Enhanced recovery protocol applied to liver surgery reduced costs

SCOTTSDALE, ARIZ. – A new study shows that an Enhanced Recovery in Liver Surgery (ERLS) program reduced costs at a high-volume liver surgery center. The savings were lower in patients receiving epidurals, which is prompting the center to explore alternative methods of pain control. The program reduced costs in minor hepatectomies, but not major hepatectomies.

“It has been clearly demonstrated that patients benefit from enhanced recovery programs – they’re getting home sooner, they’re on fewer opioids, and they do better. What’s less clear is if it’s cost effective. If you can demonstrate lower costs, then all the major stakeholders involved would potentially benefit,” Michael Egger, MD, assistant professor of surgery at the University of Louisville (Ky.), said in an interview.

The study was conducted at the University of Texas MD Anderson Cancer Center, Houston. Dr. Egger presented the research at the annual meeting of the Western Surgical Association.

The liver program is similar to other enhanced recovery protocols and includes use of nonnarcotic analgesia, early ambulation, and early initiation of oral diet. Aspects unique to liver surgery include avoidance of drains and tubes placed in the operating room and limitation of intravenous fluids during and following surgery.

The researchers analyzed data from 212 patients who underwent hepatectomy between February 2012 and September 2016: 72 patients who were in an ERLS program and 140 were enrolled in a traditional recovery (TR) program. The ERLS program included patient education, narcotic-sparing anesthesia and analgesia, rapid diet advancement, restrictive fluid use, early ambulation, and avoidance of drains and tubes.

A total of 32% of patients in the ERLS group underwent major hepatectomy, compared to 64% of patients in the TR group. Forty-three percent in the ERLS group had an epidural, compared with 75% in the TR group.

The ERLS group had a shorter median length of stay (5 days vs. 6 days; P = .001) and had a 9.1% reduction in costs (P = .001). The largest cost differences were attributable to lab costs (–15.0%), room and board (–13.9%), and professional costs (–19.3%; all P less than .05).

ERLS was not associated with a statistically significant cost saving in patients undergoing major hepatectomy. In minor hepatectomy, ERLS was associated with a 17.6% reduction in overall costs (P less than .05). There was no reduction in patients who had a hospital stay over 90 days

Among patients who received patient-controlled analgesia, those in the ERLS program had a 32.0% reduction in overall costs (P less than .001), largely driven by a 34.3% reduction in lab costs, a 33.3% reduction in room and board, a 51.6% reduction in professional costs, and a 22.5% reduction in pharmacy costs (all P less than .05).

There was also no difference in cost between the two programs in patients who underwent an epidural, which suggests an avenue for improvement. “We’re looking at other regional pain blocks, such as transverse abdominis plane (TAP) block using a long-acting analgesic, and that’s our trend going forward. We’re hoping we can reduce some of those increased costs associated with the epidural, but still reap the benefits of improved pain control and reduction of narcotics use,” said Dr. Egger.

The National Institutes of Health funded the study. Dr. Egger reported having no financial disclosures.

SCOTTSDALE, ARIZ. – A new study shows that an Enhanced Recovery in Liver Surgery (ERLS) program reduced costs at a high-volume liver surgery center. The savings were lower in patients receiving epidurals, which is prompting the center to explore alternative methods of pain control. The program reduced costs in minor hepatectomies, but not major hepatectomies.

“It has been clearly demonstrated that patients benefit from enhanced recovery programs – they’re getting home sooner, they’re on fewer opioids, and they do better. What’s less clear is if it’s cost effective. If you can demonstrate lower costs, then all the major stakeholders involved would potentially benefit,” Michael Egger, MD, assistant professor of surgery at the University of Louisville (Ky.), said in an interview.

The study was conducted at the University of Texas MD Anderson Cancer Center, Houston. Dr. Egger presented the research at the annual meeting of the Western Surgical Association.

The liver program is similar to other enhanced recovery protocols and includes use of nonnarcotic analgesia, early ambulation, and early initiation of oral diet. Aspects unique to liver surgery include avoidance of drains and tubes placed in the operating room and limitation of intravenous fluids during and following surgery.

The researchers analyzed data from 212 patients who underwent hepatectomy between February 2012 and September 2016: 72 patients who were in an ERLS program and 140 were enrolled in a traditional recovery (TR) program. The ERLS program included patient education, narcotic-sparing anesthesia and analgesia, rapid diet advancement, restrictive fluid use, early ambulation, and avoidance of drains and tubes.

