Association Between Use of Enhanced Recovery After Surgery Protocol and Postoperative Complications in Total Hip and Knee Arthroplasty in the Postoperative Outcomes Within Enhanced Recovery After Surgery Protocol in Elective Total Hip and Knee Arthroplasty Study (POWER2)

Abstract

Importance: The Enhanced Recovery After Surgery (ERAS) care protocol has been shown to improve outcomes compared with traditional care in certain types of surgery.

Objective: To assess the association of use of the ERAS protocols with complications in patients undergoing elective total hip arthroplasty (THA) and total knee arthroplasty (TKA).

Design, setting, and participants: This multicenter, prospective cohort study included patients recruited from 131 centers in Spain from October 22 through December 22, 2018. All consecutive adults scheduled for elective THA or TKA were eligible for inclusion. Patients were stratified between those treated in a self-designated ERAS center (ERAS group) and those treated in a non-ERAS center (non-ERAS group). Data were analyzed from June 15 through September 15, 2019.

Exposures: Total hip or knee arthroplasty and perioperative management. Sixteen individual ERAS items were assessed in all included patients, whether they were treated at a center that was part of an established ERAS protocol or not.

Main outcomes and measures: The primary outcome was postoperative complications within 30 days after surgery. Secondary outcomes included length of stay and mortality.

Results: During the 2-month recruitment period, 6146 patients were included (3580 women [58.2%]; median age, 71 [interquartile range (IQR), 63-76] years). Of these, 680 patients (11.1%) presented with postoperative complications. No differences were found in the number of patients with overall postoperative complications between ERAS and non-ERAS groups (163 [10.2%] vs 517 [11.4%]; odds ratio [OR], 0.89; 95% CI, 0.74-1.07; P = .22). Fewer patients in the ERAS group had moderate to severe complications (73 [4.6%] vs 279 [6.1%]; OR, 0.74; 95% CI, 0.56-0.96; P = .02). The median overall adherence rate with the ERAS protocol was 50.0% (IQR, 43.8%-62.5%), with the rate for ERAS facilities being 68.8% (IQR, 56.2%-81.2%) vs 50.0% (IQR, 37.5%-56.2%) at non-ERAS centers (P < .001). Among the patients with the highest and lowest quartiles of adherence to ERAS components, the patients with the highest adherence had fewer overall postoperative complications (144 [10.6%] vs 270 [13.0%]; OR, 0.80; 95% CI, 0.64-0.99; P < .001) and moderate to severe postoperative complications (59 [4.4%] vs 143 [6.9%]; OR, 0.62; 95% CI, 0.45-0.84; P < .001) and shorter median length of hospital stay (4 [IQR, 3-5] vs 5 [IQR, 4-6] days; OR, 0.97; 95% CI, 0.96-0.99; P < .001).

Conclusions and relevance: An increase in adherence to the ERAS program was associated with a decrease in postoperative complications, although only a few ERAS items were individually associated with improved outcomes.

Conflict of interest statement

Conflict of Interest Disclosures: Dr Ripollés-Melchor reported receiving personal fees from Edwards Lifesciences and Fresenius Kabi outside the submitted work. Dr Bisbe reported receiving personal fees from Vifor Pharma outside the submitted work. Dr Abad-Gurumeta reported receiving personal fees from Merck & Co, Ferrer Pharmaceuticals, Braun PharmaCare, Panamericana Editorial, 3M Company, Rovipharm, and Altan Pharma Ltd outside the submitted work. Dr Jiménez-López reported receiving personal fees from Edwards Lifesciences outside the submitted work. Dr Marin-Peña reported receiving personal fees from Johnson & Johnson, 3M Company, and Stryker Corporation outside the submitted work. Dr Cassinello-Ogea reported receiving personal fees from Vifor Pharma outside the submitted work. Dr García-Erce reported receiving personal fees from Alexion Pharmaceuticals, Inc, Amgen, Inc, Braun PharmaCare, Celgene Corporation, Ferrer Pharmaceuticals, GlaxoSmithKline, Inmucor, Jansen Pharmaceutica, Novartis International AG, Octapharma AG, Sanofi, Sandoz, Inc, Terumo Corporation, Vifor Pharma, and Zambon and nonfinancial support from Vifor Pharma outside the submitted work. No other disclosures were reported.

Figures

Figure 1.. STROBE Flow Diagram for Included Patients

Figure 2.. Postoperative Outcomes and Enhanced Recovery After Surgery (ERAS) Adherence

Patients are stratified by complications, type of complication, and other secondary outcomes and by quartile of adherence to the ERAS protocol. Surgical complications included all postoperative complications as defined by protocol according to the standards for definitions and use of outcome measures for clinical effectiveness research in perioperative medicine: European Perioperative Clinical Outcome (EPCO) definitions, the standardized list, definitions, and the stratification developed by the Hip Society, the standarized list and definitions of the Knee Society, and the Standardized Bleeding Definitions for Cardiovascular Clinical Trials. IQR indicates interquartile range; LOS; length of stay; and OR, odds ratio. aUnless otherwise indicated, data are expressed as number (percentage) of patients.

Figure 3.. Bubble Plot of the Rate of Postoperative Complications vs Length of Stay, Number of Participating Patients, and Rate of ERAS Program Adherence

For each hospital, the plot shows the mean percentage of adherence to the Enhanced Recovery After Surgery (ERAS) program (bubble color), the mean length of hospital stay, and percentage of patients who have postoperative complications. The bubble diameter indicates the number of patients that the hospital contributed to the study.