Effect of enhanced surgical recovery program for thoracolumbar spine surgery on opioid use, length of hospital stay, and hospital readmissions: evaluation of 51,236 cases.

Background context: Evidence-based enhanced surgical recovery (ESR) programs integrate a multidimensional approach to optimize patients during the pre-, intra-, and postoperative phases of surgery. Smaller studies suggest several benefits of spine surgery ESR; this study evaluates the effects of ESR for thoracolumbar (TL) fusion surgery on a national scale.

Purpose: Determine if ESR is associated with a reduction in daily morphine milligram equivalents (MME), length of hospital stay (LOS), and 30-day readmission (READMIT) rates compared to non-ESR controls.

Study design: Multicenter, retrospective, case-control study of a prospectively adopted healthcare system ESR program from October 2018 to December 2021.

Patient sample: Consecutive adult patients undergoing TL fusion with known ESR participation status and without a primary diagnosis of tumor, infection, or trauma were included.

Outcomes measures: Primary outcomes include daily MME, LOS, and 30-day READMIT rates. Outcomes were analyzed for single-level, multi-level, and all TL fusions.

Methods: Data from TL fusion procedures performed within a large healthcare system were extracted from hospital-based electronic medical records derived from 1352 surgeons within 138 facilities. Patients were divided as ESR (cases) or non-ESR (controls) based upon enrollment into an ESR program defined by (1) preoperative patient education, (2) multimodal analgesia, (3) intraoperative fluid optimization, (4) opioid-sparing anesthesia, and (5) early postoperative nutrition and ambulation. Outcomes were compared between groups.

Results: Of 51,236 TL fusion cases (45% male, mean age of 63 years), 24,391 participated in an ESR program and 26,845 did not. For single-level TL fusions, ESR was associated with decreased MME (β= -8.76, p<.001), LOS (β= -8.85, p<.001), and READMIT (OR=0.77, 95% CI: 0.67-0.88) compared to controls. For multi-level TL fusions, ESR was associated with decreased MME (β= -7.32, p<.001) and LOS (β= -12.14, p<.001) compared to controls. For all TL fusions, ESR was associated with decreased MME (β= -7.94, p<.001), LOS (β= -10.54, p<.001), and READMIT (OR=0.91, 95% CI: 0.84-0.98) compared to non-ESR controls.

Conclusions: This national healthcare system analysis of over 50,000 TL spine fusion cases by 1,352 surgeons at 138 centers across the US confirms that ESR adoption is associated with decreased daily MME, LOS, and READMIT compared to non-ESR controls. Surgeons should consider adoption of ESR programs to improve patient care.