Return on investment of the Enhanced Recovery After Surgery (ERAS) multiguideline, multisite implementation in Alberta, Canada

Background: Enhanced Recovery After Surgery (ERAS) is a global surgical quality-improvement initiative. Little is known about the economic effects of implementing multiple ERAS guidelines in both the short and long term. Methods: We performed a return on investment (ROI) analysis of the implementation of multiple ERAS guidelines (for colorectal, pancreas, cystectomy, liver and gynecologic oncology procedures) across multiple sites (9 hospitals) in Alberta using 30-, 180- and 365-day time horizons. The effects of ERAS on health services utilization (length of stay of the primary admission, number of readmissions, length of stay of the readmissions, number of emergency department visits, number of outpatient clinic visits, number of specialist visits and number of general practitioner visits) were assessed by mixed-effect multilevel multivariate negative binomial regressions. Net benefits and ROI were estimated by a decision analytic modelling analysis. All costs were reported in 2019 Canadian dollars. Results: The net health system savings per patient ranged from $26.35 to $3606.44 and ROI ranged from 1.05 to 7.31, meaning that every dollar invested in ERAS bro-brought $1.05 to $7.31 in return. Probabilities for ERAS to be cost-saving were from 86.5% to 99.9%. The effects of ERAS were found to be larger in the longer time horizons, indicating that if only the 30-day time horizon had been used, the benefits of ERAS would have been underestimated. Conclusion: These results demonstrated that ERAS multiguideline implementation was cost-saving in Alberta. To produce a better ROI, it is important to consider a broad range of health service utilizations, long-term impact, economies of scale, productive efficiency and allocative efficiency for sustainability, scale and spread of ERAS implementations. Contexte : L'initiative de recuperation amelioree apres la chirurgie (RAAC) est un projet international d'amelioration de la qualite en chirurgie. On en sait peu sur les retombees economiques, tant a court qu'a long terme, de la mise en [alpha]euvre de multiples lignes directrices de RAAC. Methodes : Nous avons realise une analyse du rendement sur l'investissement (RSI) visant la mise en oeuvre de multiples lignes directrices de RAAC (pour les operations colorectales, pancreatiques, hepatiques ou d'oncologie gynecologique et la cystectomie) dans 9 hopitaux albertains sur un horizon temporel de 30, 180 et 365 jours. L'incidence de la RAAC sur l'utilisation des services de sante (duree du sejour a l'hospitalisation initiale, nombre de readmissions, duree du sejour a la rehospitalisation et nombre de visites a l'urgence, en consultation externe, chez un specialiste et chez un omnipraticien) a ete evaluee a l'aide d'un modele multiniveau de regressions binomiales negatives a effets mixtes multivaries. Les benefices nets et le RSI ont ete estimes a l'aide d'un processus de modelisation analytique decisionnelle. Tous les couts ont ete rapportes en dollars canadiens de 2019. Resultats : Les economies nettes du systeme de sante allaient de 26,35 $ a 3606,44 $ par patient, et le RSI variait de 1,05 a 7,31; chaque dollar investi dans l'initiative de RAAC a donc genere un retour sur l'investissement de 1,05 $ a 7,31 $. Les probabilites d'economie grace au RAAC allaient de 86,5 % a 99,9 %. Les retombees generees augmentaient avec un horizon temporel a plus long terme, ce qui suggere que l'utilisation unique d'un horizon temporel de 30 jours aurait mene a une sous-estimation des benefices. Conclusion : Les resultats montrent que la mise en oeuvre de multiples lignes directrices de RAAC a permis des economies en Alberta. En vue d'obtenir un RSI optimal, il est important de tenir compte d'une grande variete d'utilisations des services de sante, des retombees a long terme, des economies d'echelle, de l'efficacite productive et de l'efficience des allocations pour la perennite, la mise a l'echelle et la diffusion des projets de mise en oeuvre de RAAC.
Enhanced Recovery After Surgery (ERAS) is a multi-modal, multidisciplinary approach to providing best practice perioperative care before, during and after surgery. (1) Drawing from best practices and evidence from around [...]