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An overview and methodological assessment of systematic reviews and meta-analyses of enhanced recovery programmes in colorectal surgery.

ABSTRACT: To identify and critically assess the extent to which systematic reviews of enhanced recovery programmes for patients undergoing colorectal surgery differ in their methodology and reported estimates of effect.Review of published systematic reviews. We searched the Cochrane Database of Systematic Reviews, the Database of Abstracts of Reviews of Effects (DARE) and Health Technology Assessment (HTA) Database from 1990 to March 2013. Systematic reviews of enhanced recovery programmes for patients undergoing colorectal surgery were eligible for inclusion.The primary outcome was length of hospital stay. We assessed changes in pooled estimates of treatment effect over time and how these might have been influenced by decisions taken by researchers as well as by the availability of new trials. The quality of systematic reviews was assessed using the Centre for Reviews and Dissemination (CRD) DARE critical appraisal process.10 systematic reviews were included. Systematic reviews of randomised controlled trials have consistently shown a reduction in length of hospital stay with enhanced recovery compared with traditional care. The estimated effect tended to increase from 2006 to 2010 as more trials were published but has not altered significantly in the most recent review, despite the inclusion of several unique trials. The best estimate appears to be an average reduction of around 2.5?days in primary postoperative length of stay. Differences between reviews reflected differences in interpretation of inclusion criteria, searching and analytical methods or software.Systematic reviews of enhanced recovery programmes show a high level of research waste, with multiple reviews covering identical or very similar groups of trials. Where multiple reviews exist on a topic, interpretation may require careful attention to apparently minor differences between reviews. Researchers can help readers by acknowledging existing reviews and through clear reporting of key decisions, especially on inclusion/exclusion and on statistical pooling.

SUBMITTER: Chambers D

PROVIDER: S-EPMC4039862 | biostudies-other | 2014 May

REPOSITORIES: biostudies-other

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An overview and methodological assessment of systematic reviews and meta-analyses of enhanced recovery programmes in colorectal surgery.

Chambers Duncan D Paton Fiona F Wilson Paul P Eastwood Alison A Craig Dawn D Fox Dave D Jayne David D McGinnes Erika E

BMJ open 20140530 5

<h4>Objectives</h4>To identify and critically assess the extent to which systematic reviews of enhanced recovery programmes for patients undergoing colorectal surgery differ in their methodology and reported estimates of effect.<h4>Design</h4>Review of published systematic reviews. We searched the Cochrane Database of Systematic Reviews, the Database of Abstracts of Reviews of Effects (DARE) and Health Technology Assessment (HTA) Database from 1990 to March 2013. Systematic reviews of enhanced r ...[more]

PMID: 24879828

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Project description:ObjectivesTo assess the evidence on the impact of enhanced recovery programmes for patients undergoing elective surgery in acute hospital settings in the UK.DesignRapid evidence synthesis. Eight databases were searched from 1990 to March 2013 without language restrictions. Relevant reports and guidelines, websites and reference lists of retrieved articles were scanned to identify additional studies. Systematic reviews, RCTs not included in the systematic reviews, economic evaluations and UK NHS cost analysis, implementation case studies and surveys of patient experience in a UK setting were eligible for inclusion.Primary and secondary outcome measuresWe assessed the impact of enhanced recovery programmes on health or cost-related outcomes, and assessed implementation case studies and patient experience in UK settings. Studies were quality assessed where appropriate using the Centre for Reviews and Dissemination Database of Abstracts of Reviews of Effects critical appraisal process.Results17 systematic reviews and 12 additional RCTs were included. Ten relevant economic evaluations were included. No cost analysis studies were identified. Most of the evidence focused on colorectal surgery. 14 innovation case studies and 15 implementation case studies undertaken in National Health Service settings described factors critical to the success of an enhanced recovery programme. Evidence for colorectal surgery suggests that enhanced recovery programmes may reduce hospital stays by 0.5-3.5?days compared with conventional care. There were no significant differences in reported readmission rates. Other surgical specialties showed greater variation in reductions in length of stay reflecting the limited evidence identified. Findings relating to other outcomes were hampered by a lack of robust evidence and poor reporting.ConclusionsThere is consistent, albeit limited, evidence that enhanced recovery programmes can reduce length of patient hospital stay without increasing readmission rates. The extent to which managers and clinicians considering implementing enhanced recovery programmes in UK settings can realise savings will depend on length of stay achieved under their existing care pathway.

