Evidence review for enhanced recovery programmes

National Guideline Centre (UK)

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Evidence review for enhanced recovery programmes

Perioperative care in adults

Evidence review B

NICE Guideline, No. 180

National Guideline Centre (UK).

London: National Institute for Health and Care Excellence (NICE); 2020 Aug.

ISBN-13: 978-1-4731-3827-8

1. Postoperative management and recovery

1.1. Review question: What is the clinical and cost effectiveness of enhanced recovery programmes for adults having major surgery?

1.2. Introduction

Enhanced recovery is a multimodal approach optimising patients’ physiological and psychological states across preoperative, intraoperative and postoperative domains of care. The aim of enhanced recovery programmes (ERP) or enhanced recovery after surgery (ERAS) is for patients to return to their baseline function as quickly as possible and to reduce the incidence of postoperative complications. There are self-evident patient-centred and fiscal benefits if an expeditious and uncomplicated recovery can be achieved.

There are national variations in the delivery of enhanced recovery programmes. There is therefore a lack of standardisation of practice allowing outcomes to be objectively compared on a national scale. Furthermore, there is also a question as to the cost effectiveness of these programmes when compared to ‘traditional’ care.

1.3. PICO table

For full details see the review protocol in appendix A.

Table 1

PICO characteristics of review question.

1.4. Clinical evidence

1.4.1. Included studies

Seventy six randomly controlled trials were included in the review;¹^, ⁵^, ⁶^, ²¹^, ²⁶^, ²⁷^, ³⁸^, ⁴¹^, ⁴³^, ⁴⁶^, ⁵²^–⁵⁵^, ⁵⁹^, ⁶¹^, ⁶⁴^, ⁶⁵^, ⁶⁷^, ⁶⁹^, ⁷⁰^, ⁷⁴^, ⁷⁹^, ⁸⁰^, ⁸²^, ⁸⁴^, ⁸⁷^, ⁸⁸^, ⁹⁰^, ⁹⁸^, ¹⁰¹^, ¹⁰³^, ¹⁰⁵^, ¹⁰⁷^, ¹⁰⁹^, ¹¹²^, ¹¹⁶^, ¹²⁰^, ¹²²^, ¹²⁴^, ¹²⁹^, ¹³²^, ¹³³^, ¹³⁸^, ¹⁴⁰^–¹⁴²^, ¹⁵⁴^, ¹⁵⁷^, ¹⁵⁸^, ¹⁶¹^, ¹⁶⁵^, ¹⁶⁹^–¹⁷¹^, ¹⁷³^, ¹⁸¹^–¹⁸⁴^, ¹⁸⁷^, ¹⁸⁹^, ¹⁹¹^, ¹⁹³^–¹⁹⁷^, ²⁰⁰^, ²¹¹^, ²¹²^, ²¹⁵^, ²²¹^–²²³^, ²²⁷ these are summarised in Table 2 below. Evidence from these studies is summarised in the clinical evidence summary below (Table 4).

See also the study selection flow chart in appendix C, study evidence tables in appendix D, forest plots in appendix E and GRADE tables in appendix F.

1.4.2. Excluded studies

See the excluded studies list in appendix I.

1.4.3. Summary of clinical studies included in the evidence review

Table 2

Common enhanced recovery components from pre, peri and postoperative period.

Table 3

Summary of studies included in the evidence review.

See appendix D for full evidence tables.

1.4.4. Quality assessment of clinical studies included in the evidence review

Table 4

Clinical evidence summary: ERP compared to standard care.

Table 5

Evidence not suitable for GRADE analysis: ERP compared to standard care.

See appendix F for full GRADE tables.

1.5. Economic evidence

1.5.1. Included studies

Five health economic studies with the relevant comparison were included in this review.⁹⁷^, ¹⁰³^, ¹⁷⁰^, ¹⁸²^, ¹⁹¹ These are summarised in the health economic evidence profiles below (Table 6 – Table 10) and the health economic evidence tables in Appendix H:.

1.5.2. Excluded studies

No relevant health economic studies were excluded due to assessment of limited applicability or methodological limitations.

See also the health economic study selection flow chart in Appendix G:.

