Adherence to Enhanced Recovery Protocols in NSQIP and Association with Colectomy Outcomes

Julia R. Berian, Kristen A. Ban, Jason B. Liu, Clifford Y. Ko, Liane S. Feldman, Julie K. Thacker

Research output: Contribution to journalArticlepeer-review

24 Scopus citations


Objective: To evaluate the effect of protocol adherence on length of stay (LOS) and recovery-specific outcomes after colectomy. Background: Enhanced recovery protocols (ERPs) may decrease postoperative morbidity and LOS; however, the effect of overall protocol adherence remains unclear. Methods: Using American College of Surgeons' National Surgical Quality Improvement Program colectomy data (July 2014-December 2015) and 13 novel ERP variables, propensity scores were constructed for low (0-5), moderate (6-9), and high adherence (10-13 components). Prolonged LOS (>75th percentile, uncomplicated cases) was modeled with multivariable logistic regression with robust standard errors, adjusted for hospital-level clustering and propensity score. Secondary recovery-specific outcomes were modeled with negative binomial regression. Subgroup analysis was conducted on uncomplicated cases. Results: Among 8139 elective colectomies at 113 hospitals, LOS increased with decreasing adherence (4.3 days [SD 3.3] high adherence vs 7.8 [SD 6.8] low adherence; P < 0.0001). High adherence was associated with fewer complications, including postoperative ileus, compared with moderate (P < 0.0001) and low adherence (P < 0.0001). High-adherence patients achieved recovery milestones earlier (vs low adherence), with return of bowel function at 1.9 (vs 3.7) days, tolerance of diet at 2.4 (vs 5.4) days, and oral pain control at 2.7 (vs 5.0) days (P < 0.0001). Risk-adjusted odds of prolonged LOS were significantly increased for low (odds ratio 2.7, 95% confidence interval 2.0-3.6) and moderate-adherence (odds ratio 1.7, 95% confidence interval 1.4-2.1) groups. In a negative binomial regression, time to recovery was 60% to 95% longer for low versus high adherence (P < 0.0001). Conclusions: In this large, multi-institutional North American data registry, high adherence to ERPs was associated with earlier recovery, decreased complications, and shorter LOS. ERPs can improve outcomes; however, benefits correlate with adherence.

Original languageEnglish (US)
Pages (from-to)486-493
Number of pages8
JournalAnnals of surgery
Issue number3
StatePublished - Mar 1 2019

Bibliographical note

Funding Information:
Conflicts of interest: Dr Berian receives salary support from the John A. Hartford Foundation. Dr Ban receives salary support from the Agency for Healthcare Research and Quality. Dr Ko is Co-Principal Investigator for the aforemen-tioned grants from the John A. Hartford Foundation and the Agency for Healthcare Research and Quality. Dr Feldman discloses receipt of an investi-gator-initiated research grant from Merck. Dr Thacker discloses financial relationships with the following entities: Merck, Edwards LifeScience, Chee-tah Medical, Covidien-Medtronic, Premier, and Abbott Nutritional.

Publisher Copyright:
Copyright © 2017 Wolters Kluwer Health, Inc. All rights reserved.

Copyright 2019 Elsevier B.V., All rights reserved.


  • colectomy outcomes
  • enhanced recovery
  • implementation science
  • protocol adherence
  • protocol compliance
  • quality improvement

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