Project description:Rationale, aims, and objectivesCOVID-19 has caused an ongoing public health crisis. Many systematic reviews and meta-analyses have been performed to synthesize evidence for better understanding this new disease. However, some concerns have been raised about rapid COVID-19 research. This meta-epidemiological study aims to methodologically assess the current systematic reviews and meta-analyses on COVID-19.MethodsWe searched in various databases for systematic reviews with meta-analyses published between 1 January 2020 and 31 October 2020. We extracted their basic characteristics, data analyses, evidence appraisal, and assessment of publication bias and heterogeneity.ResultsWe identified 295 systematic reviews on COVID-19. The median time from submission to acceptance was 33 days. Among these systematic reviews, 73.9% evaluated clinical manifestations or comorbidities of COVID-19. Stata was the most used software programme (43.39%). The odds ratio was the most used effect measure (34.24%). Moreover, 28.14% of the systematic reviews did not present evidence appraisal. Among those reporting the risk of bias results, 14.64% of studies had a high risk of bias. Egger's test was the most used method for assessing publication bias (38.31%), while 38.66% of the systematic reviews did not assess publication bias. The I2 statistic was widely used for assessing heterogeneity (92.20%); many meta-analyses had high values of I2 . Among the meta-analyses using the random-effects model, 75.82% did not report the methods for model implementation; among those meta-analyses reporting implementation methods, the DerSimonian-Laird method was the most used one.ConclusionsThe current systematic reviews and meta-analyses on COVID-19 might suffer from low transparency, high heterogeneity, and suboptimal statistical methods. It is recommended that future systematic reviews on COVID-19 strictly follow well-developed guidelines. Sensitivity analyses may be performed to examine how the synthesized evidence might depend on different methods for appraising evidence, assessing publication bias, and implementing meta-analysis models.

Project description:To study the implementation of an enhanced recovery after surgery (ERAS) program at a large University Hospital from "pilot study" to "standard of care".The study was designed as a prospective single centre cohort study. A prospective evaluation of compliance to a protocol based on full application of all ERAS principles, through the progressive steps of its implementation, was performed. Results achieved in the initial pilot study conducted by a dedicated team (n = 47) were compared to those achieved in the shared protocol phase (n = 143) three years later. Outcomes were length of postoperative hospital stay, readmission rate, compliance to the protocol and morbidity. Primary endpoint was the description of the results and the identification of critical issues of large scale implementation of an ERAS program in colorectal surgery emerged in the experience of a single center. Secondary endpoint was the identification of interventions that have been proven to be effective for facilitating the transition from traditional care pathways to a multimodal management protocol according to ERAS principles in colorectal surgery at a single center.During the initial pilot study (March 2009 to December 2010; 47 patients) conducted by a dedicated multidisciplinary team, compliance to the items of ERAS protocol was 93%, with a median length of hospital stay (LOS) of 3 d. Early anastomotic fistulas were observed in 2 cases (4.2%), which required reoperation (Clavien-Dindo grade IIIb). None of the patients had been discharged before the onset of the complication, which could therefore receive prompt treatment. There were also four (8.5%) minor complications (Clavien-Dindo grade II). Thirty days readmission rate was 4%. Perioperative mortality was nil. After implementation of the protocol throughout the Hospital in unselected patients (May 2012 to December 2012; 147 patients) compliance was 74%, with a median LOS of 6 d. Early anastomotic fistulas were observed in 11 cases (7.7%), 5 (3.5%) of which required reoperation (Clavien-Dindo grade IIIb). Two early anastomotic fistulas were treated by radiologic/endoscopic manoeuvres and 4 were treated conservatively. There were also 36 (25.2%) minor complications, 21 (14.7%) of which were Clavien-Dindo grade II and 15 (10.5%) of which were Clavien-Dindo grade?I. Only two patients whose course was adversely affected by the development of an anastomotic leak had been discharged before the onset of the complication itself, requiring readmission. Readmission rate within 30 d was 4%. Perioperative mortality was 1%.Our results confirm that introduction of an ERAS protocol for colorectal surgery allows quicker postoperative recovery and shortens the length of stay compared to historical series.