1.5.3. Summary of studies included in the economic evidence review

Table 6

Health economic evidence profile: Enhanced recovery programme (ERP) versus standard care.

Table 7

Health economic evidence profile: Enhanced recovery after surgery programmes versus standard care.

Table 8

Health economic evidence profile: Enhanced recovery programme versus standard care.

Table 9

Health economic evidence profile: Enhanced recovery programme versus standard care.

Table 10

Health economic evidence profile: Enhanced recovery programme versus standard care.

1.5.4. Unit costs

Relevant unit costs are provided below to aid consideration of cost effectiveness. The cost of a hospital bed day is provided and the cost of additional days spent in hospital for the standard care arm is calculated based on the clinical review.

Table 11

UK costs of additional hospital length of stay.

1.6. Evidence statements

1.6.1. Clinical evidence statements

No evidence was found for patient and staff adherence and psychological distress and mental wellbeing (hospital anxiety and depression scale (HADS)).

ERP versus standard care

Mortality

Twenty eight studies showed no clinically important difference between ERP and standard care for mortality (28 studies, n=3703, very low quality evidence).

Length of stay

Eighteen studies demonstrated a clinically important benefit with ERP to length of hospital stay compared to standar care(18 studies, n = 1621, very low quality evidence).

Twenty five studies showed a clinically important benefit with ERP to postoperative length of stay compared to standard care (25 studies, n = 3815, very low quality evidence).

Three studies found no clinically important difference between ERP intervention and standard care in ICU admissions (3 studies, n= 569, very low quality evidence).

Forty three studies showed no clinically important difference between ERP and standard care in readmission rates (43 studies, n= 5159, low quality evidence).

Quality of life

One study showed no clinically important difference between ERP and standard care for patient satisfaction (1 study, n = 64, very low quality evidence).

One study using the EQ-5D scale found a clinically important benefit with ERP on quality of life at 3 months compared to standard care (1 study, n= 87, low quality evidence).

One study adopting the QLQ-C30 scale found there was no clinically important difference between ERP and standard care in quality of life at 2 weeks (1 study, n= 44, moderate quality evidence).

A single study found no clinically important difference between ERP when assessing quality of life using the Cleveland Clinic Global Scale at 30 days compared to standard care (1 study, n= 64, low quality evidence).

One study which looked at SF – 12 (physical) scores at two, six and twelve weeks found no clinically important different with ERP and two weeks and twelve weeks and a clinically important harm with ERP at six weeks compared to standard care (1 study, n=49, very low quality of evidence)

One study which looked at SF – 12 (mental) scores at two, six and twelve weeks found a clinically important benefit with ERP at six weeks but clinically important difference at two weeks or twelve weeks postoperatively compard to standard care (1 study, n=49, very low quality of evidence)

Adverse events

Fifty five studies showed a clinically important benefit between ERP for total complications compared to standard care (55 studies, n=8034, low quality evidence).

Three studies found no clinically important difference between ERP and standard care using the Clavien Dindo Grade I classification for complications (3 studies, n= 300, very low quality evidence).

Five studies found no clinically important difference between ERP and standard care in Clavien Dindo Grade II complications (5 studies, n= 522, very low quality evidence).

Four studies demonstrated no clinically important difference between ERP and standard care of Clavien Dindo Grade IIIa complications (4 studies, n= 442, very low quality evidence)

One study showed a no clinically important difference between ERP and standard care in Clavien Dindo Grade IV complications(1 study, n= 100, very low quality evidence)

A single study found no clinically important difference between ERP and standard care in Clavien Dindo Grade V complications (1 study, n= 100, very low quality evidence)

Pain

Five studies found no clinically important difference between ERP and standard care for pain scores 1 – 3 days postoperatively and (5 studies, n= 467, low quality evidence)

Five studies found no clinically important difference between ERP and standard care in pain scores between 3 – 10 days postoperatively (5 studies, n= 687, low quality evidence)

Two studies found no clinically importance difference between ERP and standard care in pain scores, beyond 10 days postoperatively, when using a visual analogue scale (2 studies, n= 164, moderate quality evidence)

