Impact of Surgeon Volume on Implementation of Enhanced Recovery After Surgery

Objectives: Enhanced Recovery After Surgery (ERAS) protocols are comprised of operative care components intended to improve surgical outcomes and patient experience. The aim of this study is to examine impact of surgeon volume on rate of ERAS protocol implementation and quality metrics in patients undergoing hysterectomy.

Methods: This study included a retrospective cohort of surgeons who performed scheduled hysterectomies at four teaching hospitals over 24 months (April 2020 – May 2022). Surgeons were analyzed by surgical volume during the study period – low volume surgeons performed 5-12 hysterectomies ( < 25^th percentile), moderate volume surgeons performed 13-40 hysterectomies (25-75^th percentile), and high-volume surgeons performed >40 hysterectomies ( >75^th percentile). The primary outcome was surgeon rate of implementation of a preoperative ERAS order set in the electronic medical record. Secondary outcomes included implementation of preoperative multimodal pain control order set, implementation of postoperative ERAS order set, and hospital length of stay in days. Analyses were conducted using SAS 9.4.

Results: Ninety-seven surgeons (low n=24, moderate n=46, high n=27) performed 3,940 hysterectomies. Cases per surgeon ranged from 5-326. Low-volume surgeons implemented the preoperative ERAS order set less often compared to moderate-volume (P=.043) and high-volume surgeons (P=.016) (Figure 1). Low- and moderate-volume surgeons implemented the preoperative multimodal pain control plan less often than high-volume surgeons (P=.027, P=.014). Low-volume surgeons were significantly less likely to implement a postoperative ERAS order set compared to moderate-volume surgeons (P=.013), and were also less likely to implement the postoperative order set compared with high-volume surgeons, although this did not reach statistical significance (Figure 1). Hospital length of stay also varied significantly by surgeon volume, with moderate volume surgeons having the longest length of stay (low 1.15±0.74, moderate 1.71±0.76, high 1.24±0.49, P = .004).

Conclusions: At the time of scheduled hysterectomy, low-volume surgeons are less likely than surgeons with moderate or high volumes to implement ERAS or multimodal pain control protocols. These protocols contain evidence-based measures to improve surgical outcomes, and healthcare quality may be improved by focused efforts to increase implementation among the lowest volume surgeons. Beneficial effects on ERAS protocol to reduce length of hospital stay may be blunted in high volume surgeons who are more likely to be subspecialists with medically complex patients.