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Enhanced recovery program is an improved, cost-effective approach for breast reconstruction patients

Cost of perioperative care process for microvascular breast reconstruction measured for first time using time-driven activity-based costing

CHICAGO (April 22, 2020): The use of an enhanced recovery after surgery (ERAS) approach for microvascular breast reconstruction is less expensive and more effective than standard care, despite the increased medication and personnel costs associated with an ERAS approach, according to an article published in the May issue of the Journal of the American College of Surgeons.

“In plastic surgery, ERAS protocols have been found to be clinically effective, helping to control pain better and more effectively than standard-of-care, but there has been little rigorous analysis on whether or not these benefits outweigh the costs associated with the ERAS infrastructure,” said lead study author Alexander F. Mericli, MD, FACS, an assistant professor of plastic surgery at The University of Texas MD Anderson Cancer Center, Houston.

In an effort to minimize complications and speed the recovery process, ERAS programs use evidence-based standards of care—including minimal preoperative fasting, early mobilization and eating after operations, and fewer narcotic analgesics during and after the operation.

“There’s a lot of perioperative counseling with ERAS programs that is not involved in standard-of-care and on top of that, there are additional medications and regional anesthetics used, and all of these require additional personnel, skill, and time. With this study, we wanted to see if the ends justify the means,” Dr. Mericli said.

The investigators reviewed current evidence, pooling data from five studies to compare the cost effectiveness of using an enhanced recovery program—before, during, and after an operation—with the standard-of-care for microvascular breast reconstruction. Standard-of-care, in this study, consisted of the use of narcotic painkillers, restricted early mobilization, and no regional anesthetics.

In total, the analysis involved 986 microvascular breast reconstruction patients: 390 in the ERAS group and 596 in the standard-of-care group. Researchers created a decision-tree model that detailed each step of the care process for microvascular breast reconstruction patients.

An innovative method, called time-driven activity-based costing, was used to estimate the additional costs attributed to the enhanced recovery program. This method provides a more realistic accounting of the costs associated with each activity in a patient encounter.

“We wanted to leverage a micro-costing approach for the care continuum nature of ERAS, but also granular enough to identify the supply and personnel costs unique to ERAS,” said study coauthor Anaeze C. Offodile II, MD, MPH, an assistant professor of plastic surgery and executive director of clinical transformation at MD Anderson. “This approach allowed us to determine the cost structure for each phase of care (preoperative, intraoperative and postoperative) in the ERAS process.”

The pooled data analysis showed that ERAS programs were associated with a $735 savings per patient and one additional day of quality-adjusted life. Patients also experienced fewer infections and flap complications in the ERAS programs.

The primary driver of cost savings was a reduced length of stay, which can be attributed to opioid-sparing pain control, early mobilization, and intensive preoperative counseling.  The average length of stay was 1.5 days less in the ERAS patients.

Using an incremental cost-utility analysis, which is a way to model hypothetical patient cohorts, the results showed that ERAS was the more cost-effective option across a range of treatment items and services. ERAS became cost-ineffective at an amount greater than $19,336.

For standard-of-care to become cost-effective, the study suggests that length of stay in this group would have to be decreased by about 2.5 days.

“In most health care situations, the implementation of new techniques or new technology means greater expense. However, we can justify that higher cost because the new approach is more clinically effective. In this case, not only is ERAS more effective, it’s also less costly,” Dr. Mericli said.

In light of the current opioid addiction crisis, the researchers believe this research also highlights a way to help address the problem because enhanced recovery programs minimize the use of narcotics during the operation and through recovery after discharge.

“Although ERAS is gaining more and more acceptance across the country, our study results make a compelling argument for even more widespread implementation,” Dr. Offodile said. “And given the larger social context of the opioid crisis, health care teams can implement enhanced recovery protocols as an opioid stewardship initiative.”

Study coauthors are Thomas McHugh, MD; Brittany Kruse, MPH; Sarah M. DeSnyder, MD,
FACS; and Elizabeth Rebello, MD, all with The University of Texas MD Anderson Cancer Center, Houston.

“FACS” designates that a surgeon is a Fellow of the American College of Surgeons

The authors have no relevant financial disclosures.

Citation: Mericli AF, McHugh T, Kruse B, et al. Time-Driven Activity-Based Costing to Model Cost Utility of Enhanced Recovery after Surgery Pathways in Microvascular Breast Reconstruction. J Am Coll Surg. 2020; 230(5): 784 94.e3. 
DOI: https://doi.org/10.1016/j.jamcollsurg.2020.01.035.

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About the American College of Surgeons
The American College of Surgeons is a scientific and educational organization of surgeons that was founded in 1913 to raise the standards of surgical practice and improve the quality of care for surgical patients. The College is dedicated to the ethical and competent practice of surgery. Its achievements have significantly influenced the course of scientific surgery in America and have established it as an important advocate for all surgical patients. The College has more than 82,000 members and is the largest organization of surgeons in the world. For more information, visit www.facs.org.