One study measured a mean difference in pain scores at two, six and twelve weeks, which showed a clinically important benefit with ERP at two and six weeks but no clinically important difference with ERP at twelve weeks compared to standard care (1 study, n=49, very low quality evidence)

One study found a clinically important benefit with ERP when measuring those with a VAS score over three on postoperative day one compared to standard care (1 study, n=32, low quality of evidence)

Evidence not suitable for GRADE analysis

One study showed no statistically significant difference between ERP and standard care in the median area under the curve for quality of life using the EQ-5D scale (1 study, n= 104, high risk of bias)

Twenty one studies showed a clinically important benefit or no statistically significant different with ERP compared to standard care for length of hospital stay (21 studies, n= 3146, high risk of bias)

Nine studies found a statistically significant difference with ERP in postoperative length of stay compared to standard care (9 studies, n= 1090, high risk of bias)

Four studies assessing pain through a visual analogue scale found no statistical difference between ERP and standard care in pain scores at different postoperative time points (4 studies, n= 378, high risk of bias)

Three studies found no statistical difference i between ERP i compared to standard care in length of stay in ICU (3 studies, n= 386, high risk of bias)

1.6.2. Health economic evidence statements

One cost-utility analysis found that ERP was dominant (less costly and more effective) compared to standard care. This analysis was assessed as partially applicable with potentially serious limitations.
Three cost-consequences analyses found that ERP was cost saving compared to standard care (cost saving: between £230 and 1800 per person). These analyses were assessed as partially applicable with potentially serious limitations.
One cost-consequence analysis found that ERP was cost saving compared to standard care (cost saving: between £100 and £1200). However, for the analysis where people underwent open surgery at a university hospital it was not cost-saving. This analysis was assessed as partially applicable with potentially serious limitations.

1.7. The committee’s discussion of the evidence

Please see recommendations 1.2.1 – 1.2.2 in the guideline.

1.7.1. Interpreting the evidence

1.7.1.1. The outcomes that matter most

The aim of ERP is for patients to return to their baseline function as quickly as possible and to reduce the incidence of postoperative complications. As such, the committee considered critical outcomes for decision making to be health-related quality of life, mortality, patient, family and carer experience of care, adverse events and complications and patient and staff adherence. Length of hospital stay, unplanned intensive care unit admission, length of stay in intensive care unit, hospital readmission and psychological distress and mental well-being were also thought to be important outcomes and were considered when weighin up the benefits and harms of ERP.

No evidence was identified for patient and staff adherence; symptom scores and function measures; and psychological distress and mental wellbeing.

1.7.1.2. The quality of the evidence

The quality of evidence that was suitable for GRADE analysis ranged from very low to moderate. The majority of the evidence was graded at very low quality. This was mostly due to risk of bias and imprecision. The committee noted the quality of evidence alongside the often relatively large size of the datasets when considering the weight of the evidence in influencing decision making.

Outcomes which were not suitable for GRADE analysis were considered to be at low to high risk of bias.

1.7.1.3. Benefits and harms

The committee discussed the evidence on enhanced recovery programmes for adults having major surgery.

The committee noted that there was some limited evidence showing a benefit of ERP for patient quality of life. Four studies reported quality of life using different measurement scales. When assessing the evidence using the EQ-5D scale, there was a clinically important benefit in quality of life. Whereas when using the QLQ-30 and Cleveland Global Quality of Life scales, no clinically important difference was identified through the evidence. One study assessed quality of life through the SF-12 score at two, six and twelve weeks. There was a clinically important harm at six and twelve weeks in the physical component but a clinically important benefit in the mental component at six weeks. Otherwise there was no clinically important difference in the physical or mental component of the score at the other time points. The committee noted that the number of patients included in these studies and the subsequent outcomes were too small to draw any strong conclusions.

Twenty eight studies showed no clinically important difference in mortality rates between enhanced recovery programmes and standard care.

When looking at total complications from fifty six different studies, the committee noted a clinically important benefit of enhanced recovery programmes. Grade of complication was also reported by some studies. Generally patients had a reduced risk of experiencing both low grade and more severe complications. However, the committee did not feel that the decreased risk of complications was a clinically important benefit due to the small risk difference. The variation of effect of enhanced recovery programmes over complication severities caused a level of uncertainty in the committee’s confidence to make a conclusion, but they noted the potential benefit of enhanced recovery programmes in reducing the total number of complications.

