Financial and documentation-related workload impact of ERAS implementation in major head and neck surgery with free flap reconstruction under the Japanese DPC system

BACKGROUND: Enhanced recovery after surgery (ERAS) improves postoperative recovery in head and neck oncologic surgery. However, its institutional impact under the Japanese Diagnosis Procedure Combination (DPC) system, particularly regarding hospital revenue and frontline workload, remains unclear. METHODS: This retrospective cohort study included patients who underwent major resection of malignant head and neck tumors with free tissue transfer reconstruction at the National Cancer Center Hospital between April 2018 and March 2022. Patients were classified into pre-ERAS and post-ERAS groups according to implementation of the PreSte ERAS protocol in May 2020. Financial outcomes included DPC revenue, fee-for-service revenue, total hospital revenue, and revenue efficiency defined as revenue per hospital day. Frontline workload was assessed using the total number of characters documented in electronic medical records by non-physician healthcare professionals. RESULTS: A total of 310 patients were analyzed (155 per group). Median length of stay decreased after ERAS implementation (25 vs. 23 days; p = 0.002). Total revenue showed a non-significant decreasing trend after ERAS implementation (109,360 vs. 98,626 points; p = 0.104). Revenue efficiency increased after ERAS implementation (3627 vs. 3984 points per hospital day; p < 0.001). Documentation volume tended to increase but did not differ significantly overall. Sensitivity analysis excluding free fibula flap reconstruction showed consistent results. CONCLUSION: ERAS implementation was associated with shorter hospitalization and improved revenue efficiency under the Japanese DPC-based system. Although total revenue did not increase, and an increased multidisciplinary workload cannot be excluded, these findings support the potential institutional feasibility of ERAS.