Clinical care guidelines optimize patient care, including Enhanced Recovery after Surgery (ERAS) guidelines specific to surgery. However despite their efficacy, compliance to guidelines by providers remains a challenge. Understanding ways to predict, and thus prevent, non-compliance can aid in improving uptake by providers and post-surgical recovery for patients.
Four approaches were taken to understand the issue. A novel method coined Vertical Compliance for measuring ERAS compliance in real-time can predict and prevent adverse surgical outcomes before they occur. Next, a multi-institutional, multi-surgical specialty retrospective data analysis revealed specific ERAS recommendations that - if not performed - predict adverse patient outcomes such as increased length of stay (LOS) and clinically-relevant complications. To understand the barriers to compliance, a meta-analysis was conducted for all medical literature and regression models developed to understand which barriers predict non-compliance to guidelines. Finally, to understand barriers to compliance specific to surgery and ERAS, a survey was developed and analyzed using a mixed-methods approach to understand which barriers to compliance predict reduces feelings of compliance assurance amongst ERAS professionals.
While conceptually different, vertical compliance and multi-institutional data analysis revealed similarities in which specific recommendations predict adverse outcomes, including oral carbohydrate loading, early removal of Foley catheter, and limited use of nasogastric tubes affected LOS. The two studies examining barriers to compliance revealed lack of familiarity and acceptance, and presence of external barriers were drivers of non-compliance.
Taken both individually and collectively, these four studies reveal why predicting adverse surgical outcomes due to non-compliance to evidence-based care is important, yet, predicting barriers may prove a critical element to preventing that non-compliance before it occurs.