Within the evidence, length of stay was divided into two outcomes as reported by the incuded studies: length of hospital stay and postoperative length of stay. The committee noted that the length of hospital stay would in turn be shortened by the reduced postoperative length of stay. The committee reviewed the evidence which showed a clinically important benefit in reducing length of hospital stay and reducing postoperative length of stay across eighteen studies and twenty five studies respectively. The committee felt that this large body of evidence showing a benefit with ERP in reduced complications and length of hospital stay was significant and contributed heavily to discussions around a recommendation for ERP.

The committee noted that the evidence presented showed a higher rate of intensive care admission in the enhanced recovery arm, but agreed that this difference was not of clinical importance overall and was possibly related to the use of epidurals in the studies. The committee also added that this is not consistent with routine clinical practice as epidurals are typically avoided if possible in enhanced recovery programmes. The committee considered that this noted difference could have alternatively been due to a higher level of attention given in the review of patients with ERP with some of the admissions not being necessary.

Forty two studies reported readmission rates within a one month period. When assessing these results, the committee agreed there was no clinically important difference in readmission rates between enhanced recovery programmes and standard care.

There were no clinically important differences in pain scores between postoperative days one to three, three to ten and over ten days. One study assessed the mean difference in pain scores over two, six and twelve weeks postoperatively. This study showed a clinically important benefit at two and six weeks, but this trend was not continued at twelve weeks. Another study showed a clinically important benefit in reducing the number of people who reported a VAS score >3 on postoperative day one. Overall, the committee felt that while there is a general trend in reduction of pain scores for patients in the enhanced recovery programmes, the difference in mean pain scores between the groups was not enough to draw a strong conclusion.

In summary, the committee agreed that while there was no notable evidence of difference with ERP for a number of outcomes, an enhanced recovery program may result in a reduction in perioperative complications and a shorter length of hospital stay, as well as some potential improvements in quality of life.

1.7.2. Cost effectiveness and resource use

Five economic evaluations were included in the evidence. One study was a cost-utility analysis and four were cost-consequences analyses.

One study was a cost-utility analysis based on a single RCT in Denmark. The study implemented an enhanced recovery programme for adults undergoing joint replacement (hip and knee). The study looked at a one year time horizon and showed that for both hip and knee surgery, the enhanced recovery programme was dominant as it resulted in fewer costs and more QALYs (utility was measured using the EQ-5D). They also looked at hip and knee replacement separately. For hip surgery, the enhanced recovery programme remained dominant. For knee surgery, the enhanced recovery programme was less costly but resulted in slightly fewer QALYs. This study was assessed as partially applicable with potentially serious limitations. This was because 2006 Danish costs and societal perspective may not be relevant to current UK practice and the analysis was based on a single RCT and therefore does not reflect the full body of available evidence in this area.

One study conducted a cost-consequences analysis based on a single RCT looking at adults undergoing elective laparoscopic sleeve gastrectomy in New Zealand. The analysis showed that the enhanced recovery programme resulted in a reduction in length of stay of one day and a reduction in costs. Readmission was also reduced but total complications were slightly higher in the enhanced recovery programme arm. This study was assessed as partially applicable with potentially serious limitations. Reasons for this included that the cost year was not reported, the measure of effect was not in line with the NICE reference case as they did not measure QALYs and the analysis was based on a single RCT.

Another study also conducted a cost-consequences analysis based on a single RCT in Italy. They assessed implementing the enhanced recovery programme for women undergoing laparoscopic surgery for bowel endometriosis. The results showed that there was a reduction in length of stay of 4 days, a reduction in complications and reduction in costs. Another cost-consequences analysis based on a single RCT in Japan compared an enhanced recovery programme to standard care for adults undergoing curative gastrectomy for stomach cancer. The results also showed that there was a reduction in length of stay, a reduction in complications and reduction in costs. Both studies were assessed as partially applicable with potentially serious limitations. As neither of them measured QALYs, it was unclear whether they included the cost of the intervention and the analysis was based on a single RCT, and therefore does not reflect the full body of evidence available in this area.

