Initiatives to reduce length of stay in acute hospital settings: A rapid synthesis of evidence relating to enhanced recovery programmes

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Chapter 1 Background

The NHS faces severe funding constraints now and in the medium term. The forecast reduction in resources provides an enormous challenge to NHS organisations and staff. The savings required are substantial and are estimated to equate to an increase in productivity of more than 7%. 1 Service providers can improve productivity by carefully identifying initiatives that produce more value from the finite resources available: ‘doing things right and doing the right things’. 2

NHS managers and clinicians need to make full use of available evidence when considering how best to configure and organise care. Service redesign can save money and improve quality, but much depends on how care is co-ordinated and the way services are implemented in a local setting. 3,4 NHS decision-makers need to consider not only the clinical effectiveness and cost-effectiveness of any initiative but also how best to implement it. Consideration also needs to be given to the likely implications for service delivery, budgets and equity of access.

The need to reduce lengths of stay in secondary care hospital settings provides a key potential productivity opportunity. There has been growing interest over recent years in the use of enhanced recovery programmes [also known as enhanced recovery after surgery (ERAS), fast-track, multimodal, rapid or accelerated recovery programmes]. Such programmes seek to design and implement an optimal pathway (covering the preoperative, intraoperative and postoperative periods) that is focused on rapid recovery and discharge for patients. The approach was pioneered in Denmark in the late 1990s for patients undergoing colorectal surgery and is now spreading to other surgical pathways such as musculoskeletal, urology and gynaecology.

Enhanced recovery programmes for patients undergoing elective surgery involve development of enhanced recovery multidisciplinary teams, agreed basic principles, improved efficiency around the surgical pathway, increased patient awareness about the process, and early discharge planning using agreed criteria. 5 Since 2011, the Department of Health’s Enhanced Recovery Partnership Programme (ERPP) has sought to raise the profile and promote the benefits of enhanced recovery for elective surgical care across the NHS.

The underlying aim of enhanced recovery programmes is to ensure that patients are in optimal condition for treatment (to minimise the risk of surgery being postponed or cancelled because of the patient’s condition), receive innovative care during surgery and experience optimal postsurgical rehabilitation. 5 Programmes differ widely but share common elements such as patient education and involvement in preoperative planning processes, preoperative oral carbohydrates, improved anaesthetic and postoperative analgesic techniques to reduce the physical stress of the operation, early oral feeding and mobilisation. 6,7 Enhanced recovery programmes have been delivered in the UK NHS since the early 2000s. Implementation has to date been variable despite the support of the Department of Health and, more recently, the Royal Colleges. It is likely that this variation reflects both the complexity of enhanced recovery programmes themselves and issues around implementing change in fundamental surgical procedures at a time when the NHS is facing severe funding constraints. Differences in programme implementation may also reflect differences between surgical specialties. For example, enhanced recovery has been more widely implemented in colorectal surgery than in the higher volume field of orthopaedics. 8

This study was commissioned in response to a call for research on initiatives to reduce length of stay in acute hospitals; a key feature of enhanced recovery programmes is that they should reduce hospital length of stay compared with usual operative care (referred to in this report as ‘conventional care’). The ERPP has estimated that national implementation of enhanced recovery programmes in colorectal, gynaecology, urology and musculoskeletal surgery could save 140,000–200,000 bed-days per year. 9 Enhanced recovery programmes have a range of other potential benefits. Some of these, such as reduced exposure to risk of hospital-acquired infections, follow directly from reductions in length of hospital stay. Benefits may also be derived from another important feature of enhanced recovery, namely that it ‘empowers the patient to be a partner in their own care and have greater choice through shared and informed decision making’. 5 This means that enhanced recovery can potentially improve patients’ experience of surgery and subsequent recovery, an important consideration as the NHS seeks to be increasingly patient centred. 10 Commissioners of local NHS services have supported implementation of enhanced recovery programmes through a variety of mechanisms, notably the use of Commissioning for Quality and Innovation (CQUIN) payments to support providers in the establishment of enhanced recovery programmes. 9

Set against the benefits of enhanced recovery programmes are concerns that discharging patients too soon after surgery could increase complications and readmissions, thereby worsening patient experience and increasing pressure on primary and/or secondary health-care services. In many cases, maximising the benefits of enhanced recovery will require integrated working between health and social services. Any assessment of the evidence base for enhanced recovery programmes requires consideration of many outcomes and issues beyond simple reductions in length of stay.

Having potential for productivity gains does not guarantee that any change will deliver gains. Initiatives that look effective in theory may not have the hoped for impact when implemented in practice and on a large scale. 11 Before embarking on large-scale adoption of such a major initiative, NHS managers and clinicians need to be fully aware of the strength of the underlying evidence base to support the use of such programmes. Managers and clinicians need to have a clear understanding of how best to implement enhanced recovery programmes and the likely implications for service delivery within finite budgets and considering the need for equity of access.

As part of the National Institute for Health Research Collaborations for Leadership in Applied Health Research and Care for Leeds, York and Bradford, researchers at the Centre for Reviews and Dissemination (CRD) have been developing a rapid response knowledge translation service aimed at NHS commissioners and senior managers in provider trusts (see www.york.ac.uk/inst/crd/projects/knowledge_translation_service.html). The methods we have employed to assist evidence-informed decision-making at the local level in the NHS are ideally suited for rapid evidence syntheses that focus on high-profile initiatives and that are being widely promoted and advocated. Our approach to evidence synthesis12 highlights the quality and the strength of existing systematic reviews and economic evaluations and goes beyond clinical effectiveness and cost-effectiveness to consider applicability, implications relating to service delivery, resource use, implementation and equity.

There are a substantial number of systematic reviews and economic evaluations that examine the clinical effectiveness and cost-effectiveness of enhanced recovery programmes. This study uses this evidence as the basis of a comprehensive rapid evidence synthesis relating to the clinical effectiveness, cost-effectiveness, implementation, delivery and impact of enhanced recovery programmes and contextualise the findings to secondary care hospital settings in the NHS.

Chapter 2 Aims and objectives

The aim of this project was to conduct a rapid synthesis of the evidence on the clinical effectiveness, cost-effectiveness, implementation, delivery and impact of enhanced recovery programmes in secondary care.

The project addressed three main objectives:

1. Clinical effectiveness and cost-effectiveness: Evaluation of the clinical effectiveness and cost-effectiveness of enhanced recovery programmes designed to improve clinical pathways in acute hospital settings in patients undergoing elective surgery, including the impact on the organisation of care, configuration of workforce and resource utilisation in UK NHS settings.

2. Implementation: Identification and critical description of the key factors associated with successful adoption, implementation and sustainability of enhanced recovery programmes in UK settings.

3. Patient experience: Summary of existing knowledge about patient experience of enhanced recovery programmes in UK settings, including issues surrounding equity of access.

Chapter 3 Methods

The rapid synthesis was undertaken systematically following established principles13,14 and adapted as appropriate to ensure relevance to the current context. We followed a protocol drawn up in advance of the evidence synthesis.

The rapid nature and resource constraints of this project mean that we will focus on the best available evidence. Therefore, the primary sources of evidence about clinical effectiveness and cost-effectiveness will be derived from existing systematic reviews and economic evaluations. We have augmented this evidence with recent randomised trials and studies of implementation and patient experience of enhanced recovery programmes in NHS settings.

Chapter 4 Effectiveness

Description of studies

Systematic reviews

Initial screening of titles and abstracts identified 24 potentially relevant reviews. We identified one additional review15 which was published after the last literature search and this is discussed separately from the main synthesis. Full-paper screening resulted in the exclusion of two systematic reviews that did not meet inclusion criteria, as they only compared open versus laparoscopic surgery within an ERAS programme. 16,17 Two reviews did not specifically meet our inclusion criteria as they discussed individual elements of ERAS programmes rather than the effects of a complete ERAS programme; these reviews are discussed briefly in the systematic review results summary. 18,19 Four articles were linked to systematic reviews included in this section (some reviews had multiple publications). Any additional details presented in these four articles were extracted alongside the main review details and are not discussed separately (see Figure 1 for full details).

FIGURE 1.

Study flow diagram.

