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Racial and Socioeconomic Differences Manifest in Process Measure Adherence for Enhanced Recovery After Surgery Pathway

Leeds, Ira L. M.D., M.B.A.1; Alimi, Yewande M.D., M.H.S.1; Hobson, Deborah R. R.N.2; Efron, Jonathan E. M.D.1; Wick, Elizabeth C. M.D.1; Haut, Elliott R. M.D., Ph.D.1; Johnston, Fabian M. M.D., M.H.S.1

doi: 10.1097/DCR.0000000000000879
Original Contributions: Socioeconomic
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BACKGROUND: Adherence to care processes and surgical outcomes varies by population subgroups for the same procedure. Enhanced recovery after surgery pathways are intended to standardize care, but their effect on process adherence and outcomes for population subgroups is unknown.

OBJECTIVE: This study aims to demonstrate the association between recovery pathway implementation, process measures, and short-term surgical outcomes by population subgroup.

DESIGN: This study is a pre- and post-quality improvement implementation cohort study.

SETTING: This study was conducted at a tertiary academic medical center.

INTERVENTION: A modified colorectal enhanced recovery after surgery pathway was implemented.

PATIENTS: Patients were included who had elective colon and rectal resections before (2013) and following (2014–2016) recovery pathway implementation.

MAIN OUTCOME MEASURE: Thirty-day outcomes by race and socioeconomic status were analyzed using a difference-in-difference approach with correlation to process adherence.

RESULTS: We identified 639 cases (199 preimplementation, 440 postimplementation). In these cases, 75.2% of the patients were white, and 91.7% had a high socioeconomic status. Groups were similar in terms of other preoperative characteristics. Following pathway implementation, median lengths of stay improved in all subgroups (–1.0 days overall, p ≤ 0.001), but with no statistical difference by race or socioeconomic status (p = 0.89 and p = 0.29). Complication rates in both racial and socioeconomic groups were no different (26.4% vs 28.8%, p = 0.73; 27.3% vs 25.0%, p = 0.86) and remained unchanged with implementation (p = 0.93, p = 0.84). By race, overall adherence was 31.7% in white patients and 26.5% in nonwhite patients (p = 0.32). Although stratification by socioeconomic status demonstrated decreased overall adherence in the low-status group (31.8% vs 17.1%, p = 0.05), white patients were more likely to have regional pain therapy (57.1% vs 44.1%, p = 0.02) with a similar trend seen with socioeconomic status.

LIMITATIONS: Data were collected primarily for quality improvement purposes.

CONCLUSIONS: Differences in outcomes by race and socioeconomic status did not arise following implementation of an enhanced recovery pathway. Differences in process measures by population subgroups highlight differences in care that require further investigation. See Video Abstract at

Supplemental Digital Content is available in the text.

1 Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland

2 The Johns Hopkins Hospital, Baltimore, Maryland

Supplemental digital content is available for this article. Direct URL citations appear in the printed text, and links to the digital files are provided in the HTML and PDF versions of this article on the journal’s Web site (

Funding/Support: Drs Leeds and Alimi were supported while conducting this research by National Institutes of Health National Cancer Institute T32 training grant 5T32CA126607. Dr Leeds received additional support for research expenses from the American Society of Colon and Rectal Surgeons Research Foundation General Surgery Resident Research Initiation Grant GSSRIG-031. Dr Haut was supported as the primary investigator of an Agency for Healthcare Research and Quality grant (1R01HS024547-01) and Patient Centered Outcomes Research Institute contract (CE-12-11-4489). Dr Johnston was supported as the primary investigator of an Agency for Healthcare Research and Quality grant (1K08HS024736-01) from the Agency for Healthcare Research and Quality. The remaining authors declared no funding or support.

Financial Disclosures: None reported.

Ira L. Leeds, M.D., M.B.A., and Yewande Alimi, M.D., M.H.S., contributed equally to this article.

Presented at the meeting of the Academic Surgical Congress, Las Vegas, NV, February 6 to 9, 2017.

Correspondence: Fabian M. Johnston, M.D., M.H.S., The Johns Hopkins Hospital, Department of Surgery, Division of Surgical Oncology, 600 N Wolfe St, Blalock 654, Baltimore, MD 21287. Email:

© 2017 The American Society of Colon and Rectal Surgeons