title: Implementation of Enhanced Recovery After Surgery (ERAS) Across a Provincial Healthcare System: The ERAS Alberta Colorectal Surgery Experience.
abstract: BACKGROUND
  Enhanced recovery after surgery (ERAS) colorectal guideline implementation has occurred primarily in standalone institutions worldwide. We implemented the guideline in a single provincial healthcare system, and our study examined the effect of the guideline on patient outcomes [length of stay (LOS), complications, and 30-day post-discharge readmissions] across a healthcare system.
  
  
  METHODS
  We compared pre- and post-guideline implementation in consecutive elective colorectal patients, ≥ 18 years, from six Alberta hospitals between February 2013 and December 2014. Participants were followed up to 30 days post discharge. We used summary statistics, to assess the LOS and complications, and multivariate regression methods to assess readmissions and to estimate cost impacts.
  
  
  RESULTS
  A total of 1333 patients (350 pre- and 983 post-ERAS) were analysed. Of this number, 55 % were males. Median overall guideline compliance was 39 % in pre- and 60 % in post-ERAS patients. Median LOS was 6 days for pre-ERAS compared to 4.5 days in post-ERAS patients with the longest implementation (p value <0.0001). Adjusted risk ratio (RR) was 1.71, 95 % CI 1.09-2.68 for 30-day readmission, comparing pre- to post-ERAS patients. The proportion of patients who developed at least one complication was significantly reduced, from pre- to post-ERAS, difference in proportions = 11.7 %, 95 % CI 2.5-21.0, p value: 0.0139. The net cost savings attributable to guideline implementation ranged between $2806 and $5898 USD per patient.
  
  
  CONCLUSIONS
  The findings in our study have shown that ERAS colorectal guideline implementation within a healthcare system resulted in patient outcome improvements, similar to those obtained in smaller standalone implementations. There was a significant beneficial impact of ERAS on scarce health system resources.
authors.affiliation: Department of Oncology, University of Calgary, Calgary, Canada. gregg.nelson@albertahealthservices.ca.|Tom Baker Cancer Centre, 1331 29 St NW, Calgary, AB, T2N 4N2, Canada. gregg.nelson@albertahealthservices.ca.
authors.forename: Gregg
authors.initials: G
authors.lastname: Nelson
authors.affiliation: Alberta Health Services, Alberta, Canada.
authors.forename: Lawrence N
authors.initials: LN
authors.lastname: Kiyang
authors.affiliation: Alberta Health Services, Alberta, Canada.
authors.forename: Ellen T
authors.initials: ET
authors.lastname: Crumley
authors.affiliation: Institute of Health Economics, Edmonton, AB, Canada.
authors.forename: Anderson
authors.initials: A
authors.lastname: Chuck
authors.affiliation: Institute of Health Economics, Edmonton, AB, Canada.
authors.forename: Thanh
authors.initials: T
authors.lastname: Nguyen
authors.affiliation: Alberta Health Services, Alberta, Canada.
authors.forename: Peter
authors.initials: P
authors.lastname: Faris
authors.affiliation: Alberta Health Services, Alberta, Canada.
authors.forename: Tracy
authors.initials: T
authors.lastname: Wasylak
authors.affiliation: Alberta Health Services, Alberta, Canada.
authors.forename: Carlota
authors.initials: C
authors.lastname: Basualdo-Hammond
authors.affiliation: Alberta Health Services, Alberta, Canada.
authors.forename: Susan
authors.initials: S
authors.lastname: McKay
authors.affiliation: Department of Surgery, Faculty of Medicine and Health, School of Health and Medical Sciences, Örebro University, Örebro, Sweden.
authors.forename: Olle
authors.initials: O
authors.lastname: Ljungqvist
authors.affiliation: Department of Medicine, University of Alberta, Edmonton, Canada.
authors.forename: Leah M
authors.initials: LM
authors.lastname: Gramlich
mesh_terms: D000368:Aged; D000416:Alberta; D002985:Clinical Protocols; D003106:Colon / Q000601:surgery*; D005260:Female; D019983:Guideline Adherence / Q000191:economics / Q000706:statistics & numerical data; D006801:Humans; D007902:Length of Stay / Q000706:statistics & numerical data; D008297:Male; D008875:Middle Aged; D010359:Patient Readmission / Q000706:statistics & numerical data; D019990:Perioperative Care / Q000592:standards*; D011183:Postoperative Complications; D012007:Rectum / Q000601:surgery*