Seventeen systematic reviews that assessed the effects of enhanced recovery programmes were included in this report. 7,20–35 Summary review characteristics are presented in Appendix 3 and full evidence tables are available on request from the authors.

Eleven of the reviews focused on colorectal/colon surgery. 20,21,24,25,27,29–33,35 Of the remaining reviews, one focused on liver surgery,22 one on pancreatic surgery,23 one on liver and pancreatic (hepatopancreatobiliary) surgery26 and one on gynaecological surgery. 34 Sturm and Cameron7 and Lemmens et al. 28 assessed ERAS across various different surgical specialties.

The single Cochrane systematic review34 in gynaecological cancer care did not find any evidence in the form of RCTs. One review assessed compliance with ERAS protocols in colorectal surgery21 and one review assessed the effects of an ERAS protocol on health-related quality of life and satisfaction in patients who underwent colorectal surgery. 27 The remaining reviews assessed the efficacy and safety of ERAS protocols in various surgical specialties. Reviews specified different study inclusion and exclusion criteria. Nine of the 17 reviews stated a minimum number of ERAS elements for studies to be eligible for inclusion, this ranged from four to seven.

The systematic reviews included between 4 and 13 studies conducted in various countries including the UK, Germany, Denmark, Switzerland, Czech Republic and the Netherlands. Six reviews were restricted to RCTs,7,20,24,30,31,35 although Sturm and Cameron7 is a HTA report that also includes the results of a systematic review. 33 One review did not report individual study designs. 21 The remaining reviews included mixed study designs including RCTs, non-randomised studies or observational studies such as case–control studies or case series.

The 11 reviews in colorectal/colon surgery and one of the reviews in various surgical specialties7 presented evidence from different combinations of the same six RCTs ( Table 1). 36–41 The most recent of the systematic reviews35 included these six RCTs plus an additional four-arm RCT42 that compared ERAS with traditional care in both laparoscopy and open surgery. This four-arm trial was the only multicentre trial, the remaining trials were small, single-centre trials. One of the six commonly reported RCTs37 only included postoperative elements and was not considered to represent a comprehensive ERAS protocol as required by our inclusion criteria. Similarly, two reviews included a different RCT43 that was excluded from our synthesis as the intervention did not encompass enough components to represent a comprehensive ERAS protocol (i.e. preoperative or intraoperative and postoperative elements).

TABLE 1 - Randomised controlled trials included in systematic reviews and not individually data extracted

Author	Linked articles	Linked systematic reviews
Anderson (2003)36		Adamina (2011);20 Eskicioglu (2009);24 Gouvas (2009);25 Khan (2010);27 Spanjersberg (2011);30 Varadhan (2010);31 Wind (2006);33 Walter (2008);32 Sturm (2009);7 Rawlinson (2011)29
Delaney (2003)37		Adamina (2011);20 Eskicioglu (2009);24 Gouvas (2009);25 Khan (2010);27 Spanjersberg (2011);30 Varadhan (2010);31 Wind (2006);33 Walter (2008);32 Sturm (2009);7 Rawlinson (2011);29 Lv (2012)35
Gatt (2005)38		Adamina (2011);20 Eskicioglu (2009);24 Gouvas (2009);25 Khan (2010);27 Spanjersberg (2011);30 Varadhan (2010);31 Wind (2006);33 Walter (2008);32 Sturm (2009);7 Rawlinson (2011)29
Gralla (2007)44		Sturm (2009)7
Khoo (2007)39		Adamina (2011);20 Eskicioglu (2009);24 Gouvas (2009);25 Spanjersberg (2011);30 Varadhan (2010);31 Sturm (2009);7 Rawlinson (2011)29
Larsen (2008)45		Sturm (2009)7
Muehling (2009)46	Muehling (2008);47 Muehling (2011)48	Sturm (2009)7
Muehling (2008)49		Sturm (2009)7
Muller (2009)40	Hübner (2010);50 Hübner (2012)51	Adamina (2011);20 Spanjersberg (2011)30
Petersen (2006)52	Petersen (2008)53	Sturm (2009)7
Recart (2005)54		Sturm (2009)7
Serclova (2009)41		Adamina (2011);20 Spanjersberg (2011);30 Varadhan (2010);31 Rawlinson (2011)29
Vlug (2011)55	Van Bree (2011);56 Vlug (2011);55 Wind (2006);57 Vlug (2011)42	Lv (2012)35

Where reviews reported the number of included patients, sample sizes ranged between 99 and 5747patients in the ERAS group and between 99 and 1062 in comparator groups. Publication dates of studies included in the systematic reviews ranged from 1998 to 2012. Indications for surgery were rarely reported, but five reviews diagnosed patients as having benign, malignant or inflammatory disease. Where the age of patients was reported, this suggested that all patients were adults within similar age ranges.

The number and combination of ERAS elements varied considerably across reviews and individual studies, and within and across surgical specialties. The number of ERAS elements in individual pathways ranged from 4 to 14. The elements reported to differ most between reviews were avoidance of mechanical bowel preparation,7,23–25 no premedication,23,25,29,30,33 avoidance of nasogastric tubes or abdominal drains,7,22,25 and prevention of hypothermia. 23,25,29,30,33

The elements most frequently reported as part of an ERAS protocol were preoperative patient information20–26,28,29,31,32 and early postoperative oral nutrition and mobilisation. 7,20–26,28–33

Surgical techniques differed across reviews. One review in colorectal surgery included only patients who underwent major elective open surgery. 31 Another review in colorectal surgery included only patients who underwent open surgery but trials that used minimally invasive techniques were eligible. 30 Some reviews did not mention surgical techniques and some reviews included both open and laparoscopic techniques.

Where reviews reported the type of care received by comparator groups, this was defined as traditional care, conventional care or standard care (herein referred to as conventional care). Most reviews did not provide further details on the content of conventional care and it was not possible to determine the extent to which there was overlap between ERAS and conventional care pathways. One review stated that conventional care included up to four ERAS elements. 30 This had implications for the overall findings as some ERAS protocols included only four elements.

The main end points assessed in the reviews were length of hospital stay, readmission rates and morbidity and mortality rates. Some reviews distinguished between primary and total hospital stay. Primary hospital stay represented the number of days in hospital after surgery. Total length of stay was defined as total days spent in hospital including possible readmissions. Other reviews did not distinguish between the two measures and the inconsistency may, to some extent, explain the variability in length of stay across studies.

There was variability in how other outcomes (such as pain, readmission rates and morbidity) were defined and measured, and the reviews may have been measuring slightly different outcomes. This may, to some extent, explain the inconsistencies between reviews in reported event rates. Where reported, most reviews stated a follow-up duration of up to 30 days.

Several reviews reported findings on outcomes such as lung function, immune system function, gut and pulmonary function that were beyond the scope of this review and are not discussed further.

Other reviews

The systematic review identified after the final literature search included 13 RCTs in colorectal surgery. 15 Ten of the RCTs were identified in the reviews discussed above and three were not. 58–60 These three RCTs were identified in our separate search for RCTs and are discussed in the following section.

Two reviews focused on individual ERAS elements and so did not strictly meet eligibility criteria, but they provided some interesting findings which are reported in the systematic review results summary section. 18,19 Arsalani-Zadeh et al. 18 reviewed ERAS elements in patients who underwent breast surgery. Where evidence was scarce, data were extrapolated from non-breast surgery trials. Hoffmann and Kettelhack19 focused on challenges of postsurgical treatment and the role of translational research elements in ERAS, including investigations on stress, and immune and inflammatory responses after surgery.

Randomised controlled trials

Screening of titles and abstracts identified 56 potentially relevant RCTs; full-text screening identified 28 trials (reported in 38 articles due to multiple publications) that met our inclusion criteria.

Of these, 12 RCTs (21 articles due to multiple publications) were included in published systematic reviews discussed in the systematic reviews section above and will not be discussed here further. 36,38–42,44–57,61 Another 12 RCTs (13 articles) that were not included in the systematic reviews are discussed here separately. 58–60,62–71

Two foreign-language articles were identified: one Russian72 and one Chinese. 73 Time and resource constraints did not permit full translation of these articles, but we mention them briefly under ‘other evidence’ (see Chapter 4, Results) along with two RCTs that were available only in abstract form. 74,75

The 12 RCTs not discussed in the systematic review discussions were all single-centre trials above enrolled patients between 2006 and 2012. Clinical practice may have changed during this time. Inclusion/exclusion criteria varied considerably between the individual trials. Most trials selected patients with independent daily lifestyles and excluded patients with factors (such as comorbidities) that might impede a fast recovery. Therefore, patient populations in the trials should be reflective of patients undergoing enhanced recovery in clinical practice.

