Association of an enhanced recovery pilot with length of stay in the national surgical quality improvement program

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

Research output: Contribution to journalArticlepeer-review

22 Scopus citations


IMPORTANCE Enhanced recovery protocols (ERPs) are standardized care plans of best practices that can decrease morbidity and length of stay (LOS). However, many hospitals need help with implementation. The Enhanced Recovery in National Surgical Quality Improvement Program (ERIN) pilot was designed to support ERP implementation. OBJECTIVE To evaluate the association of the ERIN pilot with LOS after colectomy. DESIGN, SETTING, AND PARTICIPANTS Using a difference-in-differences design, pilot LOS before and after ERP implementation was compared with matched controls in a hierarchical model, adjusting for case mix and random effects of hospitals and matched pairs. The setting was 15 hospitals of varied size and academic status from the National Surgical Quality Improvement Program. Preimplementation and postimplementation colectomy cases (July 1, 2013, to December 31, 2015) were collected using novel ERIN variables. Emergency and septic cases were excluded. A propensity score match identified a 2:1 control cohort of patients undergoing colectomy at non-ERIN hospitals. INTERVENTIONS Pilot hospitals developed and implemented ERPs that included expert guidance, multidisciplinary teams, data audits, and opportunities for collaboration. MAIN OUTCOMES AND MEASURES The primary outcome was LOS, and the secondary outcome was serious morbidity or mortality composite. RESULTS There were 4975 colectomies performed by 15 ERIN pilot hospitals (3437 before implementation and 1538 after implementation) compared with a control cohort of 9950 colectomies (4726 before implementation and 5224 after implementation). The mean LOS decreased by 1.7 days in the pilot (6.9 [interquartile range (IQR), 4-8] days before implementation vs 5.2 [IQR, 3-6] days after implementation, P < .001) compared with 0.4 day in controls (6.4 [IQR, 4-7] days before implementation vs 6.0 [IQR, 3-7] days after implementation, P < .001). Readmission did not differ pre-post for the pilot or controls. Serious morbidity or mortality decreased for pilot participants (485 [14.1%] before implementation vs 162 [10.5%] after implementation, P < .001), with no difference in controls, and remained significant after risk adjustment (adjusted odds ratio, 0.76; 95% CI, 0.60-0.96). After adjusting for differences in case mix and for clustering in hospitals and matched pairs, the adjusted difference-in-differences model demonstrated a decrease in LOS by 1.1 days in the pilot over controls (P < .001). CONCLUSIONS AND RELEVANCE Participating ERIN pilot hospitals achieved shorter LOS and decreased complications after elective colectomy, without increasing readmissions. The ability to implement ERPs across hospitals of varied size and resources is essential. Lessons from the ERIN pilot May inform efforts to scale this effective and evidence-based intervention.

Original languageEnglish (US)
Pages (from-to)358-365
Number of pages8
JournalJAMA Surgery
Issue number4
StatePublished - Apr 2018
Externally publishedYes

Bibliographical note

Funding Information:
reported receiving salary support from The John A. Hartford Foundation. Dr Ban reported receiving salary support from the Agency for Healthcare Research and Quality. Dr Ko reported being coprincipal investigator for the grants from The John A. Hartford Foundation and the Agency for Healthcare Research and Quality. Dr Thacker reported having financial relationships with the following entities: Merck, Edwards Lifesciences, Cheetah Medical, Covidien-Medtronic, Premier, and Abbott Nutritional. Dr Feldman reported receiving an investigator-initiated research grant from Merck. No other disclosures were reported.

Publisher Copyright:
© 2017 American Medical Association. All rights reserved.


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