Enhanced Recovery After Surgery (ERAS) in gynecologic oncology: System-wide implementation and audit leads to improved value and patient outcomes.

OBJECTIVE: Enhanced recovery pathways have been shown to reduce length of stay without increasing readmission or complications in numerous areas of surgery. Uptake of gynecologic oncology ERAS guidelines has been limited. We describe the effect of ERAS guideline implementation in gynecologic oncology on length of stay, patient outcomes, and economic impact for a province-wide single-payer system. METHODS: We compared pre- and post-guideline implementation outcomes in consecutive staging and debulking patients at two centers that provide the majority of surgical gynecologic oncology care in Alberta, Canada between March 2016 and April 2017. Clinical outcomes and compliance were obtained using the ERAS Interactive Audit System. Patients were followed until 30 days after discharge. Negative binomial regression was employed to adjust for patient characteristics. RESULTS: We assessed 152 pre-ERAS and 367 post-ERAS implementation patients. Mean compliance with ERAS care elements increased from 56% to 77.0% after implementation (p < 0.0001). Median length of stay for all surgeries decreased from 4.0 days to 3.0 days post-ERAS (p < 0.0001), which translated to an adjusted LOS decrease of 31.4% (95% CI = [21.7% - 39.9%], p < 0.0001). In medium/high complexity surgery median LOS was reduced by 2.0 days (p = 0.0005). Complications prior to discharge decreased from 53.3% to 36.2% post-ERAS (p = 0.0003). There was no significant difference in readmission (p = 0.6159), complications up to 30 days (p = 0.6274), or mortality (p = 0.3618) between the cohorts. The net cost savings per patient was $956 (95%CI: $162 to $1636). CONCLUSIONS: Systematic implementation of ERAS gynecologic oncology guidelines across a healthcare system improves patient outcomes and saves resources.

Cost impact analysis of Enhanced Recovery After Surgery program implementation in Alberta colon cancer patients.

BACKGROUND: The Enhanced Recovery After Surgery (eras) colorectal guideline has been implemented widely across Alberta. Our study examined the clinical and cost impacts of eras on colon cancer patients across the province. METHODS: We first used both summary statistics and multivariate regression methods to compare, before and after guideline implementation, clinical outcomes (length of stay, complications, readmissions) in consecutive elective colorectal patients 18 or more years of age and in colon cancer and non-cancer patients treated at the Peter Lougheed Centre and the Grey Nuns Hospital between February 2013 and December 2014. We then used the differences in clinical outcomes for colon cancer patients, together with the average cost per hospital day, to estimate cost impacts. RESULTS: The analysis considered 790 patients (398 cancer and 392 non-cancer patients). Mean guideline compliance increased to 60% in cancer patients and 57% in non-cancer patients after eras implementation from 37% overall before eras implementation. From pre- to post-eras, mean length of stay declined to 8.4 ± 5 days from 9.5 ± 7 days in cancer patients, and to 6.4 ± 4 days from 8.8 ± 5.5 days in non-cancer patients (p = 0.0012 and p = 0.0041 respectively). Complications declined significantly in the renal, hepatic, pancreatic, and gastrointestinal groups (difference in proportions: 13% in cancer patients; p < 0.05). No significant change in the risk of readmission was observed. The net cost savings attributable to eras implementation ranged from $1,096 to $2,771 per cancer patient and from $3,388 to $7,103 per non-cancer patient. CONCLUSIONS: Implementation of eras not only resulted in clinical outcome improvements, but also had a significant beneficial impact on scarce health system resources. The effect for cancer patients was different from that for non-cancer patients, representing an opportunity for further refinement and study.

Drinking alcohol during pregnancy: evidence from Canadian Community Health Survey 2007/2008.

BACKGROUND: Drinking alcohol during pregnancy may cause many health problems for the child, one of which is fetal alcohol spectrum disorder (FASD). Since FASD is incurable, actions meant to prevent the occurrence of the disability by targeting drinking women become more important. Epidemiological data on drinking among pregnant women, including prevalence and determinants/risk factors, is essential for designing and evaluating prevention programs. OBJECTIVES: To estimate the prevalence of drinking alcohol during pregnancy and examine the determinants of this behaviour. METHODS: Using the 2007/8 Canadian Community Health Survey (CCHS) data, we estimated the weighted prevalence of women who drank alcohol during their last pregnancy by provinces. We used a weighted logistic regression to examine associations between drinking patterns, substance abuse behaviours, health-related and socio-demographic characteristics of the women, and the outcome variable. RESULTS: There were two main findings of this study. One was that the 2007/8 prevalence of drinking alcohol during pregnancy in ON, BC, and Canada was estimated at 5.4%, 7.2%, and 5.8%, respectively. The other was that the use of general practitioners (GP) or family physicians (FP) associated with a decreased risk of drinking alcohol during pregnancy. DISCUSSION: The results suggest that interventions that involve GP or FP and that increase the use of GP or FP by pregnant women can be effective in reducing drinking alcohol during pregnancy.

Costs of fetal alcohol spectrum disorder in Alberta, Canada.

BACKGROUND: Although many programs targeting fetal alcohol spectrum disorder (FASD) are implemented, the province of Alberta is still lacking information on costs of FASD. OBJECTIVES: To estimate the costs of FASD in Alberta based on available US and Canadian research on costs of FASD, and Alberta data. METHODS: Two types of costs were estimated. The annual long-term economic cost of FASD, which referred to a projected amount of money incurred by lives of the cohort of children born with FASD each year, was estimated by multiplying the lifetime cost of caring for each child born with FASD with the number of children born with FASD each year. The annual short-term economic cost of FASD, which referred to the amount of money incurred by people who are presently living with FASD, was estimated by using a FASD cost calculator online at http://www.online-clinic.com. Both were societal costs adjusted to 2008 Canadian dollars. RESULTS: The annual long-term economic cost from the disorders rose from $130 to $400 million each year for the Alberta economy. The annual short-term economic cost for FASD in Alberta was from $48 to $143 million, and the daily cost for FASD in Alberta was from $105 to $316 thousand. CONCLUSION: These numbers suggest a need for a provincial FASD prevention strategy. The costs of FASD can be used to evaluate the benefits of prevention programs to society.