost data, costs that vary with care decisions, were collected from the institution’s financial department for the inpatient stay of patients undergoing elective colorectal surgery from 2012-2014 (pre-ERAS) and 2015-2017 (ERAS). Costs were adjusted for inflation to 2017 US dollars using the Producer Price Index and compared using Wilcoxon tests between the high cost patients (upper 10th percentile of the total variable costs) and non-high cost patients (lower 90th percentile) for both before and after ERAS. Postoperative complications were identified using National Surgical Quality Improvement Project definitions. Severity of illness (SOI) (minor, moderate, major, and extreme) was used as an indicator of burden of illness.
Results: Of 842 included patients (389 pre-ERAS and 453 ERAS), there was no significant difference in the proportion of high cost patients between the two groups (10.8% vs 9.5% patients, p=0.60). Within the pre-ERAS group, high and non-high cost patients had an average total variable cost per patient of $21,107 and $7,432, respectively ($13,675 difference, p<0.01). Within the ERAS group, high and non-high cost patients had an average total variable cost per patient of $22,737 and $6,810 ($15,926 difference, p<0.01). Over 80% of patients in the extreme SOI group were in the high cost cohort for both pre-ERAS and ERAS patients. Compared to non-high cost patients, high cost pre-ERAS patients had a longer average length of stay (LOS) (13.1 vs 5.2 days, p<0.01) with a great proportion of that time in ICU (19 vs 1%, p<0.01). High cost ERAS patients also had a longer average LOS (15.9 vs 4 days, p<0.01) and proportion of ICU time (14 vs 1%, p<0.01). High cost pre-ERAS patients experienced significantly more post-op complications (p<0.01) including myocardial infarction and pneumonia for pre-ERAS patients and pneumonia, acute renal failure, ventilator dependency, and blood transfusions for ERAS. High cost pre-ERAS patients had higher mean anesthesia costs when compared to high cost ERAS patients ($1,173 vs $841, p<0.01) but lower mean pharmacy costs ($1,453 vs $3,200, p=0.02); there were no significant differences in complications.
Conclusion: SOI and post-op complications were key drivers of high costs before and after ERAS implementation. High cost patients continued to experience significantly longer LOS and ICU stays. The need for quality improvement in surgical care remains even in the era of ERAS.