Seven RCTs (eight articles) were conducted in China,58–60,62,68–71 two in the Republic of Korea63,66 and one each in Spain,64 Romania65 and New Zealand. 67 Health systems in these countries differ from each other and the NHS in England. Seven RCTs (eight articles) were in colorectal surgery,58–60,64–66,69,71 four were in gastrointestinal surgery62,63,68,70 and one was in bariatric surgery. 67 Most of the trials were in patients with cancer; Lemanu et al. 67 was in obese patients.

All RCTs were in adults and there were no significant differences in mean age or sex proportions between ERAS and conventional care groups. Most trials analysed < 100 patients (range 44–597 patients). One trial did not report follow-up duration65 and a second trial reported follow-up between 3 and 44 months. 58 Follow-up in the other trials was up to 30 days post discharge. We considered 30-day postoperative follow-up sufficient to capture the benefits of enhanced recovery programmes and any complications or readmissions.

Details on health professionals involved in the ERAS programmes were scarce and only briefly mentioned as surgeon, anaesthetist and nurse involvement.

It appeared that individual trials were of fairly comprehensive ERAS programmes that included between 10 and 14 ERAS elements (see Appendix 4 ). All trials included preoperative and postoperative elements; individual elements and their combinations differed between trials regardless of surgical specialty. This may reflect changes over time where additional elements were added into the ERAS clinical pathway model. Similarly, different elements may be used dependent on surgical specialty and local preference. Descriptions and the amount of detail provided on each element varied across trials and made it difficult to determine whether or not elements such as preoperative information, pain management and mobilisation were applied consistently across trials. This highlights a lack of standardisation for ERAS programmes.

The most common preoperative elements were information/counselling (nine RCTs),59,62–68,70 no or selective mechanical bowel preparation (nine RCTs)58,59,62–65,68–70 and no prolonged preoperative fasting (10 RCTs). 58,59,62–64,66–70

The most frequently reported intraoperative elements were avoidance of drains (unless necessary), implemented in seven RCTs,59,60,62,63,67–69,71 and use of mid-thoracic epidural anaesthesia/analgesia, implemented in five RCTs. 58–60,69–71

The only postoperative element consistently implemented across all 12 RCTs was early mobilisation. Eleven RCTs implemented early oral nutrition. 58–60,62,64–71 The next most frequently used postoperative elements were avoidance of nasogastric tubes (unless necessary) in nine RCTs58–60,62,63,65,66,68,70,71 and early removal of drains/catheter in 10 RCTs. 58–60,62,64–66,68–71

Discharge criteria differed across the trials. All patients had to be mobile before they would be discharged from hospital; other criteria were reported inconsistently. Some trials stated a need for patients to be taking oral fluids. 62,67 Other trials stated a need for patients to tolerate soft diets. 64 Some patients were required to be analgesia free in order to be discharged66 and other trials discharged patients with analgesics for pain relief. 62,67 Discharge criteria relating to defecation and normothermia also varied across trials.

Traditionally, conventional care includes some form of bowel preparation, prolonged preoperative fasting, use of nasogastric tubes or catheters, later postoperative mobilisation and oral intake. However, approximately half of the RCTs identified in this report described a conventional care pathway that included at least one ERAS element (such as preoperative carbohydrate loading and no preoperative bowel preparation), which could reflect change in practice over time. Liu et al. 68 described a conventional care pathway that included four ERAS elements [use of antibiotic prophylaxis, avoidance of long-acting opioids, maintenance of normothermia and use of epidural mid-thoracic anaesthetic/non-steroidal anti-inflammatory drugs (NSAIDs)]. As highlighted by the systematic reviews discussed above, some ERAS programmes included only four elements. This further highlights the lack of standardisation across ERAS programmes and agreement on what constitutes an ERAS pathway, and will have implications on the overall findings.

These individual RCTs reported various definitions for length of hospital stay consistent with the evidence presented in the systematic reviews. Some RCTs distinguished between primary and total hospital stay, and others did not. Variability in how other outcomes (such as pain, readmissions and morbidity) were measured was also similar to the systematic reviews.

Other evidence

The two articles available in abstract form included only small numbers of patients. One involved 60 patients who underwent elective colorectal surgery in Egypt74 and the other involved 50 patients who underwent laparoscopic radical prostatectomy in Germany. 75 Migheli et al. 75 appeared to focus only on postoperative care rather than a full ERAS pathway with preoperative and/or intraoperative elements. Without the full article it was not clear whether or not this RCT would have met our inclusion criteria for this report and will not be discussed further. From the information provided in the abstract, it seemed that the trial in colorectal surgery would have met inclusion criteria;74 the results are discussed briefly as ‘other evidence’ under RCT results (see Chapter 4, Results).

The articles in foreign languages represented two small RCTs in two very different countries. It was unclear from the information provided in the abstract whether or not the RCT conducted in Russia would have met inclusion criteria. This RCT included 44 patients who underwent caesarean section but it was unclear whether surgery was elective or emergency, and the study appeared to focus on the anaesthesiologist’s role in fast-track surgery. 72 The results from this trial will not be discussed. The trial in China involved 80 patients who underwent surgery for lung cancer. 73 The limited results provided in the abstract are discussed briefly in the RCT results section on clinical effectiveness.

Nineteen ongoing trials were identified from ClinicalTrials.gov.uk in the initial literature search but given the lack of details and results on the trials, and the time and resource constraints, they were not followed up and will not be discussed further. Details are available on request.

Chapter 5 Cost-effectiveness

Chapter 6 Implementation

Chapter 7 Patient experience

Chapter 8 Discussion

Service redesign can save money and improve quality but much depends on how care is co-ordinated and how services are implemented in the local setting. There has been growing interest in the NHS over recent years in the use of enhanced recovery programmes to deliver productivity gains through reduced length of stay, fewer postoperative complications, reduced readmissions and improved patient outcomes. This rapid synthesis represents to our knowledge the most comprehensive overview of the evidence relating to the clinical effectiveness, cost-effectiveness, implementation, delivery and impact of enhanced recovery programmes in secondary care.

Seventeen systematic reviews of varying quality were included in this rapid review. Twelve additional RCTs were included; all were considered at high risk of bias. Most of the evidence focused on colorectal surgery and, with the exception of one RCT, were conducted in single settings. Twenty-nine case studies undertaken in NHS settings were identified and provide descriptions of factors critical to the success of an enhanced recovery programme. Ten relevant economic evaluations were identified evaluating costs and outcomes over short time horizons.

Despite the plethora of studies robust evidence was sparse. Evidence for colorectal surgery suggests that enhanced recovery programmes can reduce hospital stays by 0.5–3.5 days compared with conventional care. The mean length of stay in enhanced recovery ranged from 4.15 to 6.43 days. For conventional care, length of stay ranged from 6.6 to 11.7 days. Other surgical specialties showed greater variation in reported reductions in length of stay but this greater uncertainty reflects the more limited evidence base for these specialties.

We found consistent evidence that enhanced recovery programmes can provide some benefit to adults undergoing elective surgery. In particular, there is a suggestion that optimising conditions before, during and after elective surgery can reduce length of patient hospital stay without increasing readmission rates. This finding is consistent with systematic reviews that evaluate other structured multidisciplinary care pathways in hospital settings where clinical care is predictable. 122–125

Our overall results suggest that enhanced recovery programmes do not compromise patient safety but this evidence was based on variably defined outcomes. Differences in morbidity rates between enhanced recovery and conventionally treated patients were observed but these were not consistent. Reviews and trials provided limited data on levels of patient pain. Data on reintervention rates and patient-reported outcomes were limited but did not suggest significant differences between enhanced recovery and conventional care patients.

