Gynecologic Oncology xxx (xxxx) xxx

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Gynecologic Oncology
journal homepage: www.elsevier.com/locate/ygyno

The financial impact of an enhanced recovery after surgery (ERAS)

protocol in an academic gynecologic oncology practice*
Zachary L. Gentry a, *, Teresa K.L. Boitano b, Haller J. Smith c, Dustin K. Eads d,
John F. Russell d, J. Michael Straughn Jr. c
a
School of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA
b
Department of Obstetrics and Gynecology, University of Alabama at Birmingham, Birmingham, AL, USA
c
Division of Gynecologic Oncology, University of Alabama at Birmingham, Birmingham, AL, USA
d
UAB Finance, University of Alabama at Birmingham, Birmingham, AL, USA

h i g h l i g h t s

The enhanced recovery after surgery (ERAS) protocol at our institution was cost-neutral compared to a pre-ERAS cohort.

Length of stay was decreased by one day with no increase in readmission rates.

Contribution margin on a per-patient day basis was the same between the ERAS and pre-ERAS cohorts.

a r t i c l e i n f o a b s t r a c t

Article history: Objective: To determine the financial impact of an enhanced recovery after surgery (ERAS) protocol in
Received 1 August 2019 gynecologic oncology patients.
Received in revised form Methods: This study identified gynecologic oncology patients who were placed on the ERAS protocol
1 November 2019
after elective laparotomy from 10/2016e6/2017. A control group was identified from the year prior to
Accepted 10 November 2019
ERAS implementation. Financial experts assisted in procuring data for these patient encounters,
Available online xxx
including payer status, direct and indirect costs, contribution margin, and length of stay (LOS). SPSS
Statistics v. 24 was used for statistical analysis.
Results: 376 patients met criteria for inclusion: 179 in the ERAS group and 197 in the control group.
Patient demographics were similar between the two cohorts. Payer status across the groups was not
statistically significant in patients with private insurance (control 43.7% vs. ERAS 41.3%), Medicare (38.1%
vs. 31.8%), or self-pay patients (12.2% vs. 15.1%). There was a significantly higher number of Medicaid
patients in the ERAS group (6.1% vs. 11.7%; p ¼ 0.05). Hospital direct costs ($5596 vs. 5346) and indirect
costs ($5182 vs. $4954) per encounter were similar between groups. However, overall contribution
margin per encounter decreased in the ERAS group ($11,619 vs. $8528; p ¼ 0.01). LOS was significantly
lower in the ERAS group (4.1 vs. 2.9 days; p ¼ 0.04).
Conclusions: Implementation of the ERAS protocol in gynecologic oncology patients does not lead to
increased costs for the patient or hospital system. The decreased contribution margin is likely due to a
reduction in per diem payments caused by the reduction in LOS. On a per-patient-day basis, contribution
margin was the same for both groups ($2877 vs $2857). The reduction in LOS also created capacity for
additional cases, the financial impact of which was not evaluated.
© 2019 Elsevier Inc. All rights reserved.

1. Introduction

Until recently, postoperative management of patients has been

widely variable, with most decisions being made due to surgeon
* preference based on prior experience. The goal of an enhanced
Poster Presentation at the Society of Gynecologic Oncology 50th Annual
Meeting on Women’s Cancer, March 18, 2019, Honolulu, HI. recovery after surgery (ERAS) pathway is to standardize post-
* Corresponding author. 2348 Garland Drive, Birmingham, AL, 35216, USA. operative care by merging best practices from both surgery and
E-mail address: gentryzl@uab.edu (Z.L. Gentry).

https://doi.org/10.1016/j.ygyno.2019.11.017
0090-8258/© 2019 Elsevier Inc. All rights reserved.