Project description:BackgroundWith obesity prevalence projected to increase, the demand for bariatric surgery will consequently rise. Enhanced recovery programmes aim for improved recovery, earlier discharge, and more efficient use of resources following surgery. This systematic literature review aimed to evaluate the evidence available on the effects of enhanced recovery programmes after three common bariatric procedures: laparoscopic Roux-en-Y gastric bypass (LRYGB), laparoscopic sleeve gastrectomy (LSG), and one anastomosis gastric bypass (OAGB).MethodsMEDLINE, Embase, the Cochrane Library and the National Health Service Economic Evaluation Database were searched for studies published in 2012-2019 comparing outcomes with enhanced recovery programmes versus conventional care after bariatric surgery in Europe, the Middle East and Africa. Data were extracted and meta-analyses or descriptive analyses performed when appropriate using R.ResultsOf 1152 screened articles, seven relevant studies including 3592 patients were identified. Six reported outcomes for 1434 patients undergoing LRYGB; however, as only individual studies reported on LSG and OAGB these could not be included in the analyses. The meta-analysis revealed a significantly shorter mean duration of hospital-stay for LRYGB enhanced recovery programmes than conventional care (mean difference [95% CI]: -1.34 days [-2.01, -0.67]; p<0.0001), supported by sensitivity analysis excluding retrospective studies. Meta-analysis found no significant difference in 30-day readmission rate (risk ratio [95% CI]: 1.39 [0.84, 2.28]; p = 0.2010). Complication rates were inconsistently reported by Clavien-Dindo grade, but descriptive analysis showed generally higher low-grade rates for enhanced recovery programmes; the trend reversed for high-grade complications. Reoperation rates were rarely reported; no significant differences were seen.ConclusionThese results support enhanced recovery programmes allowing shorter inpatient stay without significant differences in readmission rate following LRYGB, although complication and reoperation rate comparisons were inconclusive. Further research is needed to fill current data gaps including the lack of studies on LSG and OAGB.

Project description:Importance:Enhanced Recovery After Surgery (ERAS) care has been reported to be associated with improvements in outcomes after colorectal surgery compared with traditional care. Objective:To determine the association between ERAS protocols and outcomes in patients undergoing elective colorectal surgery. Design, Setting, and Participants:The Postoperative Outcomes Within Enhanced Recovery After Surgery Protocol (POWER) Study is a multicenter, prospective cohort study of 2084 consecutive adults scheduled for elective colorectal surgery who received or did not receive care in a self-declared ERAS center. Patients were recruited from 80 Spanish centers between September 15 and December 15, 2017. All patients included in this analysis had 1 month of follow-up. Exposures:Colorectal surgery and perioperative management were the exposures. Twenty-two individual ERAS items were assessed in all patients, regardless of whether they were included in an established ERAS protocol. Main Outcomes and Measures:The primary study outcome was moderate to severe postoperative complications within 30 days after surgery. Secondary outcomes included ERAS adherence, mortality, readmissions, reoperation rates, and hospital length of stay. Results:Between September 15 and December 15, 2017, 2084 patients were included in the study. Of these, 1286 individuals (61.7%) were men; mean age was 68 years (interquartile range [IQR], 59-77). A total of 879 patients (42.2%) presented with postoperative complications and 566 patients (27.2%) developed moderate to severe complications. The number of patients with moderate or severe complications was lower in the ERAS group (25.2% vs 30.3%; odds ratio [OR], 0.77; 95% CI, 0.63-0.94; P?=?.01). The overall rate of adherence to the ERAS protocol was 63.6% (IQR, 54.5%-77.3%), and the rate for patients from hospitals self-declared as ERAS was 72.7% (IQR, 59.1%-81.8%) vs non-ERAS institutions, which was 59.1% (IQR, 50.0%-63.6%; P?<?.001). Adherence quartiles among patients receiving the highest and lowest ERAS components showed that the patients with the highest adherence rates had fewer moderate to severe complications (OR, 0.34; 95% CI, 0.25-0.46; P?<?.001), overall complications (OR, 0.33; 95% CI, 0.26-0.43; P?<?.001), and mortality (OR, 0.27; 95% CI, 0.07-0.97; P?=?.06) compared with those who had the lowest adherence rates. Conclusions and Relevance:An increase in ERAS adherence appears to be associated with a decrease in postoperative complications.

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An overview and methodological assessment of systematic reviews and meta-analyses of enhanced recovery programmes in colorectal surgery.

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An overview and methodological assessment of systematic reviews and meta-analyses of enhanced recovery programmes in colorectal surgery.

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