Early mobilisation is one of the core elements in an enhanced recovery protocol, yet results were rarely reported in the systematic reviews. What each intervention actually entailed is obscured by very limited reporting, but it is clear that there is variation in the type and duration of mobilisation elements delivered. Owing to the limitations in reporting, informed judgements on both the cost and the optimal offering for mobilisation are difficult to make.

Patient experience was reported very rarely and what few data were provided were anecdotal in nature. The ERPP that set up the innovation sites proposed use of the 2010 National Inpatient Survey to measure patient experience. Innovation sites may have followed this instruction but no evidence of use is presented in the case study reports. Data from national initiatives such as the Friends and Family Test are too limited to provide meaningful measurement of patient experience. Patient experience is an important outcome and more needs to be done to help facilitate its measurement. Using questions from the National Inpatient Survey [or another validated survey instrument, such as those developed by the Picker Institute Europe (www.pickereurope.org)] would enable standardised and comparative reporting of meaningful performance data across the NHS.

Over the last few years, lengths of stay for elective procedures have been in decline in the NHS. Given this, if real benefits from implementing enhanced recovery programmes are to be realised, much will depend on the length of stay being achieved via the existing conventional care pathway. The selection of patients for enhanced recovery programmes should also be given consideration as patients are usually relatively fit and may be more likely to have shorter lengths of hospital stay compared with less fit/high-risk patients. However, this reflects practice as enhanced recovery programmes would not be offered to patients who are not fit enough to be candidates for such programmes.

Managers and clinicians need to weigh up potential benefits from enhanced recovery against likely implementation costs of service redesign, the potential impact on budgets and on equity of access. To do this well and build a robust business case access to reliable information on benefits and costs is required. Our review of the cost-effectiveness literature suggests that enhanced recovery programmes that achieve a reduction in length of stay may save costs without detrimental effects on complication rates, readmission and health-related quality of life. These findings are also supported by systematic reviews and trials focusing on clinical effectiveness. However, generalisability of the results of the economic evaluations is limited by a lack of transparency in reporting, use of different settings and populations and variable methodology in analyses. Data were lacking for resource use and costs and could not usefully inform the review of economic evaluations. In addition, the clinical effectiveness of some of the programmes considered in economic evaluations was not based on robust evidence. The implementation evidence included resource use in terms of the professionals involved in enhanced recovery programmes but details were very limited and did not add to the evidence synthesis. The impact of surgical experience and surgical volume on clinical outcomes was not explored and any implications of differences in these areas remain unknown.

Acknowledgements

This project was funded as part of a programme of research funded by the NIHR Health Services and Delivery Research programme (project reference: 11/1026/04).

We would like to thank all the NHS staff that took the time to respond and help us identify grey literature considered for inclusion in this review.

