Compliance to an enhanced recovery pathway among patients with a high frailty index after major gastrointestinal surgery results in improved 30-day outcomes

Jessica P. Hampton, Oluwafemi P. Owodunni, Dianne Bettick, Sophia Y. Chen, Sara Sateri, Thomas Magnuson, Susan L Gearhart

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Abstract

Background: Enhanced recovery pathways have been shown to improve clinical outcomes after surgery. Concerns exist about the feasibility of implementing enhanced recovery pathways in frail patients, who are at a greater risk for adverse postoperative outcomes. This study evaluated compliance and outcomes after enhanced recovery pathway implementation in high-risk, abdominal surgery patients. Methods: Patients entered into the American College of Surgeons National Surgical Quality Improvement Program database who underwent abdominal surgery after enhanced recovery pathway implementation at two Johns Hopkins Medical Institutions were included. Risk was assessed using the American College of Surgeons National Surgical Quality Improvement Program validated, modified 5-item frailty index. Primary outcomes included compliance with 14 enhanced recovery pathway standards and postoperative length of stay, major complications (Clavien-Dindo score II–IV), and 30-day readmission. Results: This study included 646 patients who participated in our enhanced recovery pathway program and 65 patients with modified 5-item frailty index ≥ 2 before enhanced recovery pathway implementation. Overall, 325 patients (50.3%) were high compliers (>75% compliance) with enhanced recovery pathway standards, with similar proportions of patients with a modified 5-item frailty index ≥ 2 or < 2 achieving high compliance (51.6% vs 50.2%, P =.89, respectively). Examining causality for “low compliers” among patients with a high frailty score (modified 5-item frailty index ≥2) demonstrated significant less use of goal-directed therapy when compared with “high compliers” (43% vs 75%, P =.01). Low compliers were also less likely than high compliers to experience mobilization the day of surgery (43% vs 78%, P =.01), postoperative day 1 (43% vs 88%, P <.01), and postoperative day 2 (60% vs 100%, P <.01). In addition, low compliers were less likely than high compliers to have their diet advanced to solids on postoperative day 1 (17% vs 59%, P <.01) and have their Foley catheter removed on postoperative day 1 (45% vs 97%, P <.01). Comparing our pre-enhanced recovery pathway patients with our enhanced recovery pathway cohort with a high frailty score, enhanced recovery pathway patients had a significantly shorter length of stay (4.5 vs 6 days, P =.04). However, adjusted analysis demonstrated that high compliance, and not just the enhanced recovery pathway intervention among patients with a high frailty score, was independently associated with a decrease in length of stay (odds ratio 0.72, 95% confidence interval 0.63–0.82, P <.01) and a significant reduction in major complications (odds ratio 0.30, 95% confidence interval 0.14–0.65, P <.01. Conclusion: This study demonstrates that frail patients comply well with a robust enhanced recovery pathway protocol and subsequently experience improved outcomes. Targeted interventions that seek to maximize compliance with specific enhanced recovery pathway standards may further improve outcomes in this population.

Original languageEnglish (US)
JournalSurgery (United States)
DOIs
StatePublished - Jan 1 2019

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Compliance
Length of Stay
Quality Improvement
Odds Ratio
Confidence Intervals
Ambulatory Surgical Procedures
Causality
Catheters
Databases
Diet