A total of 32% of patients in the ERLS group underwent major hepatectomy, compared to 64% of patients in the TR group. Forty-three percent in the ERLS group had an epidural, compared with 75% in the TR group.

The ERLS group had a shorter median length of stay (5 days vs. 6 days; P = .001) and had a 9.1% reduction in costs (P = .001). The largest cost differences were attributable to lab costs (–15.0%), room and board (–13.9%), and professional costs (–19.3%; all P less than .05).

ERLS was not associated with a statistically significant cost saving in patients undergoing major hepatectomy. In minor hepatectomy, ERLS was associated with a 17.6% reduction in overall costs (P less than .05). There was no reduction in patients who had a hospital stay over 90 days

Among patients who received patient-controlled analgesia, those in the ERLS program had a 32.0% reduction in overall costs (P less than .001), largely driven by a 34.3% reduction in lab costs, a 33.3% reduction in room and board, a 51.6% reduction in professional costs, and a 22.5% reduction in pharmacy costs (all P less than .05).

There was also no difference in cost between the two programs in patients who underwent an epidural, which suggests an avenue for improvement. “We’re looking at other regional pain blocks, such as transverse abdominis plane (TAP) block using a long-acting analgesic, and that’s our trend going forward. We’re hoping we can reduce some of those increased costs associated with the epidural, but still reap the benefits of improved pain control and reduction of narcotics use,” said Dr. Egger.

The National Institutes of Health funded the study. Dr. Egger reported having no financial disclosures.

SCOTTSDALE, ARIZ. – A new study shows that an Enhanced Recovery in Liver Surgery (ERLS) program reduced costs at a high-volume liver surgery center. The savings were lower in patients receiving epidurals, which is prompting the center to explore alternative methods of pain control. The program reduced costs in minor hepatectomies, but not major hepatectomies.

“It has been clearly demonstrated that patients benefit from enhanced recovery programs – they’re getting home sooner, they’re on fewer opioids, and they do better. What’s less clear is if it’s cost effective. If you can demonstrate lower costs, then all the major stakeholders involved would potentially benefit,” Michael Egger, MD, assistant professor of surgery at the University of Louisville (Ky.), said in an interview.

The study was conducted at the University of Texas MD Anderson Cancer Center, Houston. Dr. Egger presented the research at the annual meeting of the Western Surgical Association.

The liver program is similar to other enhanced recovery protocols and includes use of nonnarcotic analgesia, early ambulation, and early initiation of oral diet. Aspects unique to liver surgery include avoidance of drains and tubes placed in the operating room and limitation of intravenous fluids during and following surgery.

The researchers analyzed data from 212 patients who underwent hepatectomy between February 2012 and September 2016: 72 patients who were in an ERLS program and 140 were enrolled in a traditional recovery (TR) program. The ERLS program included patient education, narcotic-sparing anesthesia and analgesia, rapid diet advancement, restrictive fluid use, early ambulation, and avoidance of drains and tubes.

A total of 32% of patients in the ERLS group underwent major hepatectomy, compared to 64% of patients in the TR group. Forty-three percent in the ERLS group had an epidural, compared with 75% in the TR group.

The ERLS group had a shorter median length of stay (5 days vs. 6 days; P = .001) and had a 9.1% reduction in costs (P = .001). The largest cost differences were attributable to lab costs (–15.0%), room and board (–13.9%), and professional costs (–19.3%; all P less than .05).

ERLS was not associated with a statistically significant cost saving in patients undergoing major hepatectomy. In minor hepatectomy, ERLS was associated with a 17.6% reduction in overall costs (P less than .05). There was no reduction in patients who had a hospital stay over 90 days

Among patients who received patient-controlled analgesia, those in the ERLS program had a 32.0% reduction in overall costs (P less than .001), largely driven by a 34.3% reduction in lab costs, a 33.3% reduction in room and board, a 51.6% reduction in professional costs, and a 22.5% reduction in pharmacy costs (all P less than .05).

There was also no difference in cost between the two programs in patients who underwent an epidural, which suggests an avenue for improvement. “We’re looking at other regional pain blocks, such as transverse abdominis plane (TAP) block using a long-acting analgesic, and that’s our trend going forward. We’re hoping we can reduce some of those increased costs associated with the epidural, but still reap the benefits of improved pain control and reduction of narcotics use,” said Dr. Egger.

The National Institutes of Health funded the study. Dr. Egger reported having no financial disclosures.