References

1. Dixon J. Making Progress on Efficiency in the NHS in England: Options for System Reform. London: The Nuffield Trust; 2010.
2. Appleby J, Ham C, Imison C, Jennings M. Improving NHS Productivity. More With the Same Not More of the Same. London: King’s Fund; 2010.
3. Øvretveit J. Does Improving Quality Save Money? A Review of Evidence of Which Improvements to Quality Reduce Costs for Health Service Providers. London: The Health Foundation; 2009.
4. Øvretveit J. Does improving Care Coordination Save Money: A Review of Research. London: The Health Foundation; 2011.
5. Delivering Enhanced Recovery – Helping Patients to Get Better Sooner After Surgery. London: Department of Health; 2010.
6. Kehlet H, Wilmore DW. Multimodal strategies to improve surgical outcome. Am J Surg 2002;183:630-41. http://dx.doi.org/10.1016/S0002-9610(02)00866-8.
7. Sturm L, Cameron AL. Brief Review: Fast-Track Surgery and Enhanced Recovery After Surgery (ERAS) Programs. Melbourne: Australian Safety and Efficacy Register of New Interventional Procedures – Surgical (ASERNIP-S) 2009. http://docs.health.vic.gov.au/docs/doc/1177A3B11FBE1D2ACA2579280016A633/$FILE/enhanced_patient_recovery_programs.pdf (accessed 29 April 2014).
8. Wainwright T, Middleton R. An orthopaedic enhanced recovery pathway. Curr Anaesth Crit Care 2010;21:114-20. http://dx.doi.org/10.1016/j.cacc.2010.01.003.
9. Fulfilling the Potential: A Better Journey for Patients and a Better Deal for the NHS. London: NHS Enhanced Recovery Partnership; 2012.
10. Liberating the NHS: No Decision About Me, Without Me – Government Response to the Consultation. London: Department of Health; 2012.
11. Marshall M, Øvretveit J. Can we save money by improving quality?. BMJ Qual Saf 2011;20:293-6. http://dx.doi.org/10.1136/bmjqs.2010.050237.
12. Chambers D, Wilson P. A framework for production of systematic review based briefings to support evidence-informed decision-making. Syst Rev 2012;1. http://dx.doi.org/10.1186/2046-4053-1-32.
13. Systematic Reviews: CRD’s Guidance for Undertaking Reviews in Health Care. York: Centre for Reviews and Dissemination, University of York; 2009.
14. Moher D, Liberati A, Tetzlaff J, Altman DG. PRISMA Group . Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. PloS Med 2009;6. http://dx.doi.org/10.1371/journal.pmed.1000097.
15. Zhuang CL, Ye XZ, Zhang XD, Chen BC, Yu Z. Enhanced recovery after surgery programs versus traditional care for colorectal surgery: A meta-analysis of randomised controlled trials. Dis Colon Rectum 2013;56:667-78. http://dx.doi.org/10.1097/DCR.0b013e3182812842.
16. Li MZ, Xiao LB, Wu WH, Yang SB, Li SZ. Meta-analysis of laparoscopic versus open colorectal surgery within fast-track perioperative care. Dis Colon Rectum 2012;55:821-7. http://dx.doi.org/10.1097/DCR.0b013e31824bd31e.
17. Vlug MS, Wind J, van der Zaag E, Ubbink DT, Cense HA, Bemelman WA. Systematic review of laparoscopic vs open colonic surgery within an enhanced recovery programme. Colorectal Dis 2009;11:335-43. http://dx.doi.org/10.1111/j.1463-1318.2008.01679.x.
18. Arsalani-Zadeh R, ElFadl D, Yassin N, MacFie J. Evidence-based review of enhancing postoperative recovery after breast surgery. Br J Surg 2011;98:181-96. http://dx.doi.org/10.1002/bjs.7331.
19. Hoffmann H, Kettelhack C. Fast-track surgery – conditions and challenges in postsurgical treatment: a review of elements of translational research in enhanced recovery after surgery. Eur Surg Res 2012;49:24-3. http://dx.doi.org/10.1159/000339859.
20. Adamina M, Kehlet H, Tomlinson GA, Senagore AJ, Delaney CP. Enhanced recovery pathways optimise health outcomes and resource utilisation: a meta-analysis of randomised controlled trials in colorectal surgery. Surgery 2011;149:830-40. http://dx.doi.org/10.1016/j.surg.2010.11.003.
21. Ahmed J, Khan S, Lim M, Chandrasekaran TV, MacFie J. Enhanced recovery after surgery protocols – compliance and variations in practice during routine colorectal surgery. Colorectal Dis 2012;14:1045-51. http://dx.doi.org/10.1111/j.1463-1318.2011.02856.x.
22. Coolsen MME, Wong-Lun-Hing EM, van Dam RM, van der Wilt AA, Slim K, Lassen K, et al. A systematic review of outcomes in patients undergoing liver surgery in an enhanced recovery after surgery pathways. HPB (Oxford) 2013;15:245-51. http://dx.doi.org/10.1111/j.1477-2574.2012.00572.x.
23. Coolsen MME, van Dam RM, van der Wilt AA, Slim K, Lassen K, Dejong CHC. Systematic review and meta-analysis of enhanced recovery after pancreatic surgery with particular emphasis on pancreaticoduodenectomies. World J Surg 2013;37:1909-18. http://dx.doi.org/10.1007/s00268-013-2044-3.
24. Eskicioglu C, Forbes SS, Aarts M-A, Okrainec A, McLeod RS. Enhanced recovery after surgery (ERAS) programs for patients having colorectal surgery: a meta-analysis of randomized trials. J Gastrointest Surg 2009;13:2321-9. http://dx.doi.org/10.1007/s11605-009-0927-2.
25. Gouvas N, Tan E, Windsor A, Xynos E, Tekkis PP. Fast-track vs standard care in colorectal surgery: a meta-analysis update. Int J Colorectal Dis 2009;24:1119-31. http://dx.doi.org/10.1007/s00384-009-0703-5.
26. Hall TC, Dennison AR, Bilku DK, Metcalfe MS, Garcea G. Enhanced recovery programmes in hepatobiliary and pancreatic surgery: a systematic review. Ann R Coll Surg Engl 2012;94:318-26. http://dx.doi.org/10.1308/003588412X13171221592410.
27. Khan S, Wilson T, Ahmed J, Owais A, MacFie J. Quality of life and patient satisfaction with enhanced recovery protocols. Colorectal Dis 2010;12:1175-82. http://dx.doi.org/10.1111/j.1463-1318.2009.01997.x.
28. Lemmens L, van Zelm R, Borel Rinkes I, van Hillegersberg R, Kerkkamp H. Clinical and organizational content of clinical pathways for digestive surgery: a systematic review. Dig Surg 2009;26:91-9. http://dx.doi.org/10.1159/000206142.
29. Rawlinson A, Kang P, Evans J, Khanna A. A systematic review of enhanced recovery protocols in colorectal surgery. Ann R Coll Surg Engl 2011;93:583-8. http://dx.doi.org/10.1308/147870811X605219.
30. Spanjersberg Willem R, Reurings J, Keus F, van Laarhoven Cornelis JHM. Fast track surgery versus conventional recovery strategies for colorectal surgery. Cochrane Database Syst Rev 2011;16. http://dx.doi.org/10.1002/41651858j.CD007635.pub2.
31. Varadhan KK, Neal KR, Dejong CH, Fearon KC, Ljungqvist O, Lobo DN. The enhanced recovery after surgery (ERAS) pathway for patients undergoing major elective open colorectal surgery: a meta-analysis of randomized controlled trials. Clin Nutr 2010;29:434-40. http://dx.doi.org/10.1016/j.clnu.2010.01.004.
32. Walter CJ, Collin J, Dumville JC, Drew PJ, Monson JR. Enhanced recovery in colorectal resections: a systematic review and meta-analysis. Colorectal Dis 2009;11:344-53. http://dx.doi.org/10.1111/j.1463-1318.2009.01789.x.
33. Wind J, Polle SW, Fung Kon Jin PH, Dejong CH, von Meyenfeldt MF, Ubbink DT, et al. Systematic review of enhanced recovery programmes in colonic surgery. Br J Surg 2006;93:800-9. http://dx.doi.org/10.1002/bjs.5384.
34. Lv D, Wang X, Shi G. Perioperative enhanced recovery programmes for gynaecological cancer patients. Cochrane Database Syst Rev 2012;12.
35. Lv L, Shao YF, Zhou YB. The enhanced recovery after surgery (ERAS) pathway for patients undergoing colorectal surgery: an update of meta-analysis of randomized controlled trials. Int J Colorectal Dis 2012;27:1549-54. http://dx.doi.org/10.1007/s00384-012-1577-5.
36. Anderson AD, McNaught CE, MacFie J, Tring I, Barker P, Mitchell CJ. Randomized clinical trial of multimodal optimization and standard perioperative surgical care. Br J Surg 2003;90:1497-504. http://dx.doi.org/10.1002/bjs.4371.
37. Delaney CP, Zutshi M, Senagore AJ, Remzi FH, Hammel J, Fazio VW. Prospective, randomized, controlled trial between a pathway of controlled rehabilitation with early ambulation and diet and traditional postoperative care after laparotomy and intestinal resection. Dis Colon Rectum 2003;46:851-9. http://dx.doi.org/10.1007/s10350-004-6672-4.
38. Gatt M, Anderson AD, Reddy BS, Hayward-Sampson P, Tring IC, MacFie J. Randomized clinical trial of multimodal optimization of surgical care in patients undergoing major colonic resection. Br J Surg 2005;92:1354-62. http://dx.doi.org/10.1002/bjs.5187.
39. Khoo CK, Vickery CJ, Forsyth N, Vinall NS, Eyre-Brook IA. A prospective randomized controlled trial of multimodal perioperative management protocol in patients undergoing elective colorectal resection for cancer. Ann Surg 2007;245:867-72. http://dx.doi.org/10.1097/01.sla.0000259219.08209.36.
40. Muller S, Zalunardo MP, Hubner M, Clavien PA, Demartines N. Zurich Fast Track Study Group . A fast-track program reduces complications and length of hospital stay after open colonic surgery. Gastroenterology 2009;136:842-7. http://dx.doi.org/10.1053/j.gastro.2008.10.030.
41. Serclová Z, Dytrych P, Marvan J, Nová K, Hankeová Z, Ryska O, et al. Fast-track in open intestinal surgery: prospective randomized study (Clinical Trials Gov Identifier no. NCT00123456). Clin Nutr 2009;28:618-24. http://dx.doi.org/10.1016/j.clnu.2009.05.009.
42. Vlug MS, Wind J, Hollmann MW, Ubbink DT, Cense HA, Engel AF, et al. Laparoscopy in combination with fast track multimodal management is the best perioperative strategy in patients undergoing colonic surgery: a randomized clinical trial (LAFA-study). Ann Surg 2011;254:868-75. http://dx.doi.org/10.1097/SLA.0b013e31821fd1ce.
43. Hendry PO, van Dam RM, Bukkems SF, McKeown DW, Parks RW, Preston T, et al. Randomized clinical trial of laxatives and oral nutritional supplements within an enhanced recovery after surgery protocol following liver resection. Br J Surg 2010;97:1198-206. http://dx.doi.org/10.1002/bjs.7120.
44. Gralla O, Haas F, Knoll N, Hadzidiakos D, Tullmann M, Romer A, et al. Fast-track surgery in laparoscopic radical prostatectomy: basic principles. World J Urol 2007;25:185-91. http://dx.doi.org/10.1007/s00345-006-0139-2.
45. Larsen K, Sørensen OG, Hansen TB, Thomsen PB, Søballe K. Accelerated perioperative care and rehabilitation intervention for hip and knee replacement is effective: a randomized clinical trial involving 87 patients with 3 months of follow-up. Acta Orthop 2008;79:149-59. http://dx.doi.org/10.1080/17453670710014923.
46. Muehling B, Schelzig H, Steffen P, Meierhenrich R, Sunder-Plassmann L, Orend KH. A prospective randomized trial comparing traditional and fast-track patient care in elective open infrarenal aneurysm repair. World J Surg 2009;33:577-85. http://dx.doi.org/10.1007/s00268-008-9892-2.
