Enhanced recovery after surgery components and perioperative outcomes: a nationwide observational study.

Enhanced recovery after surgery (ERAS) protocols have been shown to benefit recovery after several operations. However, large-scale data on the association between the level of ERAS use and perioperative complications are scarce, particularly in surgeries with increasing ERAS uptake, including total hip (THA) and knee arthroplasty (TKA). Using US national data, we examined the relationship between the number of ERAS components implemented ('level') and perioperative outcomes. After ethics approval, we included 1 540 462 elective THA/TKA procedures (2006-2016, as recorded in the Premier Healthcare claims database) in this retrospective cohort study. Main outcomes were any complication, cardiopulmonary complications, mortality, blood transfusions, and length of stay. Eight commonly used ERAS components were included. Mixed-effects models measured associations between ERAS level and outcomes, with odds ratios (OR) and confidence intervals (CI) reported. ERAS use increased over time; overall, 21.6% (n=324 437), 62.7% (n=965 953), and 18.0% (n=250 072) of cases were classified as 'High', 'Medium', or 'Low' ERAS. 'High ERAS', 'Medium ERAS', and 'Low ERAS' level of use were defined as such if they received either >6, 5-6, or <5 ERAS components, respectively. After adjustment for relevant covariates, higher levels of ERAS use were associated with incremental reductions in 'any complication': 'Medium' vs 'Low' (OR=0.84; CI, 0.82-0.86) and 'High' vs 'Low' (OR=0.71; CI, 0.68-0.74). Similar patterns were found for the other study outcomes. Individual ERAS components with the strongest effect estimates were early physical therapy, avoidance of a urinary catheter, and tranexamic acid administration. ERAS components were used more frequently over time, and the level of utilisation was independently associated with incrementally improved complication odds and reduced length of stay during the primary admission. Possible indication bias limits the certainty of these findings.

Memtsoudis SG ，Fiasconaro M ，Soffin EM ，Liu J ，Wilson LA ，Poeran J ，Bekeris J ，Kehlet H ... -  《-》

Association Between Use of Enhanced Recovery After Surgery Protocol and Postoperative Complications in Total Hip and Knee Arthroplasty in the Postoperative Outcomes Within Enhanced Recovery After Surgery Protocol in Elective Total Hip and Knee Arthroplast

Ripollés-Melchor J ，Abad-Motos A ，Díez-Remesal Y ，Aseguinolaza-Pagola M ，Padin-Barreiro L ，Sánchez-Martín R ，Logroño-Egea M ，Catalá-Bauset JC ，García-Orallo S ，Bisbe E ，Martín N ，Suárez-de-la-Rica A ，Cuéllar-Martínez AB ，Gil-Trujillo S ，Estupiñán-Jiménez JC ，Villanova-Baraza M ，Gil-Lapetra C ，Pérez-Sánchez P ，Rodríguez-García N ，Ramiro-Ruiz A ，Farré-Tebar C ，Martínez-García A ，Arauzo-Pérez P ，García-Pérez C ，Abad-Gurumeta A ，Miñambres-Villar MA ，Sánchez-Campos A ，Jiménez-López I ，Tena-Guerrero JM ，Marín-Peña O ，Sánchez-Merchante M ，Vicente-Gutiérrez U ，Cassinello-Ogea MC ，Ferrando-Ortolá C ，Berges-Gutiérrez H ，Fernanz-Antón J ，Gómez-Ríos MA ，Bordonaba-Bosque D ，Ramírez-Rodríguez JM ，García-Erce JA ，Aldecoa C ，Postoperative Outcomes Within Enhanced Recovery After Surgery Protocol in Elective Total Hip and Knee Arthroplasty (POWER2) Study Investigators Group for the Spanish Perioperative Audit and Research Network (REDGERM) ... -  《-》

Enhanced Recovery Implementation and Perioperative Outcomes in Posterior Fusion Patients.