ASJC Scopus subject areas

  • Surgery

Cite this

@article{2ce369a5b0964e4f80a369048e7f4d9f,
title = "Compliance to an enhanced recovery pathway among patients with a high frailty index after major gastrointestinal surgery results in improved 30-day outcomes",
abstract = "Background: Enhanced recovery pathways have been shown to improve clinical outcomes after surgery. Concerns exist about the feasibility of implementing enhanced recovery pathways in frail patients, who are at a greater risk for adverse postoperative outcomes. This study evaluated compliance and outcomes after enhanced recovery pathway implementation in high-risk, abdominal surgery patients. Methods: Patients entered into the American College of Surgeons National Surgical Quality Improvement Program database who underwent abdominal surgery after enhanced recovery pathway implementation at two Johns Hopkins Medical Institutions were included. Risk was assessed using the American College of Surgeons National Surgical Quality Improvement Program validated, modified 5-item frailty index. Primary outcomes included compliance with 14 enhanced recovery pathway standards and postoperative length of stay, major complications (Clavien-Dindo score II–IV), and 30-day readmission. Results: This study included 646 patients who participated in our enhanced recovery pathway program and 65 patients with modified 5-item frailty index ≥ 2 before enhanced recovery pathway implementation. Overall, 325 patients (50.3{\%}) were high compliers (>75{\%} compliance) with enhanced recovery pathway standards, with similar proportions of patients with a modified 5-item frailty index ≥ 2 or < 2 achieving high compliance (51.6{\%} vs 50.2{\%}, P =.89, respectively). Examining causality for “low compliers” among patients with a high frailty score (modified 5-item frailty index ≥2) demonstrated significant less use of goal-directed therapy when compared with “high compliers” (43{\%} vs 75{\%}, P =.01). Low compliers were also less likely than high compliers to experience mobilization the day of surgery (43{\%} vs 78{\%}, P =.01), postoperative day 1 (43{\%} vs 88{\%}, P <.01), and postoperative day 2 (60{\%} vs 100{\%}, P <.01). In addition, low compliers were less likely than high compliers to have their diet advanced to solids on postoperative day 1 (17{\%} vs 59{\%}, P <.01) and have their Foley catheter removed on postoperative day 1 (45{\%} vs 97{\%}, P <.01). Comparing our pre-enhanced recovery pathway patients with our enhanced recovery pathway cohort with a high frailty score, enhanced recovery pathway patients had a significantly shorter length of stay (4.5 vs 6 days, P =.04). However, adjusted analysis demonstrated that high compliance, and not just the enhanced recovery pathway intervention among patients with a high frailty score, was independently associated with a decrease in length of stay (odds ratio 0.72, 95{\%} confidence interval 0.63–0.82, P <.01) and a significant reduction in major complications (odds ratio 0.30, 95{\%} confidence interval 0.14–0.65, P <.01. Conclusion: This study demonstrates that frail patients comply well with a robust enhanced recovery pathway protocol and subsequently experience improved outcomes. Targeted interventions that seek to maximize compliance with specific enhanced recovery pathway standards may further improve outcomes in this population.",
author = "Hampton, {Jessica P.} and Owodunni, {Oluwafemi P.} and Dianne Bettick and Chen, {Sophia Y.} and Sara Sateri and Thomas Magnuson and Gearhart, {Susan L}",
year = "2019",
month = "1",
day = "1",
doi = "10.1016/j.surg.2019.01.027",
language = "English (US)",
journal = "Surgery",
issn = "0039-6060",
publisher = "Mosby Inc.",

}

TY - JOUR

T1 - Compliance to an enhanced recovery pathway among patients with a high frailty index after major gastrointestinal surgery results in improved 30-day outcomes

AU - Hampton, Jessica P.

AU - Owodunni, Oluwafemi P.

AU - Bettick, Dianne

AU - Chen, Sophia Y.

