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Impact of an Enhanced Recovery Program for Lower Extremity Bypass on Racial Disparities
Miles Morgan, Zdenek Novak, Marvi Tariq, Emily L Spangler, Benjamin J Pearce, Mark A Patterson, Marc A Passman, Adam W Beck
University of Alabama at Birmingham, Birmingham, AL

Background: The implementation of an enhanced recovery program (ERP) has previously been shown to mitigate racial disparities in outcomes after colorectal surgery; the objective of this project is to determine if similar results can be seen in an ERP program for lower extremity bypass.
Methods: This is a single center, retrospective analysis of lower extremity bypass patients treated from January 2016 to June 2022 before and after implementation of an ERP pathway in May 2018. The primary outcome was post-operative length of stay (pLOS) and secondary outcomes included total length of stay (LOS), complications, surgical site infections, readmission, re-intervention, and mortality at 1 month postoperative . Patients self-identifying as Black or White were included in the analysis. Only the initial procedure was analyzed in patients receiving multiple procedures on the same leg within one year. Geographic measures of external stresses on health were also assessed via the Area Deprivation Index (ADI) and the Social Vulnerability Index (SVI). Chi-Squared and Mann-Whitney testing was performed between pre-ERP vs ERP and stratified by race.
Results: Of the 387 patients (158 pre-ERP and 229 ERP), 39.8% were Black. Black and White patients had similar body mass index, smoking status, diabetes, age, and American Society of Anesthesiologists class, but were dissimilar with respect to insurance status, sex, ADI, and SVI (Table 1). There was no significant difference in pLOS observed in Black patients pre-ERP vs with ERP (6 [5-9] vs 5 [3-10.75] days p=.11)(Table 2). However, pLOS in ERP White patients was 2 days shorter than that of pre-ERP White patients (6 [4-8] vs 4 [3-6.5] days p<.001). Greater receipt of ERP elements (>70% of ERP elements) correlated with shorter pLOS. Within the ERP cohort, ERP Black patients with >70% protocol element receipt, had a 3.5-day shorter median pLOS compared to those with <70% protocol element receipt (P<0.01). In ERP White patients with >70% protocol element receipt, a 3-day shorter median pLOS was seen in comparison to those with lower ERP intervention penetrance (P<0.001). This shorter length of stay in ERP patients with >70% of protocol element receipt was also apparent relative to respective historical (pre-ERP) pLOS patients in both Black (2-day shorter pLOS, p<.01) and White (3-day shorter pLOS, p<.001) patients. Secondary outcomes of complications, surgical site infections, readmission, reintervention, and mortality did not significantly differ across racial and ERP groups at 1 month (Table 2).
Conclusions: After implementation of an enhanced recovery protocol for lower extremity bypass, a significant reduction in both total and post-operative length of stay was achieved, which was statistically significant in White but not Black patients. When accounting for degree of protocol receipt, the racial disparity was less apparent, indicating areas for focused improvement in the future.

Patient Demographics
Pre-ERP Black n=54Pre-ERP White n=104Pre-ERP p-valueERP Black n=100ERP White n=129ERP p-valueOverall p-value
Age (mean)62.4365.840.0463.064.170.360.31
BMI (mean)28.9628.600.7227.2927.540.740.03
National ADI (mean)81.8265.82<0.00183.1667.09<0.0010.25
SVI (mean)0.670.40<0.0010.700.41<0.0010.14
ASA Class 420.4%22.5%0.7520%12.4%0.120.13

Patient Outcomes
Pre-ERP Black n=54Pre-ERP White n=104Pre-ERP p-valueERP Black n=100ERP White n=129ERP p-valueOverall p-value
Post-op Length of Stay, median (IQR)6 (5-9)6 (4-8)0.085 (3-10.75)4 (3-6.5)<0.001<0.001
Total Length of Stay, median (IQR)10 (5-16)7 (4-12)0.069 (4-18.5)5 (3-9)<0.001<0.01
30-day Complications22360.4544480.30.28
30-day Surgical Site Infections9100.2980.420.26
30-day Readmissions15220.3519170.230.07
30-day Reinterventions17280.5532340.350.87
30-day Mortality020.31010.380.43

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