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Purpose: Surgical care pathways can improve quality and efficiency of care but require significant resources to implement and maintain. Payers require information about cost when deciding whether to adopt new quality initiatives. Data have been lacking to support the cost-effectiveness of enhanced recovery pathways (ERP) for complex procedures, such as esophagectomy. The objective of this study was to investigate the impact of ERP on medical costs for esophagectomy.
Methods: All patients undergoing elective esophagectomy for malignancy or high-grade dysplasia from 2009 to 2011 at a single high-volume university hospital were identified from a prospective database. From June 2010, all patients were enrolled in a 7-day multidisciplinary ERP incorporating printed patient education material and structured daily care plans with indications for intensive care admission, early structured mobilization, diet and drain management. Thirty-day morbidity and mortality were graded using the Clavien classification. Total medical costs (derived by micro-costing and including overhead, but excluding physician fees) were calculated from an institutional perspective, and expressed in 2011 Canadian dollars ($CAD). Deviation-based cost modeling, a validated method to compare the clinical and economic impact of clinical pathways, was used to compare costs between the pre- and post-pathway groups. Patients were classified into four deviation groups based on length of stay (LOS) and postoperative morbidity (Table 1). Median costs and interquartile range (IQR) were calculated for each deviation group, and weighted according to relative proportion of each deviation to provide the weighted-average median cost (WAMC) per patient.
Results: A total of 106 patients were included for analysis (47 pre-pathway, 59 post-pathway). There were no differences in patient (mean age 64 (SD 10) years, 80% male), pathologic (81% adenocarcinoma, 75% received neoadjuvant therapy, 38% stage I-II, 55% stage III-IV), and operative (mean OR duration 4.6(SD 1.5) hours, 42% Ivor-Lewis, 22% minimally-invasive) characteristics between pre- and post-pathway groups. Median LOS was lower in the post-pathway group (pre 10 [IQR 9-17] vs. post 8 [IQR 7-17] days, p=0.011). There was no difference in 30-day complications between the two groups (pre 62% vs. post 59%, p=0.803), and overall mortality was low (1%, 1/106). The median costs of the on-course and minor deviation groups were significantly lower after implementation of the ERP (Table 2). The overall cost savings per patient (WAMC_pre-WAMC_post) was $1472.
Conclusions: A multidisciplinary ERP for esophagectomy was associated with significant cost-savings without increase in morbidity or mortality.
Table 1 - Definition of deviation-based cost modeling groups

Deviation	Hospital course	Clinical impact
On-course	LOS ≤ 50th percentile	None or minor severity (Clavien I-II)
Minor	LOS = 50th to 75th percentile	None or minor severity (Clavien I-II)
Moderate	LOS > 75th percentile Any hospital duration	None or minor severity (Clavien I-II) Moderate severity (Clavien IIIa)
Major	Any hospital duration	Major severity (Clavien IIIb-V)

LOS = length of stay

Table 2 - Economic impact of ERP using deviation-based cost modeling

	Pre-Pathway (n=47)	Post-Pathway (n=59)	p-value
Deviation mix, % (n)			0.559
On-course	47% (22)	56% (33)
Minor	19% (9)	13% (8)
Moderate	15% (7)	12% (7)
Major	19% (9)	19% (11)
Median costs, $CAD [IQR]
On-course	$12 195 [11 303, 13 364]	$11 225 [9 964, 12 260]	0.024
Minor deviation	$16 698 [15 094, 21 937]	$13 120 [12 222, 15 672]	0.021
Moderate deviation	$21 459 [18 022, 22 627]	$25 432 [22 837, 31 709]	0.035
Major deviation	$33 190 [24 378, 73 888]	$31 709 [24 330, 44 588]	0.732
Weighted-average median cost, $CAD	$18 457	$16 985

ERP = enhanced recovery pathway