Recovery begins upstream: Postoperative compliance reflects the cumulative effect of the enhanced recovery after...

Enhanced recovery after surgery pathways rely on compliance to optimize recovery; however, postoperative compliance remains variable and is typically measured as a process metric rather than an outcome. Vertical compliance is a patient-level, time-ordered framework that examines compliance across sequential enhanced recovery after surgery pathway elements. We evaluated whether upstream enhanced recovery after surgery elements were associated with downstream postoperative compliance among patients undergoing liver resection.

Prospectively collected data from 2 US Enhanced Recovery After Surgery Centers of Excellence were analyzed. Analyses were restricted to a fixed complete-case cohort of liver resection patients from 2015 to 2021. Preoperative and intraoperative enhanced recovery after surgery elements were screened using univariate linear regression at P < .25 and entered into sequential hierarchical multivariable models, where postoperative compliance was the outcome. Conditional predictions were generated and visualized.

Of 628 liver resections, 590 (93.9%) were analyzed. Four upstream enhanced recovery after surgery elements were associated with postoperative compliance: avoidance of bowel preparation, preoperative oral carbohydrate loading, thrombosis prophylaxis, and avoidance of resection site drainage. These factors demonstrated additive associations with postoperative compliance. Predicted postoperative compliance increased from a baseline of 32.4% to progressively higher levels with successful completion of the identified upstream elements.

Vertical compliance provides a novel, interpretable framework for evaluating enhanced recovery after surgery compliance as a temporally ordered process. Upstream enhanced recovery after surgery interventions were associated with downstream postoperative compliance, supporting the concept that postoperative recovery milestones reflect the cumulative performance of the enhanced recovery after surgery pathway. Vertical compliance may facilitate real-time identification of patients at risk for pathway noncompliance and could inform targeted interventions.