Is Recovery Really 'enhanced' Through Enhanced Recovery Programs? an Analysis of Patient-Reported Perioperative Symptom Burden Before and after Implementation of an Enhanced Recovery Pathway for Gynecologic Surgery

Objectives: With the growing focus on patient-centered care, patient-reported outcomes are increasingly important in comparative effectiveness research. Our objective was to compare patient-reported symptom burden and functional recovery in women undergoing surgery before and after implementation of an enhanced recovery pathway (ERP). Methods: Perioperative patient-reported symptom burden was measured in women undergoing laparotomy on the gynecologic oncology service of a tertiary cancer center before and after implementation of an ERP. Symptoms were assessed using the MD Anderson Symptom Inventory–Ovarian Cancer module (MDASI-OC), a 27-item validated tool. The MDASI-OC was administered as a preoperative baseline, daily while hospitalized, and at least weekly for 8 weeks postoperatively. Fisher exact test and mixed-effect modeling were performed. Results: A total of 167 patients (74 pre-ERP, 93 post-ERP) completed the MDASI-OC longitudinally. Even though there was a 77% reduction in opioid intake (median morphine equivalents) during the first 3 days after surgery in the ERP group, there was no significant difference in mean pain scores between the pre- and post-ERP cohorts. Compared with traditional perioperative care, patients in the ERP reported significantly lower severity of a composite score of the most highly rated symptoms (fatigue, dry mouth, drowsiness, pain, and abdominal pain) during their hospitalization (P = .002). In addition, the ERP cohort had significantly lower composite scores in physical interference (walking, work, activity; P = .008), and lower affective interference scores (mood, relations with other people, enjoyment of life; P < .0001. During the 8 weeks after discharge, women in the ERP continued to report significantly less fatigue (P =.009), drowsiness (P < .0009), and pain (P = .02). Although no significant differences were noted in physical interference scores in the 8 weeks after discharge, improvements in affective interference continued (P =.0009). Memory and ability to concentrate were significantly better in the ERP group both during hospitalization and after discharge. Conclusions: Adoption of an ERP can significantly reduce opioid consumption without worsening patients’ subjective feeling of pain and may improve functional recovery in the immediate and extended postoperative setting.