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Meta-Analysis
. 2024 Jun 3;7(6):e2417310.
doi: 10.1001/jamanetworkopen.2024.17310.

Enhanced Recovery After Surgery Guidelines and Hospital Length of Stay, Readmission, Complications, and Mortality: A Meta-Analysis of Randomized Clinical Trials

Khara M Sauro  1   2   3 , Christine Smith  1 , Seremi Ibadin  1 , Abigail Thomas  1 , Heather Ganshorn  4 , Linda Bakunda  1 , Bishnu Bajgain  1 , Steven P Bisch  5 , Gregg Nelson  5   6
Affiliations
Meta-Analysis

Enhanced Recovery After Surgery Guidelines and Hospital Length of Stay, Readmission, Complications, and Mortality: A Meta-Analysis of Randomized Clinical Trials

Khara M Sauro et al. JAMA Netw Open. .

Erratum in

  • Errors in Figures.
    [No authors listed] [No authors listed] JAMA Netw Open. 2024 Jul 1;7(7):e2428433. doi: 10.1001/jamanetworkopen.2024.28433. JAMA Netw Open. 2024. PMID: 39023898 Free PMC article. No abstract available.

Abstract

Importance: A comprehensive review of the evidence exploring the outcomes of enhanced recovery after surgery (ERAS) guidelines has not been completed.

Objective: To evaluate if ERAS guidelines are associated with improved hospital length of stay, hospital readmission, complications, and mortality compared with usual surgical care, and to understand differences in estimates based on study and patient factors.

Data sources: MEDLINE, Embase, Cumulative Index to Nursing and Allied Health Literature, and Cochrane Central were searched from inception until June 2021.

Study selection: Titles, abstracts, and full-text articles were screened by 2 independent reviewers. Eligible studies were randomized clinical trials that examined ERAS-guided surgery compared with a control group and reported on at least 1 of the outcomes.

Data extraction and synthesis: Data were abstracted in duplicate using a standardized data abstraction form. The study followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses. Risk of bias was assessed in duplicate using the Cochrane Risk of Bias tool. Random-effects meta-analysis was used to pool estimates for each outcome, and meta-regression identified sources of heterogeneity within each outcome.

Main outcome and measures: The primary outcomes were hospital length of stay, hospital readmission within 30 days of index discharge, 30-day postoperative complications, and 30-day postoperative mortality.

Results: Of the 12 047 references identified, 1493 full texts were screened for eligibility, 495 were included in the systematic review, and 74 RCTs with 9076 participants were included in the meta-analysis. Included studies presented data from 21 countries and 9 ERAS-guided surgical procedures with 15 (20.3%) having a low risk of bias. The mean (SD) Reporting on ERAS Compliance, Outcomes, and Elements Research checklist score was 13.5 (2.3). Hospital length of stay decreased by 1.88 days (95% CI, 0.95-2.81 days; I2 = 86.5%; P < .001) and the risk of complications decreased (risk ratio, 0.71; 95% CI, 0.59-0.87; I2 = 78.6%; P < .001) in the ERAS group. Risk of readmission and mortality were not significant.

Conclusions and relevance: In this meta-analysis, ERAS guidelines were associated with decreased hospital length of stay and complications. Future studies should aim to improve implementation of ERAS and increase the reach of the guidelines.

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Conflict of interest statement

Conflict of Interest Disclosures: Dr Bisch reported receiving personal fees from Pfizer Canada, Astra Zeneca, and Johnson and Johnson and receiving grants from Pfizer Canada and Pharmacosmos outside the submitted work. Dr Nelson reported receiving personal fees from Pfizer, GSK, Astra Zeneca, and Smith and Nephew and being the treasurer of the ERAS Society and co-chair of Enhanced Recovery Canada outside the submitted work. No other disclosures were reported.

Figures

Figure 1.
Figure 1.. Study Characteristics
(A) Among the studies that reported the enhanced recovery after surgery (ERAS) elements, most included early mobilization, postoperative analgesia considerations, and postoperative diet and bowel management. (B) Reporting on ERAS Compliance, Outcomes, and Elements Research (RECOvER) checklist items of included studies. PRO indicates patient reported outcomes.
Figure 2.
Figure 2.. Meta-Analysis of Hospital Length of Stay
Patients in enhanced recovery after surgery (ERAS) groups stayed 1.9 days less in hospital compared with control groups. Patient undergoing pancreatic, orthopedic, and gastrointestinal (GI) surgical procedures had greater reductions in hospitals stays than patients undergoing gynecological and breast surgery. ERP, enhanced recovery protocol; RECOvER, Reporting on ERAS Compliance, Outcomes, and Elements Research.
Figure 3.
Figure 3.. Meta-Analysis of Hospital Readmission
Patients in the enhanced recovery after surgery (ERAS) groups had a lower risk of being readmitted after their index hospitalization than patients in the control group. None of the variables explored were associated with the risk of readmission. ERP indicates enhanced recovery protocol; GI, gastrointestinal; NA, not applicable; RECOvER, Reporting on ERAS Compliance, Outcomes, and Elements Research; RR, risk ratio.
Figure 4.
Figure 4.. Meta-Analysis of Complications
Patients in the enhanced recovery after surgery (ERAS) groups had a lower risk of having complications after their surgery than patients in the control group. None of the variables explored were associated with the risk of complications. ERP indicates enhanced recovery protocol; GI, gastrointestinal; NA, not applicable; RR, risk ratio.
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References

    1. Inpatient hospitalization, surgery, and newborn statistics, 2019-2020. Canadian Institute for Health Information. Accessed May 30, 2024. https://www.cihi.ca/en/hospital-stays-in-canada-series
    1. Weiser TG, Haynes AB, Molina G, et al. . Estimate of the global volume of surgery in 2012: an assessment supporting improved health outcomes. Lancet. 2015;385(suppl 2):S11. doi:10.1016/S0140-6736(15)60806-6 - DOI - PubMed
    1. Baker GRN, Norton PG, Flintoft V, et al. . The Canadian Adverse Events Study: the incidence of adverse events among hospital patients in Canada. CMAJ. 2004;170(11):1678-1686. doi:10.1503/cmaj.1040498 - DOI - PMC - PubMed
    1. Brennan TAL, Leape LL, Laird NM, et al. . Incidence of adverse event and negligence in hospitalized patients. Results of the Harvard Medical Practice Study I. N Engl J Med. 1991;324(6):370-376. doi:10.1056/NEJM199102073240604 - DOI - PubMed
    1. Forster AJA, Asmis TR, Clark HD, et al. ; Ottawa Hospital Patient Safety Study . Ottawa Hospital Patient Safety Study: incidence and timing of adverse events in patients admitted to a Canadian teaching hospital. CMAJ. 2004;170(8):1235-1240. doi:10.1503/cmaj.1030683 - DOI - PMC - PubMed

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