Please cite this article as: Z.L. Gentry et al., The financial impact of an enhanced recovery after surgery (ERAS) protocol in an academic
gynecologic oncology practice, Gynecologic Oncology, https://doi.org/10.1016/j.ygyno.2019.11.017
2 Z.L. Gentry et al. / Gynecologic Oncology xxx (xxxx) xxx

anesthesia [1]. In the United States, ERAS initially gained traction This data included payer status, direct and indirect costs, and
with colorectal surgeons with benefits including decreased length contribution margin. Direct costs included only costs associated
of stay (LOS), fewer complications, and decreased cost [1,2]. After its with direct patient care during the surgical encounter, including
success in both the United States and Europe, many other fields operating room, anesthesia, laboratory, radiology, pharmacy,
adopted ERAS pathways, including surgical oncology, urology, and nursing units, and ICU care. Costs for any other encounters of these
gynecologic oncology. In 2016, the first set of ERAS guidelines for patients were not included. Indirect costs include overhead and
gynecologic oncology were published, with over 50 recommen- administrative costs. Contribution margin was calculated as Net
dations for the care of postoperative patients [3,4]. Since then, ERAS Revenue less Direct Cost. Length of stay (LOS) was also evaluated.
pathways have become a mainstay of gynecologic oncology prac- The primary outcome of this study was the direct cost per
tice and have been shown to decrease LOS, rates of ileus [5], and encounter associated with the hospital stay for surgery. Secondary
complication rates [1,2]. outcomes included indirect hospital costs, overall contribution
In today’s healthcare climate, cost is becoming an increasing margin, patient payer status, and LOS. The data was analyzed using
concern as healthcare expenditures continue to rise [6]. Any independent t-test and chi square, and patient and surgical risk
method of lowering cost while maintaining quality of care is highly factors were controlled for using a multivariate logistic regression.
favorable. ERAS pathways have been proven to be cost-effective SPSS version 24 (IBM, Armonk, NY) was used for statistical analysis.
across a number of surgical subspecialties. In colorectal surgery,
one meta-analysis showed that ERAS protocols save an average of
$2245 per patient [7]. In a study of urology patients undergoing 3. Results
cystectomy for bladder cancer, ERAS pathways were shown to
decrease total 30-day costs by $4488 per procedure [8]. ERAS has 376 patients met criteria for inclusion: 179 (48%) in the ERAS
also been shown to significantly decrease costs associated with group, and 197 (52%) in the control group. Patient demographics,
breast surgery [9], as well as lung resection [10]. Two studies including age, BMI, primary diagnosis, Charlson Comorbidity Index,
investigating hepatobiliary surgeries demonstrated decreased costs and surgical complexity were similar across the two groups
for ERAS versus non-ERAS cohorts, however these studies did not (Table 1). The most common diagnoses were benign pathology
reach statistical significance [11,12]. (primarily including cystadenomas and leiomyomas) (50.9%),
Cost analyses of ERAS have been performed in gynecologic ovarian cancer (34.6%), and uterine cancer (11.2%) (Table 1). Read-
surgery as well. Pache et al. found that ERAS protocols decreased mission rates were similar between both cohorts (10.1% vs. 10.7%,
costs by $4381 per patient for gynecologic surgery. They also found p ¼ 0.61).
that these costs continued to decrease the further out from Hospital direct cost per encounter ($5346 vs. $5596; p ¼ 0.40)