Fiasconaro M ，Wilson LA ，Bekeris J ，Liu J ，Poeran J ，Soffin EM ，Memtsoudis SG ... -  《-》

Enhanced Recovery After Surgery Protocols in Lower Extremity Joint Arthroplasty: Using Observational Data to Identify the Optimal Combination of Components.

Enhanced recovery after surgery (ERAS) protocols are increasingly used in orthopedic surgery. Data are lacking on which combinations of ERAS components are (1) the most commonly used and (2) the most effective in terms of outcomes. This retrospective cohort study utilized claims data (Premier Healthcare, n = 1,539,432 total joint arthroplasties, 2006-2016). Eight ERAS components were defined: (A) regional anesthesia, (B) multimodal analgesia, (C) tranexamic acid, (D) antiemetics on day of surgery, (E) early physical therapy, and avoidance of (F) urinary catheters, (G) patient-controlled analgesia, and (H) drains. Outcomes were length of stay, "any complication," and hospitalization cost. Mixed-effects models measured associations between the most common ERAS combinations and outcomes. Odds ratios (ORs) and 95% confidence intervals (CIs) are reported. In 2006-2012 and 2013-2016, the most common ERAS combinations were B/D/E/F/G/H (20%, n = 172,397) and B/C/D/E/F/G/H (17%, n = 120,266), respectively. The only difference between the most commonly used ERAS combinations over the years is the addition of C (addition of tranexamic acid to the protocol). The most pronounced beneficial effects in 2006-2012 were seen for combination A/B/D/E/F/G/H (6% of cases vs less prevalent ERAS combinations) for the outcome of "any complication" (OR 0.87, CI 0.83-0.91, P < .0001). In 2013-2016, the strongest effects were seen for combination B/C/D/E/F/G/H (17% of cases) also for the outcome of "any complication" (OR 0.86, CI 0.83-0.89, P < .0001). Relatively minor differences existed between ERAS protocols for the other outcomes. Despite varying ERAS protocols, maximum benefits in terms of complication reduction differed minimally. Further study may elucidate the balance between an increasing number of ERAS components and incremental benefits realized. III.

Chen KK ，Chan JJ ，Zubizarreta NJ ，Poeran J ，Chen DD ，Moucha CS ... -  《-》

Enhanced recovery short-stay hip and knee joint replacement program improves patients outcomes while reducing hospital costs.

An attractive option to reduce hospital length of stay (LOS) after hip or knee joint replacement (THA, TKA) is to follow the Enhanced Recovery After Surgery principles (ERAS) to improve patient experience to a level where they will feel confident to leave for home earlier. The objective of this study was to evaluate the implementation of short-stay protocol following the ERAS principles. We hypothesized that our ERAS THA and TKA short-stay protocol would result in a lower complication rate, shorter hospital LOS and reduced direct health care costs compared to our standard procedure. We compared the complications rated according to Clavien-Dindo scale, hospital LOS and costs of the episode of care between a prospective cohort of 120 ERAS short-stay THA or TKA and a matched historical control group of 150 THA or TKA. Significantly lower rate of Grade 1 and 2 complications in the ERAS short-stay group compared with the standard group (mean 0.8 vs 3.0, p<0.001). No difference was found between the 2 groups for Grade 3, 4, or 5 complications. The mean hospital LOS for the ERAS short-stay group decreased by 2.8 days for the THAs (0.1 vs 2.9 days, p<0.001) and 3.9 days for the TKAs (1.0 vs 4.9 days, p<0.001). The mean estimated direct health care costs reduction with the ERAS short-stay protocol was 1489 CAD per THA and 4158 CAD per TKA. In many short-stay protocols, focus has shifted from ERAS goals of a reduction in complications and improved recuperation to use length of stay as the main factor of success. Implementation of an ERAS short-stay protocol for patients undergoing THA or TKA at our institution resulted not only in reduced hospital LOS, but also in improved patient care and reduced direct health care costs. Level II.

Vendittoli PA ，Pellei K ，Desmeules F ，Massé V ，Loubert C ，Lavigne M ，Fafard J ，Fortier LP ... -  《Orthopaedics & Traumatology-Surgery & Research》