124. Enhanced recovery after surgery protocols in spine surgery: harnessing national data to identify optimal protocols

Abstract

BACKGROUND CONTEXT Enhanced recovery after surgery (ERAS) protocols are increasingly used in spine surgery and various studies have demonstrated benefits. However, protocols consist of separate components which are variably used leading to significant discrepancies in applications. Data is currently lacking on which combinations are the most commonly used and the most effective. PURPOSE To understand what combinations of ERAS components are being implemented for patients undergoing posterior lumbar fusion surgery and which are the most effective in improving outcomes in a general population using national claims data. STUDY DESIGN/SETTING Data were extracted from the Premier Healthcare claims database (2006-2016). We identified 7 ERAS components commonly included in spine ERAS protocols: (1) use of multimodal analgesia, (2) use of tranexamic acid (TXA), (3) use of antiemetics on the day of surgery, (4) early physical therapy -on the day of surgery or the day after-, (5) avoidance of a urinary catheter, (6) avoidance of patient-controlled analgesia (PCA), and (7) avoidance of wound drains. PATIENT SAMPLE This retrospective cohort study included 132,802 posterior lumbar fusion surgeries. OUTCOME MEASURES The main outcomes were length of stay, any complication (cardiopulmonary, renal, and wound complications, stroke, sepsis, thromboembolism, delirium, and inpatient falls), and cost of hospitalization. METHODS Mixed-effects models measured associations between the most common ERAS combinations and outcomes. The most commonly occurring ERAS combinations (those that represent ≥50% or more of cases) were assessed separately for the 2006-2012 and 2013-2016 time periods, given the increasing use of ERAS protocols over time. Odds ratios (OR) and 95% confidence intervals (CI) are reported. RESULTS Overall, 74% (n=97,793) of procedures were in 2006-2012 while 26% (n=35,009) were in 2013-2016. In the 2006-2012 period, the most common ERAS combination was the use of six ERAS components: use of multimodal analgesia, antiemetics, early physical therapy, avoidance of a urinary catheter, PCA and drains (10%, n=9,425). The same combination was most commonly seen in the 2013-2016 period (19%, n=6,646). TXA was not among the most commonly used combinations. After adjustment for relevant covariates, the most pronounced beneficial effects in the 2006-2012 period were seen for combinations 2 (no multimodal analgesia) and 5 (no multimodal analgesia and no avoidance of a PCA) for the outcome of “any complication”: OR 0.73 CI 0.67-0.80 and OR 0.73 CI 0.65-0.82, respectively; both p CONCLUSIONS In this large observational study using data on patients undergoing posterior lumbar fusion surgery we were able to discern substantial variations in ERAS component combinations, which decreased in more recent years. Interestingly, while different ERAS combinations were identified in each time period, the maximum benefit in terms of complication reduction was more pronounced in the 2006-2012 period with an overall lower use of ERAS protocols. Moreover, TXA was not seen among the most commonly used ERAS protocol combinations, indicating potential room for improvement. These findings may inform future clinical trials comparing various ERAS protocols. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs.