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Article of the Week: Quality Improvement in Cystectomy Care with Enhanced Recovery (QUICCER) study

Every Week the Editor-in-Chief selects an Article of the Week from the current issue of BJUI. The abstract is reproduced below and you can click on the button to read the full article, which is freely available to all readers for at least 30 days from the time of this post.

In addition to the article itself, there is an accompanying editorial written by a prominent member of the urological community. This blog is intended to provoke comment and discussion and we invite you to use the comment tools at the bottom of each post to join the conversation.

If you only have time to read one article this week, it should be this one.

Quality Improvement in Cystectomy Care with Enhanced Recovery (QUICCER) study

Janet E. Baack Kukreja*, Maureen Kiernan*, Bethany Schempp, Aisha SiebertAdriana Hontar*, Benjamin Nelson*, James Dolan§, Katia Noyes, Ann DozierAhmed Ghazi*, Hani H. Rashid*, GuaWu* and Edward M. Messing*

 

*Department of Urology, Strong Memorial Hospital University of Rochester Medical Center, School of Nursing, School of Medicine and Dentistry, University of Rochester Medical Center, §Department of Public Health Sciences, and Department of Surgery, Strong Memorial Hospital University of Rochester Medical Center, Rochester, NY, USA

 

Objectives

To determine if patients managed with a cystectomy enhanced recovery pathway (CERP) have improved quality of care after radical cystectomy (RC), as defined by a decrease in length of hospital stay (LOS) without an increase in complications or readmissions compared with those not managed with CERP.

Subjects and Methods

The Quality Improvement in Cystectomy Care with Enhanced Recovery (QUICCER) study was a non-randomized quasi-experimental study. Data were collected between June 2011 and April 2015. The CERP was implemented in July 2013. The primary endpoint was LOS. Secondary endpoints were quality scores, complications and readmissions. Multivariable regression was performed. Propensity score matching was carried out to further simulate randomized clinical trial conditions. A CERP quality composite score was created and evaluated with regard to adherence to CERP elements.

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Results

The study included 79 patients managed with CERP and 121 who were not managed with CERP. After matching, there were 75 patients in the non-CERP group. The LOS was significantly different between the groups: the median LOS was 5 and 8 days for the CERP and non-CERP group, respectively (P < 0.001). Multivariable linear regression showed that any complication was the most significant predictor of total LOS at 90 days after RC. The higher the quality composite score the shorter the LOS (P < 0.001). There was no association between CERP and a greater number of complications or readmissions.

Conclusions

Audited quality measures in the CERP are associated with a reduction in LOS with no increase in readmissions or complications. The CERP is important for the future improvement of peri-operative care for RC and provides an opportunity to improve the quality of care provided.

Editorial: Quality improvement in cystectomy care with enhanced recovery (QUICCER) study

Enhanced recovery after surgery (ERAS) is a multidisciplinary, multi-element care pathway approach that aims to standardise and improve perioperative management. Since the first publication on ERAS for radical cystectomy in the BJUI in 2008, the literature on this important factor in postoperative management of patients undergoing major surgery in the field of urology is rather scarce and mainly in form of reviews [1]. This clearly reflects the very slow adoption of this approach, the reasons for which remain unclear.

Baack Kukreja et al. [2] in this issue of BJUI performed an analysis of sequential patients, before and after introduction of an ERAS protocol in their institution, using a propensity matched approach. The length of stay (LOS) could be reduced significantly from 8 to 5 days without increasing the rate of complications or increasing the number of readmissions or emergency department visits. The rate of readmissions is comparable to other published reported series. The difference in LOS of 3 days with an ERAS approach is impressive. However, the parameter of LOS has to be interpreted in the context of the medical system of each country in itself, as many factors may influence this parameter. The data presented indicates that there was no biased drive to discharge patients earlier in the study context.

The ERAS programme presented here included preoperative counselling and intra- and postoperative precautions and interventions. Preoperative counselling focused on information on surgery and the handling of the stoma if needed. Patients were assessed for medical and socioeconomic factors that might have an influence on anaesthesia/surgery outcome, recovery, and management after discharge. As foreseen by ERAS, patients received probiotics and preoperative carbohydrate loading [3, 4].

Apart from the LOS, one of the major findings of this study [2] was a distinct decrease in gastrointestinal complications, such as ileus, which is not surprising as this is one of the declared goals of ERAS, which was first introduced in colorectal surgery.

The reported decrease of myocardial infarction is another interesting finding. There is no difference in American Society of Anesthesiologists score between the two groups. However, there is a tendency to more blood transfusions in the cystectomy enhanced-recovery pathway group in the study. The current debate on whether blood transfusions may have a negative effect on oncological outcomes might have an influence on this eventually. Astonishingly, fluid management was not different between the two groups despite the declared goal to avoid salt and water overload. The use of pulse pressure variation or an oesophageal Doppler probe to guide fluid management might be complemented by restrictive deferred hydration combined with preemptive noradrenaline infusion [5, 6].

After discharge patients did not require home i.v. fluid administration and were able to drink at least 1 L. They did not require more support at home than the control group.

The authors are to be complemented for implementing an ERAS protocol and evaluating the effect in a scientific manner. Some of the findings are confirmatory of other studies, some are novel and worthy of further analysis, while others suggest a potential for further improvement. The results of this study [2] clearly indicate the usefulness and validity of an ERAS protocol and the need to implement and further develop such an ERAS approach in everyday urological practice.

George N. Thalmann
Department of Urology, University Hospital, Inselspital, Bern, Switzerland

 

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