47. Muehling BM, Halter G, Lang G, Schelzig H, Steffen P, Wagner F, et al. Prospective randomized controlled trial to evaluate “fast-track” elective open infrarenal aneurysm repair. Langenbecks Arch Surg 2008;393:281-7. http://dx.doi.org/10.1007/s00423-008-0284-8.
48. Muehling BM, Ortlieb L, Oberhuber A, Orend KH. Fast track management reduces the systemic inflammatory response and organ failure following elective infrarenal aortic aneurysm repair. Interact Cardiovasc Thorac Surg 2011;12:784-8. http://dx.doi.org/10.1510/icvts.2010.262337.
49. Muehling BM, Halter GL, Schelzig H, Meierhenrich R, Steffen P, Sunder-Plassmann L, et al. Reduction of postoperative pulmonary complications after lung surgery using a fast track clinical pathway. Eur J Cardiothorac Surg 2008;34:174-80. http://dx.doi.org/10.1016/j.ejcts.2008.04.009.
50. Hübner M, Müller S, Schäfer M, Clavien PA, Demartines N. Impact of the nutritional risk score in fast-track colon surgery. Dig Surg 2010;27:436-9. http://dx.doi.org/10.1159/000313692.
51. Hübner M, Schäfer M, Demartines N, Müller S, Maurer K, Baulig W, et al. Impact of restrictive intravenous fluid replacement and combined epidural analgesia on perioperative volume balance and renal function within a Fast Track program. J Surg Res 2012;173:68-74. http://dx.doi.org/10.1016/j.jss.2010.08.051.
52. Petersen MK, Madsen C, Andersen NT, Søballe K. Efficacy of multimodal optimization of mobilization and nutrition in patients undergoing hip replacement: a randomized clinical trial. Acta Anaesthesiol Scand 2006;50:712-17. http://dx.doi.org/10.1111/j.1399-6576.2006.01040.x.
53. Petersen MK, Andersen NT, Søballe K. Self-reported functional outcome after primary total hip replacement treated with two different periopera-tive regimes: a follow-up study involving 61 patients. Acta Orthop 2008;79:160-7. http://dx.doi.org/10.1080/17453670710014932.
54. Recart A, Duchene D, White PF, Thomas T, Johnson DB, Cadeddu JA. Efficacy and safety of fast-track recovery strategy for patients undergoing laparoscopic nephrectomy. J Endourol 2005;19:1165-9. http://dx.doi.org/10.1089/end.2005.19.1165.
55. Vlug MS, Bartels SA, Wind J, Ubbink DT, Hollmann MW, Bemelman WA, et al. Which fast track elements predict early recovery after colon cancer surgery?. Colorectal Dis 2012;14:1001-8. http://dx.doi.org/10.1111/j.1463-1318.2011.02854.x.
56. van Bree SH, Vlug MS, Bemelman WA, Hollmann MW, Ubbink DT, Zwinderman AH, et al. Faster recovery of gastrointestinal transit after laparoscopy and fast-track care in patients undergoing colonic surgery. Gastroenterology 2011;141:872-80. http://dx.doi.org/10.1053/j.gastro.2011.05.034.
57. Wind J, Hofland J, Preckel B, Hollmann MW, Bossuyt PM, Gouma DJ, et al. Perioperative strategy in colonic surgery; LAparoscopy and/or FAst track multimodal management versus standard care (LAFA trial). BMC Surg 2006;6. http://dx.doi.org/10.1186/1471-2482-6-16.
58. Wang Q, Suo J, Jiang J, Wang C, Zhao YQ, Cao X. Effectiveness of fast-track rehabilitation vs conventional care in laparoscopic colorectal resection for elderly patients: a randomized trial. Colorectal Dis 2012;14:1009-13. http://dx.doi.org/10.1111/j.1463-1318.2011.02855.x.
59. Wang G, Jiang ZW, Xu J, Gong JF, Bao Y, Xie LF, et al. Fast-track rehabilitation program vs conventional care after colorectal resection: a randomized clinical trial. World J Gastroenterol 2011;17:671-6. http://dx.doi.org/10.3748/wjg.v17.i5.671.
60. Yang DJ, Zhang S, He WL, Huang WQ, Cai SR, Chen CQ, et al. Fast-track surgery accelerates the recovery of postoperative humoral immune function in elective operation for colorectal carcinoma: a randomized controlled clinical trial. Chin Med J 2012;92:1112-15.
61. Veenhof AA, Vlug MS, van der Pas MH, Sietses C, van der Peet DL, de Lange-de Klerk ES, et al. Surgical stress response and postoperative immune function after laparoscopy or open surgery with fast track or standard perioperative care: a randomized trial. Ann Surg 2012;255:216-21. http://dx.doi.org/10.1097/SLA.0b013e31824336e2.
62. Chen Hu J, Xin Jiang L, Cai L, Tao Zheng H, Yuan Hu S, Bing Chen H, et al. Preliminary experience of fast-track surgery combined with laparoscopy-assisted radical distal gastrectomy for gastric cancer. J Gastrointest Surg 2012;16:1830-9. http://dx.doi.org/10.1007/s11605-012-1969-4.
63. Kim JW, Kim WS, Cheong JH, Hyung WJ, Choi SH, Noh SH. Safety and efficacy of fast-track surgery in laparoscopic distal gastrectomy for gastric cancer: a randomized clinical trial. World J Surg 2012;36:2879-87. http://dx.doi.org/10.1007/s00268-012-1741-7.
64. Garcia-Botello S, Cánovas de Lucas R, Tornero C, Escamilla B, Espí -Macías A, Esclapez-Valero P, et al. Implementation of a perioperative multimodal rehabilitation protocol in elective colorectal surgery. A prospective randomised controlled study. Cir Esp 2011;89:159-66. http://dx.doi.org/10.1016/j.ciresp.2010.12.004.
65. Ionescu D, Iancu C, Ion D, Al-Hajjar N, Margarit S, Mocan L, et al. Implementing fast-track protocol for colorectal surgery: a prospective randomized clinical trial. World J Surg 2009;33:2433-8. http://dx.doi.org/10.1007/s00268-009-0197-x.
66. Lee TG, Kang SB, Kim DW, Hong S, Heo SC, Park KJ. Comparison of early mobilization and diet rehabilitation program with conventional care after laparoscopic colon surgery: a prospective randomized controlled trial. Dis Colon Rectum 2011;54:21-8. http://dx.doi.org/10.1007/DCR.0b013e3181fcdb3e.
67. Lemanu DP, Singh PP, Berridge K, Burr M, Birch C, Babor R, et al. Randomized clinical trial of enhanced recovery versus standard care after laparoscopic sleeve gastrectomy. Br J Surg 2013;100:482-9. http://dx.doi.org/10.1002/bjs.9026.
68. Liu XX, Jiang ZW, Wang ZM, Li JS. Multimodal optimization of surgical care shows beneficial outcome in gastrectomy surgery. JPEN J Parenter Enteral Nutr 2010;34:313-21. http://dx.doi.org/10.1177/0148607110362583.
69. Ren L, Zhu D, Wei Y, Pan X, Liang L, Xu J, et al. Enhanced Recovery After Surgery (ERAS) program attenuates stress and accelerates recovery in patients after radical resection for colorectal cancer: a prospective randomized controlled trial. World J Surg 2012;36:407-14. http://dx.doi.org/10.1007/s00268-011-1348-4.
70. Wang D, Kong Y, Zhong B, Zhou X, Zhou Y. Fast-track surgery improves postoperative recovery in patients with gastric cancer: a randomized comparison with conventional postoperative care. J Gastrointest Surg 2010;14:620-7. http://dx.doi.org/10.1007/s11605-009-1139-5.
71. Yang DJ, Zhang S, He WL, Chen HY, Cai SR, Chen CQ, et al. Fast track surgery accelerates the recovery of postoperative insulin sensitivity. Chin Med J 2012;125:3261-5.
72. Antipin EE, Uvarov DN, Svirskii DA, Antipina NP, Nedashkovskii EV, Sovershaeva SL. Realization of fast track surgery principles during cesarean section. Anesteziol Reanimatol n.d.:33-6.
73. Zhao G, Huang Y, Chen X, Duan L, Ma Q, Lei Y, et al. Research on fast track surgery application in lung cancer surgery. Zhongguo Fei Ai Za Zhi 2010;13:102-6. http://dx.doi.org/10.3779/j.issn.1009-3419.2010.02.04.
74. El-Sheikh S, El-Sayed S, Mostafa A, Hussein H. Enhanced recovery program safely improves the outcome of elective colorectal surgery. Egypt J Anaesth 2010;26:229-39.
75. Magheli A, Knoll N, Lein M, Hinz S, Kempkensteffen C, Gralla O. Impact of fast-track postoperative care on intestinal function, pain, and length of hospital stay after laparoscopic radical prostatectomy. J Endourol 2011;25:1143-7. http://dx.doi.org/10.1089/end.2011.0020.
76. Coolsen MME, van Dam RM, van der Wilt AA, Slim K, Lassen K, Dejong CHC. Systematic review and meta-analysis of enhanced recovery after pancreatic surgery with particular emphasis on pancreaticoduodenectomies: Supplementary Material [published online April 9 2013]. World J Surg 2013. http://link.springer.com/article/10.1007%2Fs00268–013–2044–3.
77. Fearon K, Lobo D, Dejong C. ESPEN Congress 2010 Highlight Topics: Section 7: The Enhanced recovery After Surgery (ERAS) Protocol. Eur Soc Clin Nutr Metab 2012. www.jspen.jp/doc6/sec7.html (accessed 2 November 2012).
78. Khan S, Gatt M, Horgan A, Anderson I, MacFie J. Guidelines for Implementation of Enhanced Recovery Protocols. London: Association of Surgeons of Great Britain and Ireland; 2009.
79. Reilly KA, Beard DJ, Barker KL, Dodd CA, Price AJ, Murray DW. Efficacy of an accelerated recovery protocol for Oxford unicompartmental knee arthroplasty: a randomised controlled trial. Knee 2005;12:351-7. http://dx.doi.org/10.1016/j.knee.2005.01.002.
80. Archibald LH, Ott MJ, Gale CM, Zhang J, Peters MS, Stroud GK. Enhanced recovery after colon surgery in a community hospital system. Dis Colon Rectum 2011;54:840-5. http://dx.doi.org/10.1007/DCR.0b013e31821645bd.
81. Sammour T, Zargar-Shoshtari K, Bhat A, Kahokehr A, Hill AG. A programme of Enhanced Recovery After Surgery (ERAS) is a cost-effective intervention in elective colonic surgery. N Z Med J 2010;123:61-70.
82. King PM, Blazeby JM, Ewings P, Longman RJ, Kipling RM, Franks PJ, et al. The influence of an enhanced recovery programme on clinical outcomes, costs and quality of life after surgery for colorectal cancer. Colorectal Dis 2006;8:506-13. http://dx.doi.org/10.1111/j.1463-1318.2006.00963.x.
83. Nielsen PR, Andreasen J, Asmussen M, Tønnesen H. Costs and quality of life for prehabilitation and early rehabilitation after surgery of the lumbar spine. BMC Health Serv Res 2008;8. http://dx.doi.org/10.1186/1472-6963-8-209 (accessed June 2013).
84. Jakobsen DH, Sonne E, Andreasen J, Kehlet H. Convalescence after colonic surgery with fast-track vs conventional care. Colorectal Dis 2006;8:683-7. http://dx.doi.org/10.1111/j.1463-1318.2006.00995.x.
85. Larsen K, Hansen TB, Thomsen PB, Christiansen T, Soballe K. Cost-effectiveness of accelerated perioperative care and rehabilitation after total hip and knee arthroplasty. J Bone Joint Surg 2009;91:761-72. http://dx.doi.org/10.2106/JBJS.G.01472.
86. Kariv Y, Delaney CP, Senagore AJ, Manilich EA, Hammel JP, Church JM, et al. Clinical outcomes and cost analysis of a “fast track” postoperative care pathway for ileal pouch-anal anastomosis: a case control study. Dis Colon Rectum 2007;50:137-46. http://dx.doi.org/10.1007/s10350-006-0760-6.
87. Salhiyyah K, Elsobky S, Raja S, Attia R, Brazier J, Cooper GJ. A clinical and economic evaluation of fast-track recovery after cardiac surgery. Heart Surg Forum 2011;14:E330-4. http://dx.doi.org/10.1532/HSF98.20111029.
88. Yanatori M, Tomita S, Miura Y, Ueno Y. Feasibility of the fast-track recovery program after cardiac surgery in Japan. Gen Thorac Cardiovasc Surg 2007;55:445-9. http://dx.doi.org/10.1007/s11748-007-0162-2.
