Effect of an Enhanced Recovery After Surgery Program on Opioid Use and Patient-Reported Outcomes

Abstract

Objective: To investigate the effect of an enhanced recovery after surgery (ERAS) program on perioperative outcomes with an emphasis on opioid consumption and patient-reported outcomes in the immediate and extended postoperative periods.

Methods: We initiated our ERAS program as part of a quality improvement initiative in November 2014. We compared clinical outcomes among a cohort of 607 women undergoing open gynecologic surgery before or after implementation of ERAS. For 293 patients, patient-reported outcomes were compared using the MD Anderson Symptom Inventory-Ovarian Cancer.

Results: Median age was 58 years (range 18-85 years). Median length of stay decreased by 25% for patients in the ERAS pathway (P<.001). Overall, patients in the ERAS group had a 72% reduction in median opioid consumption and 16% were opioid-free during admission up to postoperative day 3 (P<.001). There was no difference in pain scores (P=.80). Patients on ERAS reported less fatigue (P=.01), interference with walking (P=.003), and total interference (composite score of physical and affective measures) during hospitalization (P=.008). After discharge, those on the ERAS pathway demonstrated a significantly shorter median time to return to no or mild fatigue (10 vs 30 days, P=.03), mild or no interference with walking (5 vs 13 days, P=.003), and mild to no total interference (3 vs 13 days, P=.02). There were no significant differences in complications, rates of readmission, or reoperation between the pre- and post-ERAS groups.

Conclusion: Implementation of an ERAS program was associated with significantly decreased opioid use after surgery and improvement in key patient-reported outcomes associated with functional recovery after surgery without compromising pain scores.

Figure 1.

Morphine equivalent dose (postanesthesia care unit and inpatient unit). The median is shown as a bold horizontal bar across the waist of the box, while the top of the box represents the third quartile of the distribution, and the bottom of the box represents the first quartile of the distribution. The notches on the box represent the 95% CI for the median. The whiskers for each box extend to 1.5 × IQR above and below the box, with a lower limit of 0. Outliers are represented by small circles beyond the whiskers. For aesthetic reasons, the extreme outliers beyond 250 are omitted from the figures. The width of a box is proportional to the sample size of the distribution represented by the box. For postoperative day 1 and 2 (P<.001), and for postoperative day 3 (P=.003).

Figure 2.

Longitudinal assessment of fatigue during hospital stay (P=.01) (A), in-hospital interference with walking (P=.003) (B), and daily total interference composite score during hospital stay (P=.008) (C). Line with bar represents mean and 95% CI. P values calculated from mixed effect model. ERAS, enhanced recovery after surgery.

Figure 3.

Time to recovery. A. Return to mild or none (<4) of fatigue level after discharge after surgery (P=.03). B. Return to mild or none (<4) of interference with walking after discharge after surgery (P=.003). C. Return to mild or none (<4) of composite total interference score after discharge after surgery (P=.02). ERAS, enhanced recovery after surgery.