1. Auckland ERAS Program Cost Analysis
Tarik Sammour
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2. Background In 2005 an ERAS program was implemented at our centre.
Approx 150 patients have gone through this program so far.

3. 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

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

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

6. 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

7. Methods Case-control design Groups matched for:
ERAS group: Dec Mar 2007
Control group: Sep 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

8. 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

9. Implementation Cost Total $ 102251 Cost of 1 Unit Units Cost
International centre visit
(Airfare + Accommodation) 3
Research Fellow salary
(15 months) 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
Tenoxicam
0.2375
71.25
Outpatient clinic at 1 week
115.77
Total $
Implementation Cost

10. 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

11. 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

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

13. “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