Understanding the Impact of Enhanced Recovery Programs on Social Vulnerability, Race, and Colorectal Surgery Outcomes

Abstract

BACKGROUND: Increasing social vulnerability measured by the social vulnerability index has been associated with worse surgical outcomes. However, less is known about social vulnerability’s impact on colorectal surgery patients under enhanced recovery programs. OBJECTIVE: We hypothesized that increasing social vulnerability is associated with worse outcomes prior to enhanced recovery implementation, but following implementation, disparities in outcomes would be reduced. DESIGN: Retrospective cohort study using multivariable logistic regression to identify associations of social vulnerability and enhanced recovery with outcomes. SETTINGS: Institutional American College of Surgeons-National Surgical Quality Improvement Program database. PATIENTS: Patients undergoing elective colorectal surgery (2010-2020). Enhanced recovery programs implemented in 2015. Those adhering to ≥70% of enhanced recovery program components defined as enhanced recovery and all others non-enhanced recovery. OUTCOMES: Length of stay, complications, and readmissions. RESULTS: Of 1,523 patients, 589 (38.7%) were in the enhanced recovery group, with 732 (40.3%) patients in the lowest third of social vulnerability index, 498 (27.4%) in the highest third, and no differences in social vulnerability index distribution by enhanced recovery group. On multivariable modeling, social vulnerability was not associated with increased length of stay, complications, or readmissions in either enhanced recovery group. Black race was associated with increased length of stay in both the non-enhanced recovery (OR 1.2, 95% CI, 1.1-1.3) and enhanced recovery groups (OR 1.2, 95% CI, 1.1-1.4). Enhanced recovery adherence was associated with reductions in racial disparities in complications as Black race was associated with increased odds of complications in the non-enhanced recovery (OR 1.9, 95% CI, 1.2-3.0) but not enhanced recovery group (OR 0.8, 95% CI, 0.4-1.6). LIMITATIONS: Details of potential factors affecting enhanced recovery program adherence was not assessed and is the subject of current work by this team. CONCLUSION: High social vulnerability was not associated with worse outcomes among both enhanced recovery and non-enhanced recovery colorectal patients. Enhanced recovery program adherence was associated with reductions in racial disparities in complication rates. However, disparities in length of stay remain and work is needed to understand the underlying mechanisms driving these disparities.