89. Enhanced Recovery Partnership Programme Case Studies 2011 . Gynaecology: Cambridge University Hospitals NHS Foundation Trust n.d. http://webarchive.nationalarchives.gov.uk/20130107105354/http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/documents (accessed 29 April 2014).
90. Enhanced Recovery Partnership Programme Case Studies 2011 . Colorectal, Gynaecology, Urology, MSK: Medway NHS Foundation Trust n.d. http://webarchive.nationalarchives.gov.uk/20130107105354/http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/documents (accessed 29 April 2014).
91. Enhanced Recovery Partnership Programme Case Studies 2011 . Colorectal Surgery (All Elective Procedures) and Most Major Emergencies from Decision to Treat Surgically; Urology: Radical Prostatectomy, Cystectomy, Nephrectomy; MSK: 1 Hip and Knee Replacement; Gynaecology: Hysterectomy (Vaginal, Abdominal and Laparoscopic) Moving to All Majors: Royal Berkshire Hospital n.d. http://webarchive.nationalarchives.gov.uk/20130107105354/http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/documents (accessed 29 April 2014).
92. Enhanced Recovery Partnership Programme Case Studies 2011 . Enhanced Recovery After Colorectal Surgery: Royal Berkshire Hospital n.d. http://webarchive.nationalarchives.gov.uk/20130107105354/http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/documents/digitalasset/dh_115737.pdf (accessed 29 April 2014).
93. Enhanced Recovery Partnership Programme Case Studies 2011 . Colorectal Surgery: Hillingdon Hospitals NHS Foundation Trust n.d. http://webarchive.nationalarchives.gov.uk/20130107105354/http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/documents (accessed 29 April 2014).
94. Enhanced Recovery Partnership Programme Case Studies 2011 . Musculo-Skeletal – Hip and Knee Joint Arthroplasty: Mount Vernon Hospital n.d. http://webarchive.nationalarchives.gov.uk/20130107105354/http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/documents/digitalasset/dh_126174.pdf (accessed 29 April 2014).
95. Enhanced Recovery Partnership Programme Case Studies 2011 . ERP: Colchester Hospital University NHS Foundation Trust n.d. http://webarchive.nationalarchives.gov.uk/20130107105354/http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/documents/digitalasset/dh_115726.pdf (accessed 29 April 2014).
96. Enhanced Recovery Partnership Programme Case Studies 2011 . Colorectal; Starting Implementation in Urology Gynaecology MSK: Salford Royal Hospital n.d. http://webarchive.nationalarchives.gov.uk/20130107105354/http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/documents/digitalasset/dh_126169.pdf (accessed 29 April 2014).
97. Enhanced Recovery Partnership Programme Case Studies 2011 . Enhanced Receover Program for All Elective Resectional Colorectal Surgery: Colorectal Surgery, Department of General Surgery, Salisbury NHS Foundation Trust n.d. http://webarchive.nationalarchives.gov.uk/20130107105354/http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/documents/digitalasset/dh_115738.pdf (accessed 29 April 2014).
98. Enhanced Recovery Partnership Programme Case Studies 2011 . Enhanced Recovery Programme: Yeovil District Hospital NHS Foundation Trust n.d. http://webarchive.nationalarchives.gov.uk/20130107105354/http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/documents/digitalasset/dh_115747.pdf (accessed 29 April 2014).
99. Enhanced Recovery Partnership Programme Case Studies 2011 . Enhanced Recovery for Colorectal Surgery: Yeovil District Hospital NHS Foundation Trust n.d. http://webarchive.nationalarchives.gov.uk/20130107105354/http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/documents/digitalasset/dh_115748.pdf (accessed 29 April 2014).
100. Enhanced Recovery Partnership Programme Case Studies 2011 . Enhanced Recovery Hip and Knee Joint Replacement: Northumbria Healthcare NHS Foundation Trust n.d. http://webarchive.nationalarchives.gov.uk/20130107105354/http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/documents/digitalasset/dh_117531.pdf (accessed 29 April 2014).
101. Enhanced Recovery Partnership Programme Case Studies 2011 . Orthopaedic Enhanced Recovery (TKR): Wrexham Maelor Hospital North Wales NHS Trust n.d. http://webarchive.nationalarchives.gov.uk/20130107105354/http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/documents/digitalasset/dh_115746.pdf (accessed 29 April 2014).
102. Schneider M, Kawahara I, Ballantyne G, McAuley C, MacGregor K, Garvie R, et al. Predictive factors influencing fast track rehabilitation following primary total hip and knee arthroplasty. Arch Orthop Trauma Surg 2009;129:1585-91. http://dx.doi.org/10.1007/s00402-009-0825-9.
103. Smart NJ, White P, Allison AS, Ockrim JB, Kennedy RH, Francis NK. Deviation and failure of enhanced recovery after surgery following laparoscopic colorectal surgery: early prediction model. Colorectal Dis 2012;14:e727-e34. http://dx.doi.org/10.1111/j.1463-1318.2012.03096.x.
104. Winning Principle 2: Improving Patient Care with Shorter Hospital Admissions for Gynaecological Patients. London: NHS Improvement; 2007.
105. Schmid KJ, Tewari R, Nordin AJ. Improving Patient Care With Shorter Hospital Admissions: East Kent Gynaecological Oncology Centre 2007. http://webarchive.nationalarchives.gov.uk/20130107105354/http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/documents/digitalasset/dh_115730.pdf (accessed 29 April 2014).
106. Letton C, Cheung C, Nordin A. Does an enhanced recovery integrated care pathway (ICP) encourage adherence to prescribing guidelines, accelerate postoperative recovery and reduce the length of stay for gynaecological oncology patients?. J Obstet Gynaecol 2013;33:296-7. http://dx.doi.org/10.3109/01443615.2012.758693.
107. Hibberd G, Wilcocks K, Cox D. Enhanced Recovery Programme for elective total hip replacement – the Salisbury experience n.d.
108. Hibberd G, Wilcocks K. Presentation for Service Improvement Awards. Salisbury NHS Foundation Trust; 2012.
109. Winning Principle 2: Reducing Length of Stay for Colorectal Surgery Patients Using Enhanced Rcovery Techniques. London: NHS Improvement; 2007.
110. 4 Winning Principles: Cancer Inpatients Case Series: Reducing Length of Stay for Colorectal Surgery Patients Using Enhanced Recovery Techniques. London: NHS Improvement; 2007.
111. Payne J, Beazley SM, Hannah. 4 Winning Principles: Cancer Inpatients Case Series: Enhanced Recovery After Surgery Program – Improving Patient Outcomes for Colorectal Surgical Patients. London: NHS Improvement; 2008.
112. Parker M. Recovery Times Slashed by Three Weeks 2008. http://webarchive.nationalarchives.gov.uk/+/www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/documents/digitalasset/dh_115755.pdf (accessed 29 April 2014).
113. Elwood M. Implementing an Enhanced Recovery Programme in Colorectal Surgery 2008. http://www.nursingtimes.net/implementing-an-enhanced-recovery-programme-in-colorectal-surgery/1247153.article (accessed 29 April 2014).
114. Hodder M, Ratnayaka N, Ali A, Hutton S. An Audit to Assess Compliance with the Enhanced Recovery After Surgery (ERAS) Programme in Colorectal Surgery at Walsall Manor Hospital. Walsall: Walsall Healthcare NHS Trust; 2012.
115. McGeehan R. Enhanced Recovery in Orthopaedics – The Journey. Sheffield: Sheffield Teaching Hospitals; 2013.
116. 4 Winning Principles: Cancer Inpatients Case Series: Enhanced Recovery for Gynaecological Patients. London; 2007.
117. Bowen-Rampling E, Carty S, Coffin K, Donovan A, Golby S, Hopwood H, et al. Enhanced Recovery Summit. London: NHS Improvement on behalf of the Enhanced Recovery Partnership; 2012.
118. Zamoyski T, Khera G, Simpson A, Wilson M, Woodcock S, Seymour K. Enhanced Recovery Program Within a Bariatric Service. Department of General Surgery, North Tyneside General Hospital; 2011.
119. Blazeby JM, Soulsby M, Winstone K, King PM, Bulley S, Kennedy RH. A qualitative evaluation of patients’ experiences of an enhanced recovery programme for colorectal cancer. Colorectal Dis 2010;12:e236-42. http://dx.doi.org/10.1111/j.1463-1318.2009.02104.x.
120. Taylor C, Burch J. Feedback on an enhanced recovery programme for colorectal surgery. Br J Nurs 2011;20:286-90.
121. Holloway I, Wheeler S. Qualitative Research for Nurses. Oxford: Blackwell Science; 1996.
122. Rotter T, Kinsman L, James E, Machotta A, Gothe H, Willis J, et al. Clinical pathways: effects on professional practice, patient outcomes, length of stay and hospital costs. Cochrane Database Syst Rev 2010;3.
123. Rotter T, Kugler J, Koch R, Gothe H, Twork S, van Oostrum JM, et al. A systematic review and meta-analysis of the effects of clinical pathways on length of stay, hospital costs and patient outcomes. BMC Health Serv Res 2008;8. http://dx.doi.org/10.1186/1472-6963-8-265.
124. Allen D, Gillen E, Rixson L. The effectiveness of integrated care pathways for adults and children in health care settings: a systematic review. JBI Database Syst Rev Implementation Rep 2009;7:80-129.
125. Allen D, Rixson L. How has the impact of ‘care pathway technologies’ on service integration in stroke care been measured and what is the strength of the evidence to support their effectiveness in this respect?. Int J Evid Based Healthcare 2008;6:78-110. http://dx.doi.org/10.1111/j.1744-1609.2007.00098.x.
126. Noyes J, Gough D, Lewin S, Mayhew A, Michie S, Pantoja T, et al. A research and development agenda for systematic reviews that ask complex questions about complex interventions. J Clin Epidemiol 2013;66:1262-70. http://dx.doi.org/10.1016/j.jclinepi.2013.07.003.
127. Report of the Mid Staffordshire NHS Foundation Trust Public Inquiry. London: The Stationery Office; 2013.
128. Aylin P, Alexandrescu R, Jen MH, Mayer EK, Bottle A. Day of week of procedure and 30 day mortality for elective surgery: retrospective analysis of hospital episode statistics. BMJ 2013;346. http://dx.doi.org/10.1136/bmj.f2424.
129. Carroll C, Patterson M, Wood S, Booth A, Rick J, Balain S. A conceptual framework for implementation fidelity. Implement Sci 2007;2. http://dx.doi.org/10.1186/1748-5908-2-40.
130. Taylor MJ, McNicholas C, Nicolay C, Darzi A, Bell D, Reed JE. Systematic review of the application of the plan–do–study–act method to improve quality in healthcare. BMJ Qual Saf 2013. http://dx.doi.org/10.1136/bmjqs-2013-001862.
131. Wind J, Polle SW, Fung Kon Jin PH, Dejong CH, Meyenfeldt MF, Ubbink DT, et al. Systematic review of enhanced recovery programmes in colonic surgery. Br J Surg 2006;93:800-9. http://dx.doi.org/10.1002/bjs.5384.