Lastly, another study conducted a cost-consequences analysis based on a single RCT looking at adults undergoing colectomy for adenocarcinoma or adenoma in the Netherlands. The study compared an enhanced recovery programme in laparoscopic surgery and open surgery. In the laparoscopy comparison there was a reduction in length of stay for the enhanced recovery programme and a reduction in costs for both university and teaching hospitals. In the open surgery comparison there was no difference in length of stay and the enhanced recovery programme resulted in fewer costs in the teaching hospitals but was more costly in the university hospitals. The committee discussed the issue that there was a different result between university and teaching hospitals in the open surgery comparison, but agreed that this could be due to differences in the health care system in the Netherlands and that in the NHS, it is unlikely that you would find a big difference in costs across different hospitals. Also, they acknowledged that laparoscopic surgery is more relevant as enhanced recovery programmes are more likely to adopt a less invasive surgery approach. This study was assessed as partially applicable with potentially serious limitations. Reasons for this rating were because the analysis did not measure QALYs, the cost year was not reported and the analysis was based on a single RCT.

Overall the results showed that the enhanced recovery programmes were cost-saving which was mostly due to a reduction in complications and length of stay. The cost-utility analysis showed that the enhanced recovery programme was dominant as it resulted in less costs and more QALYs for adults undergoing hip and knee surgery. One study included in the clinical review measured patient’s quality of life with the EQ-5D. This showed that patient’s quality of life improved at three months with the enhanced recovery programme, which could indicate that the enhanced recovery programme is potentially a dominant strategy as it results in less costs and increased benefits.

All studies were rated as partially applicable with potentially serious limitations. All studies were not from a UK NHS perspective and apart from one analysis, the studies did not measure quality of life. Also, some of the studies did not report the source of their unit costs or they obtained them from local hospitals rather than national sources. Each study was an analysis based on a single RCT which does not reflect the full body of available evidence for this area as identified in the clinical review.

The committee highlighted the importance of the reduction in postoperative length of stay in the enhanced recovery programme arm. The clinical review showed that there was a mean reduction in postoperative length of stay of 3.02 days. The committee were presented with an example of unit costs in relation to this reduction in length of stay. Using the average cost of a hospital bed day, the enhanced recovery programme would save £1,229 per person. The committee highlighted that this would offset the cost of implementing an enhanced recovery programme. A lot of the concepts involved in an enhanced recovery programme are already available in hospitals, for example, early mobilisation and early intake of food and fluids. In order to have an enhanced recovery programme it requires bundling these elements together and ensuring the patient receives the elements before, during and after surgery. There may be some additional costs due to an increase in resource use, for example, some hospitals may choose to have a dedicated member of staff, like an enhanced recovery nurse, that is responsible for ensuring the pathway is in place. However, this is not essential for delivering the programme. Another additional cost would be the carbohydrate drinks which are a common element of the enhanced recovery programme. There are different carbohydrate drinks available but the cost ranges from £2 to £8 per patient. The annual PQIP 2018 report showed that 61% of people undergoing elective surgery were enrolled on an ERP pathway, and showed that some specialities had higher uptake than others. Starting an enhanced recovery programme may have an initial resource impact, however, the committee noted that the downstream savings in relation to a reduction in length of stay would outweigh the cost of implementing the programme.

The clinical review demonstrated that there was an increase in ICU admissions for those receiving an enhanced recovery programme. The committee felt that this did not reflect what is seen in current practice in the NHS where enhanced recovery programmes tend to reduce ICU admission. They highlighted that there were factors that could have contributed to this such as the studies that reported ICU admission used epidurals, whereas in UK practice epidurals would be avoided in an enhanced recovery programme.

The economic evidence included was not from a UK perspective, which might imply that resource use could be different, for example, in terms of average length of stay. However, the committee concluded that the difference in resource use reported in the studies, like reduction in length of stay - that led to the resulting cost savings - was likely to be feasible in the UK NHS and was confirmed by the guideline evidence review. Therefore, the committee felt confident that the clinical and economic evidence demonstrated a strong case for recommending enhanced recovery programmes, and this was also in keeping with the committees own experiences in practice.

