Can enhanced recovery pathways improve outcomes of vaginal hysterectomy? Cohort control study.

STUDY OBJECTIVE: To assess the effect of enhanced recovery pathway implementation on patient outcomes after vaginal hysterectomy (VH) performed to treat benign indications. DESIGN: Case-control study examining outcome measures including length of stay, pain scores, postoperative morbidity, and readmission rates after implementation of the Enhanced Recovery after Surgery (ERAS) program for VH (Canadian Task Force classification II). SETTING: Teaching hospital. PATIENTS: Fifty patients who underwent VH after implementation of ERAS were compared with 50 control patients before ERAS. Patients were matched for age, indication for surgery, American Society of Anesthesiologists grade, and surgeon. INTERVENTION: ERAS pathway. MEASUREMENTS AND MAIN RESULTS: Length of stay, percentage of patients discharged within 24 hours, use of urinary catheter and vaginal packing, and readmission rates were determined. Perioperative expenditures were compared, and cost-effectiveness of ERAS was assessed. Median patient vs control age (49.0 vs 51.0 years), parity (2.0 vs 2.0), and body mass index (26.5 vs 28.3) were statistically comparable. After ERAS implementation, the median length of stay was reduced by 51.6% (22.0 vs 45.5 hours; p < .01), and the percentage of patients discharged within 24 hours was increased by 5-fold (78.0 vs 15.6%; p < .05). Frequency of catheter use (82.0% vs 95.6%) and use of vaginal packing (52.0 vs 82.2%) were significantly lower in the post-ERAS group, and these devices were removed earlier (14.5 vs 23.7 hours and 16.0 vs 23.0 hours, respectively; p < .05 in all cases). Attendance in the Accident and Emergency Department (12.0% vs 0%; p > .05) and inpatient readmission rate (4.0% vs 0%; p > .05) were similar in both groups. Despite having to start a "gynecology school" and employ a specialist Enhanced Recovery nurse, a cost savings of 9.25% per patient was demonstrated. CONCLUSION: The ERAS program in benign VH reduces length of stay by 51.6% and enables more women to be discharged within 24 hours, with no increase in patient readmissions rates.

Cost effectiveness of enhanced recovery after surgery programme for vaginal hysterectomy: a comparison of pre and post-implementation expenditures.

Enhanced Recovery After Surgery programmes were first conceived to optimise perioperative patient care and have been delivered by surgical specialities in the UK for over a decade. Although their safety and acceptability have been ratified in many surgical fields including gynaecology and colorectal surgery, the cost effectiveness of its implementation in benign vaginal surgery remains unclear. In this case-control study, the perioperative expenditure for 45 women undergoing vaginal hysterectomy at a North London teaching hospital after implementation of an enhanced recovery pathway was compared with 45 matched controls prior to implementation. Frequency of catheter use (84.4% vs. 95.6%) and median length of stay (23.5 vs. 42.9 h) were significantly lower following implementation of pathway (both p < 0.05). Although enhanced recovery patients were more likely to attend the accident and emergency department for minor symptoms following discharge (15.6% vs. 0%, p < 0.05), the inpatient readmission rate (6.7% vs. 0.0%, p > 0.05) was similar in both groups. Establishing the programme incurred additional expenditures including delivering a patient-orientated gynaecology 'school' and employing a specialist enhanced recovery nurse, but despite these, we demonstrated a saving of 15.2% (or £164.86) per patient. The cost efficiency savings, coupled with increased satisfaction and no rise in morbidity, offers a very attractive means of managing women undergoing vaginal hysterectomy. We believe that our data can be reproduced in other centres and recommend that the pathway be used routinely in women undergoing these procedures.

A comparison between two strategies for monitoring hepatic function during antituberculous therapy.

RATIONALE: The optimum strategy for monitoring liver function during antituberculous therapy is unclear. OBJECTIVES: To assess the value of the American Thoracic Society risk-factor approach for predicting drug-induced liver injury and to compare with a uniform policy of liver function testing in all patients at 2 weeks. METHODS: We conducted an observational study of adult patients undergoing therapy for active tuberculosis at a tertiary center. All patients had alanine transferase measurement at baseline and 2 weeks following commencement of therapy. Sensitivity, specificity, and positive and negative predictive values were used to assess strategies. MEASUREMENTS AND MAIN RESULTS: There were 288 patients included, and 21 (7.3%) developed drug-induced liver injury (57.1% "early" at 2 wk and 42.9% "late," after 2 wk). There were increased rates of individuals with HIV infection in the early drug-induced liver injury group compared with no drug-induced liver injury and late drug-induced liver injury groups (33% vs. 7.1% vs. 0%; P = 0.004). The American Thoracic Society algorithm had a sensitivity and specificity of 66.7 and 65.6%, respectively, for prediction of early and 22.2% and 63.7% for late drug-induced liver injury. The uniform monitoring policy had poor sensitivity but better specificity (22.2 and 82.1%) for prediction of late drug-induced liver injury. CONCLUSIONS: In our urban, ethnically diverse population, a risk-factor approach is neither sensitive nor specific for prediction of drug-induced liver injury. A uniform policy of liver function testing at 2 weeks is useful for prompt identification of a subgroup who develop early drug-induced liver injury and may offer better specificity in ruling out late drug-induced liver injury.