Compliance to an enhanced recovery pathway among patients with a high frailty index after major gastrointestinal surgery results in improved 30-day outcomes Jessica P. Hampton, BS a , Oluwafemi P. Owodunni, MD, MPH b , Dianne Bettick, MSN, CNS, RN c , Sophia Y. Chen, MD, MPH a , Sara Sateri, MD d , Thomas Magnuson, MD, FACS a , Susan L. Gearhart, MD, MEHP, FACS a,* a Department of Surgery, Johns Hopkins Health System, Baltimore, MD b Johns Hopkins University School of Medicine, Baltimore, MD c Department of Quality, Johns Hopkins Bayview Medical Center, Baltimore, MD d Department of Anesthesia, Johns Hopkins Medical Institution, Baltimore, MD article info Article history: Accepted 23 January 2019 Available online xxx abstract Background: Enhanced recovery pathways have been shown to improve clinical outcomes after sur- gery. Concerns exist about the feasibility of implementing enhanced recovery pathways in frail pa- tients, who are at a greater risk for adverse postoperative outcomes. This study evaluated compliance and outcomes after enhanced recovery pathway implementation in high-risk, abdominal surgery patients. Methods: Patients entered into the American College of Surgeons National Surgical Quality Improve- ment Program database who underwent abdominal surgery after enhanced recovery pathway imple- mentation at two Johns Hopkins Medical Institutions were included. Risk was assessed using the American College of Surgeons National Surgical Quality Improvement Program validated, modified 5-item frailty index. Primary outcomes included compliance with 14 enhanced recovery pathway standards and postoperative length of stay, major complications (Clavien-Dindo score IIeIV), and 30-day readmission. Results: This study included 646 patients who participated in our enhanced recovery pathway program and 65 patients with modified 5-item frailty index  2 before enhanced recovery pathway imple- mentation. Overall, 325 patients (50.3%) were high compliers (>75% compliance) with enhanced re- covery pathway standards, with similar proportions of patients with a modified 5-item frailty index  2 or < 2 achieving high compliance (51.6% vs 50.2%, P ¼ .89, respectively). Examining causality for “low compliers” among patients with a high frailty score (modified 5-item frailty index 2) demonstrated significant less use of goal-directed therapy when compared with “high compliers” (43% vs 75%, P ¼ .01). Low compliers were also less likely than high compliers to experience mobilization the day of surgery (43% vs 78%, P ¼ .01), postoperative day 1 (43% vs 88%, P < .01), and postoperative day 2 (60% vs 100%, P < .01). In addition, low compliers were less likely than high compliers to have their diet advanced to solids on postoperative day 1 (17% vs 59%, P < .01) and have their Foley catheter removed on postoperative day 1 (45% vs 97%, P < .01). Comparing our pre-enhanced recovery pathway patients with our enhanced recovery pathway cohort with a high frailty score, enhanced recovery pathway patients had a signifi- cantly shorter length of stay (4.5 vs 6 days, P ¼ .04). However, adjusted analysis demonstrated that high compliance, and not just the enhanced recovery pathway intervention among patients with a high frailty score, was independently associated with a decrease in length of stay (odds ratio 0.72, 95% confidence interval 0.63e0.82, P < .01) and a significant reduction in major complications (odds ratio 0.30, 95% confidence interval 0.14e0.65, P < .01. * Reprint requests: Susan L. Gearhart, MD, MEHP, Associate Professor of General Surgery, Johns Hopkins University School of Medicine, 600 N. Wolfe Street, Blalock 656, Baltimore, MD 21287. E-mail address: sdemees1@jhmi.edu (S.L. Gearhart). Contents lists available at ScienceDirect Surgery journal homepage: www.elsevier.com/locate/surg https://doi.org/10.1016/j.surg.2019.01.027 0039-6060/© 2019 Elsevier Inc. All rights reserved. Surgery xxx (2019) 1e7