Auckland ERAS Program Cost Analysis Tarik Sammour © 2007 Microsoft Corporation. All rights reserved. Microsoft, Windows, Windows Vista and other product names are or may be registered trademarks and/or trademarks in the U.S. and/or other countries. The information herein is for informational purposes only and represents the current view of Microsoft Corporation as of the date of this presentation. Because Microsoft must respond to changing market conditions, it should not be interpreted to be a commitment on the part of Microsoft, and Microsoft cannot guarantee the accuracy of any information provided after the date of this presentation. MICROSOFT MAKES NO WARRANTIES, EXPRESS, IMPLIED OR STATUTORY, AS TO THE INFORMATION IN THIS PRESENTATION.

Background In 2005 an ERAS program was implemented at our centre. Approx 150 patients have gone through this program so far.

Pre-admit Information sheet given Milestones set Ward visit / orientation Social issues identified Pre-op Carbohydrate loading Admit day of surgery No bowel prep No sedation Intra-op Mid-thoracic epidural IV Dexamethasone IV fluid restriction No NG tubes / drains Day of surgery Day 1 Urinary catheter removed Active walking (physio) Full oral diet Protein supplement drinks Day 2 Epidural removed Regular tenoxicam Opiates avoided Cont. mobilisation / feeding Day 3 Discharge Discharge if: eating, passing flatus, off IV therapy, mobilising independently, adequate home support. Follow-up Mobilise to chair Oral fluids started Regular anti-emetics Heparin (LMWH subcut) Nurse contact by phone Emergency action plan Follow-up clinic in 1 week

Auckland ERAS Audit (Zargar et al, Dis Colon Rect 2008)

Auckland ERAS Audit (Zargar et al, J Surg Res 2009)

Is ERAS a cost-effective intervention? Research question: Is ERAS a cost-effective intervention? Substantial costs incurred in setting up ERAS Ongoing maintenance costs Minimal literature on cost-effectiveness

Methods Case-control design Groups matched for: ERAS group: Dec 2005 - Mar 2007 Control group: Sep 2004 - Sep 2005 (before start of ERAS) Groups matched for: Sex, BMI, ASA, Cr-POSSUM, Operation Differential cost analysis (in USD) Exclude stomas, ASA >= 4, cognitive impairment

Baseline ERAS Group (n = 50) Control Group P Value Age (mean, range) 65.6 (39 – 92) 70.7 (40 – 85) 0.021* Male Female 26 24 28 22 0.688 ASA score I II III 8 29 13 31 11 1.000 0.683 0.640 BMI 28.6 27.4 0.588 CR-POSSUM Physiologic Operative 10.3 9.2 9.7 8.3 0.524 0.061 Operation R sided L sided Total colectomy 23 1 21 0.546 0.585 Diagnosis Diverticulosis IBD Adenoma Ca Dukes A Ca Dukes B Ca Dukes C Ca Dukes D 2 4 6 15 19 3 5 9 0.674 0.749 0.096 0.124 Baseline

Implementation Cost Total $ 102251 Cost of 1 Unit Units Cost International centre visit (Airfare + Accommodation) 3520.46 3 10561.39 Research Fellow salary (15 months) 84143.75 1 Patient booklet 4.20 50 210.00 Supplement drinks Pre-op carbohydrate Post-op protein 1.50 1.42 300 722.5 450.00 1025.95 Tenoxicam 0.2375 71.25 Outpatient clinic at 1 week 115.77 5788.50 Total $ 102251 Implementation Cost

Post-operative Cost Cost of 1 Unit Units used Cost ERAS Control Fluids In theatre Post-operative Epidural Apparatus Bupivacaine Complications Leak / collection Ileus Wound Urinary infection Urinary retention Cardiopulmonary Ward stay Index admission Re-admission Post-operative Cost

Differential Cost Analysis ERAS Control Post-op $480,263 Implement $70,117 $786,181 Differential Cost Analysis Overall ERAS savings = $235,801 = $4,716 per patient

Conclusion ERAS is a cost-effective intervention in elective colonic surgery. Implementation costs are offset by reduced post-op resource utilisation.

“With healthcare reform driven primarily by cost issues, there is a need to assure the public and the payers that ambulatory surgery is safe, effective, and ultimately… economical.” Greenburg AG et al. Am J Surg 1996; 172: 21-3. Festschrift to LM Nyhus written by Greenburg et al in 1996. Dr Lloyd M Nyhus, MD 1923 - 2008