ORIGINAL SCIENTIFIC ARTICLES Implementation Costs of an Enhanced Recovery After Surgery Program in the United States: A Financial Model and Sensitivity Analysis Based on Experiences at a Quaternary Academic Medical Center Alexander B Stone, BA, Michael C Grant, MD, Claro Pio Roda, MHS, Deborah Hobson, BSN, Timothy Pawlik, MD, PhD, FACS, Christopher L Wu, MD, Elizabeth C Wick, MD, FACS BACKGROUND: Despite positive results from several international Enhanced Recovery After Surgery (ERAS) protocols, the United States has been slow to adopt ERAS protocols, in part due to concern regarding the expenses of such a program. We sought to evaluate the potential annual net cost savings of implementing a US-based ERAS program. STUDY DESIGN: Using data from existing publications and experience with an ERAS program, a model of net financial costs was developed for surgical groups of escalating numbers of annual cases. Our example scenario provided a financial analysis of the implementation of an ERAS program at a United States academic institution based on data from the ERAS Program for Colorectal Surgery at The Johns Hopkins Hospital. RESULTS: Based on available data from the United States, ERAS programs lead to reductions in lengths of hospital stay that range from 0.7 to 2.7 days and substantial direct cost savings. Using example data from a quaternary hospital, the considerable cost of $552,783 associated with implementation of an ERAS program was offset by even greater savings in the first year of nearly $948,500, yielding a net savings of $395,717. Sensitivity analysis across several caseload and direct cost scenarios yielded similar savings in 20 of the 27 projections. CONCLUSIONS: Enhanced Recovery After Surgery protocols have repeatedly led to reduction in length of hos- pital stay and improved surgical outcomes. A financial model, based on published data and experience, projects that investment in an ERAS program can also lead to net financial savings for US hospitals. (J Am Coll Surg 2016;222:219e225. Ó 2016 by the American College of Surgeons. Published by Elsevier Inc. All rights reserved.) Enhanced Recovery After Surgery (ERAS) programs are multidisciplinary, evidence-based protocols implemented in the perioperative period in order to provide uniform patient care and improve clinical outcomes. These pro- grams have been shown to reduce rates of surgical complications and overall length of stay after colorectal surgery. 1 Recent international data have also shown that these programs can reduce hospital costs, making ERAS a potentially superior intervention compared with con- ventional perioperative care. 2,3 Despite these findings, adoption of ERAS has been partic- ularly slow in the United States. 4 This possibly stems from concerns that significant reductions in length of stay and cost savings associated with international programs might not be applicable to the US health care system. Two recent studies of ERAS programs after colorectal surgery at major medical centers in the US suggest that ERAS can be cost saving. 5,6 However, these articles did not explicitly report the costs of implementation of an ERAS program. Although implementation costs have been described for programs in Canada, the United Kingdom, and New Zealand, these likely underestimate the costs of creating similar domestic CME questions for this article available at http://jacscme.facs.org Disclosure Information: Authors have nothing to disclose. Timothy J Eberlein, Editor-in-Chief, has nothing to disclose. Received August 29, 2015; Revised November 3, 2015; Accepted November 10, 2015. From the Departments of Anesthesiology and Critical Care Medicine (Stone, Grant, Pio Roda, Wu,) and Surgery (Hobson, Pawlik, Wick), The Johns Hopkins Medical Institutions, Baltimore, MD. Correspondence address: Elizabeth C Wick, MD, FACS, 600 North Wolfe St Blalock 618, Baltimore, MD 21287. email: ewick1@jhmi.edu 219 ª 2016 by the American College of Surgeons. Published by Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.jamcollsurg.2015.11.021 ISSN 1072-7515/15