implementation [13]. In gynecologic oncology specifically, one was similar between the ERAS and control groups (Table 2).
study found net costs savings of $956 per patient, as well as a 2-day Hospital indirect costs per encounter were also similar between
LOS reduction in medium and high complexity surgery [14]. Finally, the two groups ($4954 vs. $5182; p ¼ 0.31) (Table 2). However,
Modesitt et al. showed a cost savings of $1273 per patient in their overall contribution margin per encounter (hospital profit) was
laparotomy ERAS subgroup [15]. decreased in the ERAS group ($8528 vs. $11,619; p ¼ 0.01)
Given these widespread cost savings, the aim of this study was (Table 2). LOS was significantly lower in the ERAS group (2.9 vs. 4.0
to determine the financial impact of an ERAS protocol in gyneco- days; p ¼ 0.04).
logic oncology patients at a high-volume academic institution. Payer status across the two groups was not statistically signifi-
cant in patients with private insurance (ERAS 41.3% vs. control
2. Materials and methods 43.7%; p ¼ 0.72), Medicare (31.8% vs. 38.1%; p ¼ 0.20), or patients
who were self-pay (15.1% vs. 12.2%; p ¼ 0.41) (Table 3). There was a
This was a retrospective cohort study that identified gynecologic
oncology patients placed on an ERAS protocol after elective lapa-
Table 1
rotomy from 10/2016e6/2017 at the University of Alabama at Bir- Patient demographics.
mingham. Patients in the ERAS cohort were managed within our
Control (N ¼ 197) ERAS(N ¼ 179) P Value
institution’s ERAS protocol, which was developed according to in-
ternational recommendations [3,4]. Key components include Age (years) a 57.8 ± 13.4 55.9 ± 13.9 0.86
intrathecal morphine injection, multimodal pain control, early BMI (kg/m2) a 33.2 ± 10.1 32.2 ± 9.6 0.24
Charlson Comorbidity Indexa 4.6 ± 3.5 4.1 ± 3.4 0.44
postoperative mobilization, and early advancement of diet [5]. A surgical complexity score
control cohort was identified from a group of patients undergoing Low moderate 144 (73.1%) 124 (69.3%) 0.54
elective laparotomy the year prior to ERAS implementation (10/ high 47 (23.9%) 46 (25.7%)
2015e6/2016). An institutional database was used to identify these 6 (3.0%) 9 (5.0%)
Tobacco Use
two groups. Emergent cases, patients with bowel perforation,
No 164 (83.2%) 148 (82.7%) 0.89
preoperative acute kidney injury, and preoperative sepsis were Yes 33 (16.8%) 17.3%)
excluded from the study, as these patients are excluded from our Performance Status
ERAS protocol. Additionally, patients undergoing laparoscopic 0 160 (81.2%) 127 (70.9%) 0.16
surgery are not eligible for ERAS at our institution and were not 1 21 (10.7%) 32 (17.9%)
2 7 (3.6%) 8 (4.5%)
included in this study. Institutional Review Board approval was 3 3 (1.5%) 2 (1.1%)
obtained for this study. Not Reported 6 (3.0%) 10 (5.6%)
The electronic medical record of each patient was reviewed to Primary Diagnosis
obtain demographic information, primary diagnosis, medical his- Benign 86 (43.7%) 91 (50.8%) 0.07
Ovarian Cancer 59 (29.9%) 62 (34.6%)
tory, and procedures performed. The Charlson Comorbidity Index
Uterine Cancer 40 (20.3%) 20 (11.2%)
was used to evaluate medical comorbidities, and a surgical Cervical Cancer 6 (3.0%) 4 (2.2%)
complexity score was evaluated using the score system developed Non-Gynecologic Cancer 6 (3.0%) 2 (1.1%)
by Atleti. Financial experts from the institution assisted in procur- ERAS ¼ enhanced recovery after surgery.
ing cost data for the surgical encounters. This included actual costs *Denotes statistically significant result.
a
from the hospital’s cost accounting system, not estimated values. Denotes means reported ± standard deviation.

