Vertical Compliance: A novel method of reporting patient specific ERAS compliance for real-time risk assessment

ERAS protocol compliance is traditionally measured and reported as 'items compliance' which is retrospective longitudinal adherence of all patients to an index element. Reporting in this manner is restrictive and cannot impact care in real-time. In order to modify behavior effectively and instantaneously, we seek to introduce the novel concept of "vertical compliance".

Vertical compliance is defined as assessment of an individual's compliance along his/her own surgical pathway as ERAS index items are encountered. Prospectively entered data from the ERAS Interactive Audit System (EIAS) database was queried for all patients who underwent pancreatic or hepatic resections. Individual linear regression models were generated using compliance data from 46 ERAS index items against LOS. Significant items with p value < 0.05 were compiled into multivariable linear regression models; each with a unique coefficient that could be used to predict effect on LOS as well as control for the effect of the other items in the model.

Compliance data from 483 patients who underwent pancreatic resections and 292 patients who underwent hepatic resections was compiled. Seven ERAS items for pancreatic resections and six ERAS items for hepatic resections were found to significantly impact LOS. Regression models were created for each of the items in an additive fashion. Calculations to determine predicted LOS as a patient progressed through a pathway was able to be determined.

Vertical compliance is a novel metric, described in this study, that can provide significant and accurate patient-specific risk prediction to impact care in real-time. This can allow for creation of a variable echelon such that pathway items can be ranked by importance on clinical outcome effect and patient progress can be monitored and altered.