Impact of the Quebec Provincial Enhanced Recovery After Surgery Program on Postoperative Outcomes for Patients Undergoing Colorectal Operation

BACKGROUND: Enhanced recovery after surgery (ERAS) pathways improve perioperative outcomes, yet large-scale implementation remains inconsistent. In 2022, Quebec launched a province-wide ERAS implementation program across all hospitals performing colorectal surgery with coordinated implementation and centralized data collection. STUDY DESIGN: Patients undergoing elective colectomy were included from pre-implementation (09-11/2022) and post-implementation (08/2024-01/2025) cohorts. Adherence to 18 ERAS process measures, hospital characteristics, and 30-day postoperative outcomes were collected. Primary outcomes were length of stay (LOS) and 30-day complications. Program effectiveness was evaluated using a continuous-treatment difference-in-differences analysis. RESULTS: Among 3,292 patients (1,405 pre-implementation; 1,887 post-implementation), adherence improved across all perioperative phases following implementation. Median LOS decreased from 4 to 3 days (p<0.001), while overall complication rates remained stable. At the hospital level, adherence improved in 49.2% of hospitals, was unchanged in 45.0%, and decreased in 6.6%. In adjusted analyses, each 10% increase in adherence was independently associated with an additional 0.11-day reduction in LOS (95% CI, 0.07-0.15) and a 5.5% reduction in complications (95% CI, 0.5-10.6) after implementation. CONCLUSIONS: Province-wide ERAS implementation was associated with higher adherence and shorter postoperative LOS without increased complications. Variation in adherence improvement across hospitals was associated with differences in outcomes, underscoring the importance of sustained ERAS adherence to maximize the benefits of large-scale quality improvement initiatives.