Overall the committee felt that there was substantial evidence to make a recommendation and felt that implementing enhanced recovery programmes will lead to future savings for the NHS.

1.7.3. Other factors the committee took into account

The adoption of ERP in the UK is evidenced by how enhanced recovery pathways feature strongly in the UK Perioperative Quality Improvement programme [PQIP] and is highlighted in their annual report. PQIP is a multi-speciality innovation between the Royal Colleges of Anaesthesia and Surgery and aims to improve surgical morbidity and outcomes for patients. Enhanced recovery has been identified as one of the top 5 National improvement priorities for 2019–2020. Speciality specific audits and shared resources could potentially strengthen the case for ERPs.

The committee noted the significant variation in the composition of ERP from the evidence presented. It was agreed that there are key components to enhanced recovery across pre, intra and post-operative care, but also that enhanced recovery should be multimodal and flexible to the institution and patient. The committee also noted that epidural pain relief was implemented in a number of the studies, although there is a general effort in the UK to minimise epidural usage and epidural catheters are now no longer usually part of an enhanced recovery programme because they can limit mobilisation and delay recovery.

The committee acknowledged that while the application of enhanced recovery programmes may not be currently available to all centres due to their resource availability and local requirements, the usefulness of ERPs for adults having major surgery by reducing the length of stay in hospital, postoperative pain scores and lowering risk of postoperative complications is significant. However, the committee felt that the enhanced recovery programmes need to be tailored to suit the individual speciality requirements. There are particularly beneficial for people undergoing gynaecological oncological, orthopaedic, colo-rectal and vascular procedures and emerengency surgery. The committee noted that ERPs are not relevant to day surgery or to dental surgery.

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Appendices

Appendix A. Review protocols

Table 12. Review protocol: enhanced recovery programmes (PDF, 254K)

Table 13. Health economic review protocol

Appendix B. Literature search strategies

The literature searches for this review are detailed below and complied with the methodology outlined in Developing NICE guidelines: the manual 2014, updated 2018.¹⁴⁵

For more detailed information, please see the Methodology Review.

B.1. Clinical search literature search strategy

Searches were constructed using a PICO framework where population (P) terms were combined with Intervention (I) and in some cases Comparison (C) terms. Outcomes (O) are rarely used in search strategies for interventions as these concepts may not be well described in title, abstract or indexes and therefore difficult to retrieve. Search filters were applied to the search where appropriate.

Table 14. Database date parameters and filters used

Medline (Ovid) search terms

Embase (Ovid) search terms

Cochrane Library (Wiley) search terms

B.2. Health Economics literature search strategy

Health economic evidence was identified by conducting a broad search relating to the perioperative care population in NHS Economic Evaluation Database (NHS EED – this ceased to be updated after March 2015) and the Health Technology Assessment database (HTA) with no date restrictions. NHS EED and HTA databases are hosted by the Centre for Research and Dissemination (CRD). Additional health economics searches were run on Medline and Embase.

Table 15. Database date parameters and filters used

Medline (Ovid) search terms

Embase (Ovid) search terms

NHS EED and HTA (CRD) search terms

Appendix C. Clinical evidence selection

Figure 1. Flow chart of clinical study selection for the review of pre-operative optimisation clinics

Appendix D. Clinical evidence tables

Download PDF (1.8M)

Appendix E. Forest plots

Appendix I. Excluded studies

I.1. Excluded clinical studies

Table 17. Studies excluded from the clinical review

I.2. Excluded health economic studies

Published health economic studies that met the inclusion criteria (relevant population, comparators, economic study design, published 2003 or later and not from non-OECD country or USA) but that were excluded following appraisal of applicability and methodological quality are listed below. See the health economic protocol for more details.

Table 18. Studies excluded from the health economic review

Appendix J. Research recommendation

Research question: What is the clinical and cost effectiveness of enhanced recovery programmes for adults having major surgery?