AU - Sateri, Sara

AU - Magnuson, Thomas

AU - Gearhart, Susan L

PY - 2019/1/1

Y1 - 2019/1/1

N2 - Background: Enhanced recovery pathways have been shown to improve clinical outcomes after surgery. Concerns exist about the feasibility of implementing enhanced recovery pathways in frail patients, who are at a greater risk for adverse postoperative outcomes. This study evaluated compliance and outcomes after enhanced recovery pathway implementation in high-risk, abdominal surgery patients. Methods: Patients entered into the American College of Surgeons National Surgical Quality Improvement Program database who underwent abdominal surgery after enhanced recovery pathway implementation at two Johns Hopkins Medical Institutions were included. Risk was assessed using the American College of Surgeons National Surgical Quality Improvement Program validated, modified 5-item frailty index. Primary outcomes included compliance with 14 enhanced recovery pathway standards and postoperative length of stay, major complications (Clavien-Dindo score II–IV), and 30-day readmission. Results: This study included 646 patients who participated in our enhanced recovery pathway program and 65 patients with modified 5-item frailty index ≥ 2 before enhanced recovery pathway implementation. Overall, 325 patients (50.3%) were high compliers (>75% compliance) with enhanced recovery pathway standards, with similar proportions of patients with a modified 5-item frailty index ≥ 2 or < 2 achieving high compliance (51.6% vs 50.2%, P =.89, respectively). Examining causality for “low compliers” among patients with a high frailty score (modified 5-item frailty index ≥2) demonstrated significant less use of goal-directed therapy when compared with “high compliers” (43% vs 75%, P =.01). Low compliers were also less likely than high compliers to experience mobilization the day of surgery (43% vs 78%, P =.01), postoperative day 1 (43% vs 88%, P <.01), and postoperative day 2 (60% vs 100%, P <.01). In addition, low compliers were less likely than high compliers to have their diet advanced to solids on postoperative day 1 (17% vs 59%, P <.01) and have their Foley catheter removed on postoperative day 1 (45% vs 97%, P <.01). Comparing our pre-enhanced recovery pathway patients with our enhanced recovery pathway cohort with a high frailty score, enhanced recovery pathway patients had a significantly shorter length of stay (4.5 vs 6 days, P =.04). However, adjusted analysis demonstrated that high compliance, and not just the enhanced recovery pathway intervention among patients with a high frailty score, was independently associated with a decrease in length of stay (odds ratio 0.72, 95% confidence interval 0.63–0.82, P <.01) and a significant reduction in major complications (odds ratio 0.30, 95% confidence interval 0.14–0.65, P <.01. Conclusion: This study demonstrates that frail patients comply well with a robust enhanced recovery pathway protocol and subsequently experience improved outcomes. Targeted interventions that seek to maximize compliance with specific enhanced recovery pathway standards may further improve outcomes in this population.

AB - Background: Enhanced recovery pathways have been shown to improve clinical outcomes after surgery. Concerns exist about the feasibility of implementing enhanced recovery pathways in frail patients, who are at a greater risk for adverse postoperative outcomes. This study evaluated compliance and outcomes after enhanced recovery pathway implementation in high-risk, abdominal surgery patients. Methods: Patients entered into the American College of Surgeons National Surgical Quality Improvement Program database who underwent abdominal surgery after enhanced recovery pathway implementation at two Johns Hopkins Medical Institutions were included. Risk was assessed using the American College of Surgeons National Surgical Quality Improvement Program validated, modified 5-item frailty index. Primary outcomes included compliance with 14 enhanced recovery pathway standards and postoperative length of stay, major complications (Clavien-Dindo score II–IV), and 30-day readmission. Results: This study included 646 patients who participated in our enhanced recovery pathway program and 65 patients with modified 5-item frailty index ≥ 2 before enhanced recovery pathway implementation. Overall, 325 patients (50.3%) were high compliers (>75% compliance) with enhanced recovery pathway standards, with similar proportions of patients with a modified 5-item frailty index ≥ 2 or < 2 achieving high compliance (51.6% vs 50.2%, P =.89, respectively). Examining causality for “low compliers” among patients with a high frailty score (modified 5-item frailty index ≥2) demonstrated significant less use of goal-directed therapy when compared with “high compliers” (43% vs 75%, P =.01). Low compliers were also less likely than high compliers to experience mobilization the day of surgery (43% vs 78%, P =.01), postoperative day 1 (43% vs 88%, P <.01), and postoperative day 2 (60% vs 100%, P <.01). In addition, low compliers were less likely than high compliers to have their diet advanced to solids on postoperative day 1 (17% vs 59%, P <.01) and have their Foley catheter removed on postoperative day 1 (45% vs 97%, P <.01). Comparing our pre-enhanced recovery pathway patients with our enhanced recovery pathway cohort with a high frailty score, enhanced recovery pathway patients had a significantly shorter length of stay (4.5 vs 6 days, P =.04). However, adjusted analysis demonstrated that high compliance, and not just the enhanced recovery pathway intervention among patients with a high frailty score, was independently associated with a decrease in length of stay (odds ratio 0.72, 95% confidence interval 0.63–0.82, P <.01) and a significant reduction in major complications (odds ratio 0.30, 95% confidence interval 0.14–0.65, P <.01. Conclusion: This study demonstrates that frail patients comply well with a robust enhanced recovery pathway protocol and subsequently experience improved outcomes. Targeted interventions that seek to maximize compliance with specific enhanced recovery pathway standards may further improve outcomes in this population.

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