Enhanced Recovery Program Adherence: Which Components are Associated with Cost Saving?

Enhanced Recovery Programs (ERPs) are standardized, evidence-based surgical care pathways consisting of pre-, intra-, and postoperative components. Although high adherence to these components improves surgical outcomes and reduces costs, which components contribute most to cost remains unclear. Therefore, we aimed to identify which ERP components are associated with cost saving to better guide implementation strategies.

A single-center retrospective cohort study was conducted among patients who received ERP for colorectal operations from 2021 to 2023. Data were obtained from our institution's ERP, financial, and medical records. A 1:1 propensity-matched analysis was conducted on patients with high (≥70%) vs low (<70%) adherence to 16 ERP components based on age, sex, race, insurance status, procedure type, and operative approach. The statistical tests performed were the Kruskal-Wallis and chi-square tests.

Of 334 patients evaluated, 41.3% were older than 65 years, 54.2% were women, 47.3% had Medicare, 37.7% had extended colectomy, and 48.5% had robotic operation. Patients in the high-adherence group had lower total costs ($17,576 vs $22,343, p < 0.001). Associations to cost saving were identified in adherence to preoperative clear-liquid diet (-$1,727), no nasogastric tube (-$16,036), early mobilization (-$3,476), early diet (-$1,572), maintenance intravenous fluid (-$4,460) discontinuation, and early Foley removal (-$4,274; all p < 0.05). When stratified by 70% overall adherence, adherence to no nasogastric tube, early mobilization, and maintenance intravenous fluid discontinuation consistently lowered costs in both groups (p < 0.05).

Adherence to ERP components is associated with cost saving. Future targeted interventions to reach 70% adherence and maximize adherence to crucial components are essential to reduce costs.