Active and passive compliance in an enhanced recovery programme.
BACKGROUND
Enhanced recovery after surgery (ERAS) is a well-established and accepted practice following colorectal surgery and has been demonstrated to reduce hospital length of stay (LOS) and 30-day morbidity. Despite evidence to support the individual elements on which the programme is based, there remains uncertainty as to how many and which of these are required to realise its benefits. Furthermore, elements of an ERAS programme might either precipitate or reflect recovery, in which case compliance could have a role in the improvement or prediction of outcome.


METHODS
A multidimensional prospective database of 799 consecutive patients undergoing colorectal surgery within an established ERAS programme at a single institution was interrogated. After application of exclusion criteria, 614 patients were studied. The novel concept of 'active compliance' is introduced. An ERAS element is classified as 'active' if the participation of the patient is required to achieve its compliance. This contrasts with 'passive' compliance, where an intervention is delivered to the patient without their direct contribution. The short-term surgical outcomes of this cohort are reported with reference to ERAS protocol compliance.


RESULTS
Compliance with the passive elements of the programme was higher than with the active elements. Univariate and multivariate analyses demonstrate that poor compliance with active but not passive elements of the programme was significantly associated with major morbidity. Receiver operator characteristic curve analysis demonstrated active compliance to be a stronger predictor of both major morbidity (AUC 0.71 vs. AUC 0.56) and length of stay (AUC 0.83 vs. 0.57) when compared with passive compliance.


CONCLUSIONS
The results suggest that poor active compliance may be a surrogate marker of morbidity which can be recognised in the early post-operative period. This implies the potential for timely diagnosis and intervention. This aspect of ERAS compliance is clinically relevant yet has achieved scant attention. Independent validation of our observations is required.
St. Mark's Hospital, Watford Road, Harrow, London, HA1 3UJ, UK.
Christopher C
CC
Thorn
St. Mark's Hospital, Watford Road, Harrow, London, HA1 3UJ, UK.
Ian
I
White
St. Mark's Hospital, Watford Road, Harrow, London, HA1 3UJ, UK.
Jennie
J
Burch
St. Mark's Hospital, Watford Road, Harrow, London, HA1 3UJ, UK.
George
G
Malietzis
St. Mark's Hospital, Watford Road, Harrow, London, HA1 3UJ, UK.
Robin
R
Kennedy
St. Mark's Hospital, Watford Road, Harrow, London, HA1 3UJ, UK. i.jenkins@nhs.net.
John T
JT
Jenkins
D000368:Aged; D015331:Cohort Studies; D005260:Female; D006801:Humans; D007902:Length of Stay; D008297:Male; D008875:Middle Aged; D015999:Multivariate Analysis; D010349:Patient Compliance; D011183:Postoperative Complications / Q000209:etiology; D012372:ROC Curve; D020127:Recovery of Function; D016896:Treatment Outcome
Enhanced recovery after surgery; Length of stay; Surgical morbidity