A Systematic Review of Enhanced Recovery After Surgery Pathways: How Are We Measuring ‘Recovery?’

Amy Neville, MD, Lawrence Lee, MD, Nancy E Mayo, PhD, Melina C Vassiliou, MD, Gerald M Fried, MD, Liane S Feldman, MD

Steinberg-Bernstein Centre for Minimally Invasive Surgery, McGill University Health Centre, Montreal QC

Introduction: Enhanced recovery after surgery (ERAS) pathways aim to improve patient “recovery.” However, there is no accepted definition of recovery and a lack of tools to measure this complex process during which patients regain preoperative function and activity. The goals of this review were to identify how recovery is measured in studies of ERAS pathways and provide recommendations for the design of future studies.

Methods: A systematic search of Medline, Embase and Cochrane databases was conducted. Eligible studies must have described an ERAS pathway conforming to established consensus guidelines. Prospective studies of ERAS pathways for abdominal surgery published between 2000-2011 were considered. Two independent reviewers evaluated 981 citations for eligibility and extracted data from the eligible studies. All outcomes were recorded and classified as per the Wilson-Cleary model. This model links clinical variables to quality of life by classifying outcomes on a continuum of increasing complexity beginning with physiologic variables and progressing through symptom status, functional status, general health perceptions and finally overall quality of life. The phase of recovery measured was defined as early (until discharge from recovery room), intermediate (from recovery room discharge until hospital discharge) and late (from discharge until return to baseline).

Results: Fourteen randomized trials and 35 prospective cohort studies were included. The most common “recovery” outcome reported was duration of hospitalization, which was reported in all studies. Other frequently reported outcomes included complications (90%) and hospital readmission (76%). Biologic outcomes were reported in 63% of studies including time to return of gastrointestinal function (49%), changes in pulmonary function (18%), physical strength (10%), changes in body composition (6%) and immunologic measures (12%). Outcomes pertaining to symptoms were reported less commonly (49% of studies) and included: pain (39%), fatigue (27%), nausea (21%), analgesia use (12%) and sleep disturbance (6%). Functional outcomes, including mobilization (31%), ability to perform activities of daily living (6%) and return to work (8%) were uncommonly reported (41% of studies). Quality of life was reported in only 12% of studies. Baseline assessment of reported outcomes were reported in 39%. All studies reported in-hospital outcomes (intermediate phase of recovery) while only 37% reported post discharge (late) outcomes other than complications or readmission.

Conclusion: The most commonly reported outcome of ERAS pathways was duration of hospitalization. Patient-centered outcomes like functional status and quality of life, which reflect important dimensions of recovery, were rarely reported. Future studies of ERAS pathways should include more patient-centered outcomes to better estimate recovery, particularly those occurring after discharge from hospital.

Session: Poster Presentation

Program Number: P613

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