Why this is important:

PICO question	Population: Adults 18 years and over who require major surgery including unplanned surgery Intervention(s): Enhanced recovery programmes Comparison: Standard care Outcome(s): Health-related quality of life, mortality, patient, family and carer experience of care, adverse events and complications (Clavien-Dindo, postoperative morbidity score (POMS)), patient and staff adherence, length of hospital stay, unplanned intensive care unit admission, length of stay in intensive care unit, hospital readmission, psychological distress and mental wellbeing (hospital anxiety and depression scale (HADS)) and pain
Importance to patients or the population	The provision of enhanced recovery programmes could improve health-related quality of life and reduce mortality and morbidity
Relevance to NICE guidance	There is currently limited evidence and guidance on the effectiveness of this limited resource.
Relevance to the NHS	Research in this area will inform NICE recommendations for service delivery and provide information about clinical and cost-effectiveness.
National priorities	Provision of enhanced recovery programmes as a resource will have financial implications on the NHS and nationally.
Current evidence base	There was a large body of evidence showing that hospital stays are shorter, postoperative complications less frequent and overall costs lower when people having elective major surgery follow an enhanced recovery programme (ERP).
Equality	Not applicable
Study design	RCT
Feasibility	There is heterogeneity regarding the provision of enhanced recovery programmes and a consistent approach would be necessary to conduct the research
Other comments	None
Importance	Medium: the research is relevant to the recommendations in the guideline and would be useful to future updates.

Final

Evidence reviews underpinning recommendations 1.2.1 and 1.2.2 and research recommendation in the NICE guideline

This evidence review was developed by the National Guideline Centre

Disclaimer: The recommendations in this guideline represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, professionals are expected to take this guideline fully into account, alongside the individual needs, preferences and values of their patients or service users. The recommendations in this guideline are not mandatory and the guideline does not override the responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and, where appropriate, their carer or guardian.

Local commissioners and providers have a responsibility to enable the guideline to be applied when individual health professionals and their patients or service users wish to use it. They should do so in the context of local and national priorities for funding and developing services, and in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities. Nothing in this guideline should be interpreted in a way that would be inconsistent with compliance with those duties.

NICE guidelines cover health and care in England. Decisions on how they apply in other UK countries are made by ministers in the Welsh Government, Scottish Government, and Northern Ireland Executive. All NICE guidance is subject to regular review and may be updated or withdrawn.

Bookshelf ID: NBK561974PMID: 32931178

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National Guideline Centre (UK). Evidence review for enhanced recovery programmes: Perioperative care in adults: Evidence review B. London: National Institute for Health and Care Excellence (NICE); 2020 Aug. (NICE Guideline, No. 180.)
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Evidence review for enhanced recovery programmes
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Evidence review for enhanced recovery programmes

1. Postoperative management and recovery

1.1. Review question: What is the clinical and cost effectiveness of enhanced recovery programmes for adults having major surgery?

1.2. Introduction

1.3. PICO table

1.4. Clinical evidence

1.4.1. Included studies

1.4.2. Excluded studies

1.4.3. Summary of clinical studies included in the evidence review

1.4.4. Quality assessment of clinical studies included in the evidence review

1.5. Economic evidence

1.5.1. Included studies

1.5.2. Excluded studies

1.5.3. Summary of studies included in the economic evidence review

1.5.4. Unit costs

1.6. Evidence statements

1.6.1. Clinical evidence statements

ERP versus standard care

Mortality

Length of stay

Quality of life

Adverse events

Pain

Evidence not suitable for GRADE analysis

1.6.2. Health economic evidence statements

1.7. The committee’s discussion of the evidence

1.7.1. Interpreting the evidence

1.7.1.1. The outcomes that matter most

1.7.1.2. The quality of the evidence

1.7.1.3. Benefits and harms

1.7.2. Cost effectiveness and resource use

1.7.3. Other factors the committee took into account

References

Appendices

Appendix A. Review protocols

Appendix B. Literature search strategies

B.1. Clinical search literature search strategy

B.2. Health Economics literature search strategy

Appendix C. Clinical evidence selection

Appendix D. Clinical evidence tables

Appendix E. Forest plots

E.1. ERP compared to standard care

Appendix F. GRADE tables

Appendix G. Health economic evidence selection

Appendix H. Health economic evidence tables

Appendix I. Excluded studies

I.1. Excluded clinical studies

I.2. Excluded health economic studies

Appendix J. Research recommendation

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