Appendix 1 Search strategies

Appendix 2 Enhanced recovery structured proforma

Appendix 3 Systematic review characteristics

Appendix 4 Individual enhanced recovery after surgery elements

Appendix 5 Systematic reviews: clinical outcomes

Appendix 6 Economic evaluations meeting the inclusion criteria

Appendix 7 Enhanced recovery programme implementation, by surgical specialty (number of sites)

Appendix 8 Reason for starting enhanced recovery programmea

Appendix 9 Brief details on enhanced recovery team and rolesa

Appendix 10 Changes made/enhanced recovery elements introduceda

Appendix 11 Barriers to changea

Appendix 12 Critical success factors/lessons learneda

Appendix 13 Evidence on improvementsa

Glossary

Care Quality Commission

Service to ensure health care in England provides people with safe, effective and high-quality care.

Commissioning for Quality and Innovation

A framework to secure improvements in quality of services and better outcomes for patients, while also maintaining strong financial management. Incentives and rewards are available to commissioners to drive improvements in care quality.

Conventional care

Also referred to as standard, usual or traditional care. Defined differently between studies or not defined.

Enhanced recovery after surgery

Also referred to as fast-track recovery, multimodal recovery, rapid recovery and accelerated recovery programmes.

Gastrectomy

Procedure to remove all or part of the stomach.

Salpingo-oophorectomy

Surgical removal of fallopian tube and ovary.

List of abbreviations

CENTRAL

Cochrane Central Register of Controlled Trials

CI

confidence interval

CRD

Centre for Reviews and Dissemination, University of York

DARE

Database of Abstracts of Reviews of Effects

ERAS

enhanced recovery after surgery

ERPP

Enhanced Recovery Partnership Programme

HEED

Health Economic Evaluations Database

HTA

Health Technology Assessment

ITT

intention to treat

MeSH

medical subject heading

MINORS

Methodological Index for NOn-Randomised Studies

NHS EED

NHS Economic Evaluation Database

NIHR

National Institute for Health Research

NSAID

non-steroidal anti-inflammatory drug

PROSPERO

International Prospective Register of Systematic Reviews

QALY

quality-adjusted life-year

RCT

randomised controlled trial

RD

risk difference

RR

relative risk