Please cite this article as: Z.L. Gentry et al., The financial impact of an enhanced recovery after surgery (ERAS) protocol in an academic
gynecologic oncology practice, Gynecologic Oncology, https://doi.org/10.1016/j.ygyno.2019.11.017
 Z.L. Gentry et al. / Gynecologic Oncology xxx (xxxx) xxx 3

Table 2 (2.5 days) [7]. These larger decreases in LOS drastically lowered
Financial data. costs related to each surgical encounter, thus allowing each study
Control (N ¼ 197) ERAS(N ¼ 179) P Value to demonstrate cost savings for their protocols. Additionally, in
Direct Hospital Cost $5596 $5346 0.40
our ERAS protocol, patients undergo additional anesthesia pro-
Indirect hospital cost $5182 $4954 0.31 cedures and other interventions that the control group do not
Contribution Margina $11,619 $8528 0.01 receive. These additional costs were offset by the one-day
ERAS ¼ enhanced recovery after surgery. reduction in LOS. Regarding patient costs, we do not have access
a
Denotes statistically significant result. to data on out-of-pocket costs to the patient. While we were un-
able to calculate whether ERAS provided cost savings for patients,
it certainly appears to be beneficial in many other ways, including
Table 3 decreased LOS, lower complication rates, and improved patient
Payer status.
satisfaction [16].
Control (N ¼ 197) ERAS(N ¼ 179) P Value Our study has several limitations. First, coding, billing, and
Private insurance 86 (43.6%) 74 (41.3%) 0.72 specific ERAS practices vary by hospital, so financial outcomes for
Medicarea 75 (38.1%) 57 (31.8%) 0.20 gynecologic oncology surgeries between institutions will also vary.
Medicaida 12 (6.1%) 21 (11.7%) 0.05 Additionally, this study was done at a tertiary care academic
Self-paya 24 (12.2%) 27 (15.1%) 0.41
institution. Because of this, our results may not be generalizable to a
ERAS ¼ enhanced recovery after surgery. private practice or community setting. Lastly, this study was per-
a
Denotes statistically significant result.
formed retrospectively, which makes it subject to the biases asso-
ciated with this study design.
In conclusion, implementation of an ERAS protocol does not lead
significantly higher amount of Medicaid patients in the ERAS group
to increased costs in gynecologic oncology patients undergoing
(11.7% vs. 6.1%; p ¼ 0.05).
exploratory laparotomy. Based on these findings, ERAS is a cost
neutral measure that provides numerous benefits including
4. Discussion decreased LOS and fewer complications.

This study offers insight into the actual cost findings of an ERAS
protocol in gynecologic oncology patients. Ultimately, we found
that the ERAS protocol implemented at our institution to be cost
neutral. However, there was a significant decrease in LOS and no
increase in 30-day readmission rates or emergency department
visits.
The only significant finding with regard to the financial analysis
was a decrease in contribution margin per encounter. This decrease
is most likely due to the loss of per diem payments from certain
payers, which make up a large percentage of the patient popula-
tion. At a high-volume center like our institution, there is never a
shortage of patients needing hospital admission. The contribution
margin per patient encounter may be decreased, but due to the
decreased LOS, contribution margin per patient day were approx-
imately the same for both groups. Additionally, more beds are
available for other patients to be admitted. Therefore, this
decreased contribution margin per encounter does not negatively
affect our hospital’s bottom line. For low-volume centers, this
decreased profit per patient may have a negative impact on the
hospital’s finances depending on their patient funding and hospital
bed status. However, as insurance plans are moving more to capi-
tated payments for certain procedures and diagnoses, an ERAS
protocol may be beneficial for all as it reduces complications and
LOS [1,2].
Two previous studies found that ERAS protocols did not impact
hospital costs in patients undergoing liver and pancreatic surgery
[11,12]. These studies did report that the ERAS cohort had signifi-
cantly less postoperative complications and a decreased LOS [11,12].
Several studies have shown that ERAS protocols were cost-effective
in colorectal, urologic, and breast surgery [7e9]. These cost studies
also confirmed a decrease LOS and complication rate in their co-
horts [8,9]. Other studies in gynecologic surgery have also shown
decreased cost with ERAS protocols [13e15], as well as lower
complication rates, decreased rates of ileus, and similar 30-day
readmission rates [5,14].
A potential reason our study was cost neutral is the shorter
relative decreased LOS seen after the implementation of our ERAS
protocol. In our study, LOS was shortened by one day compared to
other fields that have shown more dramatic decreases, such as
urology (4 days) [8], lung resection (3 days) [10] and colorectal
Author contributions
Formulation of research question: Gentry, Boitano, Straughn.
Literature Review: Gentry, Boitano.
Data Collection: Gentry, Boitano, Russell, Eads.
Statistical Analysis: Boitano.
Manuscript drafting: Gentry, Boitano.
Critical Revision: Smith, Russell, Eads, Straughn.
Declaration of competing interest
The authors attest that they have no conflict of interests to this
work.
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Please cite this article as: Z.L. Gentry et al., The financial impact of an enhanced recovery after surgery (ERAS) protocol in an academic
gynecologic oncology practice, Gynecologic Oncology, https://doi.org/10.1016/j.ygyno.2019.11.017