Racial and Socioeconomic Differences Manifest in Process Measure Adherence for Enhanced Recovery After Surgery Pathway

Abstract

BACKGROUND Adherences to care processes and surgical outcomes vary by population subgroups for the same procedure. Enhanced Recovery After Surgery pathways are intended to standardize care but their effect on process adherence and outcomes for population subgroups is unknown. OBJECTIVE To demonstrate the association between recovery pathway implementation, process measures, and short-term surgical outcomes by population subgroup. DESIGN Pre- and post-quality improvement implementation cohort study. SETTING Tertiary academic medical center. INTERVENTION Implementation of a modified colorectal Enhanced Recovery After Surgery pathway. PATIENTS Elective colon and rectal resections prior to (2013) and following (2014–2016) recovery pathway implementation. MAIN OUTCOME MEASURE 30-day outcomes by race and socioeconomic status were analyzed using a difference-in-differences approach with correlation to process adherence. RESULTS We identified 639 cases (199 pre, 440 post). 75.2% were white and 91.7% were high socioeconomic status. Groups were similar in terms of other preoperative characteristics. Following pathway implementation, median lengths of stay improved in all subgroups (−1.0 days overall, p=<0.001), but with no statistical difference by race or socioeconomic status (p=0.89 and p=0.29, respectively). Complication rates in both racial and socioeconomic groups were no different (26.4% vs. 28.8%, p=0.73; 27.3% vs. 25.0%, p=0.86, respectively) and remained unchanged with implementation (p=0.93, p=0.84). By race, overall adherence was 31.7% in white patients and 26.5% in non-white patients (p=0.32). While stratification by socioeconomic status demonstrated decreased overall adherence in the low status group (31.8% vs 17.1%, p=0.05), white patients were more likely to have regional pain therapy (57.1% vs 44.1%. p=0.02) with a similar trend seen with socioeconomic status. LIMITATIONS Data collected primarily for quality improvement purposes. CONCLUSIONS Differences in outcomes by race and socioeconomic status did not arise following implementation of a enhanced recovery pathway. Differences in process measures by population subgroups highlight differences in care that requiring further investigation. See Video Abstract at http://links.lww.com/DCR/AXXX.

The Impact of Socioeconomic Deprivation on Clinical Outcomes for Pancreatic Adenocarcinoma at a High-volume Cancer Center

“…43 Although promising, clinical pathway implementation alone is unlikely to serve as a widely-applicable panacea and more research is needed to identify interventions and policy measures to reduce socioeconomic disparities. [43][44][45] Finally, compared to national data and Florida demographics, our cohort was significantly more homogenous in terms of race/ ethnicity and insurance status, which may contribute to the results observed. Our cohort consisted of 4.5% African-Americans and 4.5% had Medicaid or were uninsured compared to national rates of 9.3% for African Americans and 8.0% for Medicaid/uninsured patients undergoing surgery, respectively.…”

Enhanced Recovery After Surgery Protocols May Help Reduce Racial and Socioeconomic Disparities in Cardiac Surgery

“…11 A growing body of literature supports the role of ERAS protocols and similar decision support tools in reducing racial and socioeconomic care inequality. [12][13][14] ERAS implementation has been associated with decreased LOS for black and white colorectal surgery patients and with an elimination of the pre-ERAS LOS disparity across racial groups. 15 Possible mechanisms by which ERAS programs improve outcomes for disadvantaged patient populations include increased patient education and compliance with preoperative recommendations; systematic implementation of best practices in the preoperative, intraoperative, and postoperative settings; decreased opportunities for providers to exercise implicit or explicit bias; and increased adherence to evidence-based care practices across institutions.…”

“…ERAS protocols typically do not address financial and geographic barriers to high-quality surgical care nor do they facilitate adequate primary care and general health maintenance in underserved populations. 16 Troublingly, providers also may be less likely to adhere to ERAS protocols when caring for nonwhite and less-affluent patient groups, 12 and less-advantaged patient groups also may be less compliant with preoperative ERAS protocols. 12,15 Nonetheless, the broad improvements in clinical outcomes associated with ERAS implementation across surgical specialties 2,4,17 suggest that ERAS can be effective in achieving better outcomes for diverse patient populations.…”

Patients undergoing colorectal surgery at a Veterans Affairs Hospital do not experience racial disparity in length of stay either before or after implementing an enhanced recovery pathway

“…For example, ERP implementation has consistently been shown to reduce post-operative complication rates without increasing cost or readmission rates [ 6 , 10 – 13 ]. A growing body of literature supports the role of ERP in reducing racial inequality in surgical care [ 14 , 15 ]. Notably, ERP implementation was recently shown to reduce racial disparities in post-operative length of stay at a large academic medical center [ 16 , 17 ].…”