Enhanced recovery after surgery in elective benign general gynaecological surgery: postoperative recovery outcomes and health economic value of hospitalisation costs under China's diagnosis-related group (DRG) payment system - a retrospective cohort study at a tertiary hospital.

objectiveThe aim of this study was to explore the application of enhanced recovery after surgery (ERAS) in patients undergoing gynaecological surgery. This investigation included an analysis of the postoperative recovery curve and the factors that influenced the number of postoperative recovery days. This study also aimed to further investigate the impact of various factors on health economics. DESIGN, SETTING AND

participantsA retrospective cohort study was conducted in the Fourth Ward of the General Gynaecology Centre of the Peking Union Medical College Hospital. A total of 1000 patients who had undergone elective benign gynaecological surgery between July 2021 and December 2022 were included. Demographic, perioperative and other relevant data were collected, and a visual analogue scale (VAS) survey was conducted using the European Five-Dimensional Health Scale (EQ-5D). The factors that influenced the number of postoperative recovery days were analysed using a multivariate linear regression analysis. Additionally, patients who had undergone laparoscopic myomectomy, laparoscopic ovarian cystectomy, laparoscopic total hysterectomy, abdominal myomectomy and abdominal total hysterectomy were grouped based on whether their ERAS implementation rate was ≥70%. Our goal was to evaluate the health economic value of the diagnosis-related group (DRG) payments from multiple perspectives and provide actionable recommendations for health insurance bureaus, hospitals and patients from a multi-dimensional perspective.

resultsERAS completion rates for measures such as avoiding preoperative sedation and early postoperative ambulation exceeded 95%, whereas rates for chewing gum and intraoperative temperature monitoring were <5%. The follow-up EQ-5D questionnaire VAS scores were as follows: a preoperative score of 79.48±13.75, score on the day of surgery of 74.18±15.43, score on the first postoperative day of 76.43±14.25, and score on the second postoperative day of 79.84±13.12. Patients returned to a healthy state with a median recovery time of 3 (range, 0-8) days. The postoperative recovery curve was then drawn based on the VAS scores. Additionally, a multivariate linear regression analysis revealed that the prevention of postoperative nausea and vomiting, correction of preoperative anaemia and malnutrition, ERAS completion rate and VAS score on the second postoperative day significantly influenced the number of postoperative recovery days (p<0.05). Patients with ERAS compliance rates of <70% incurred an average hospital cost increase of 8% compared with those with a compliance rate of ≥70%. Specifically, patients who underwent laparoscopic myomectomy and laparoscopic total hysterectomy experienced more significant and more obvious increases in hospitalisation costs of approximately 15% (p<0.001) and 8% (p=0.031), respectively.An analysis of the relationship between hospital costs and different ERAS measures, insurance types and disease types showed that seven measures could reduce hospital costs without negatively affecting the patient recovery speed, and five measures could slightly increase hospital costs. In addition, hospitalisation cost differences based on various insurance types and disease categories were statistically significant (p<0.05).

conclusionThe postoperative recovery speed was accelerated, the recovery time was shortened and the patient's quality of life was enhanced during gynaecological surgery due to the implementation of ERAS practices. Increasing the ERAS completion rate can significantly reduce patient average hospitalisation costs. Additionally, variations in medical insurance, disease categories and specific ERAS measures influenced these costs. Therefore, hospitals that are unable to fully implement all ERAS measures must prioritise those that promote recovery. In addition, hospitals should adopt flexible strategies to minimise costs, thereby achieving mutual benefits for patients and hospitals. These findings establish a foundation for the implementation of a simplified ERAS version. It has been observed through the perspective of DRG implementation in China that payment standards exceed the average hospitalisation costs associated with specific surgical procedures. This result suggests that DRG implementation can benefit both patients and hospitals. These study results will serve as a valuable reference for decision-making by health insurance bureaus, hospitals and patients.