ERAS thyroidectomy within the Italian DRG-based public health system: surgical efficiency is penalized

Enhanced Recovery After Surgery (ERAS) pathways safely reduce length of stay (LOS) and resource use in many surgical fields, but their economic impact in thyroidectomy within the Italian National Health Service (SSN) is unclear, particularly under Diagnosis-Related Group (DRG) rules that penalize early discharge. A decision-analytic model compared an ERAS-inspired thyroidectomy pathway-same-day discharge after hemithyroidectomy and 24-hour discharge after total thyroidectomy-with a conventional DRG-driven pathway based on ≥2 postoperative inpatient days. The analysis adopted a hospital/provider perspective over 30 days, using data from a high-volume endocrine surgery unit and contemporary ERAS literature. Outcomes included LOS, postoperative complications, 30-day readmissions, direct hospital costs, and contribution margin under current SSN tariffs (including early-discharge penalties) and under a neutral reimbursement scenario. In hemithyroidectomy (400 cases/year), ERAS reduced mean LOS from 2.6 to 0.33 days (-2.27 days; p<0.001), freeing 908 bed-days annually and lowering variable costs by €1,332 per patient, without increasing complications or readmissions. Despite a 30% DRG penalty for LOS <2 days, the contribution margin increased by €147 per case. In total thyroidectomy (600 cases/year), ERAS reduced LOS from 3.1 to 1.16 days (-1.94 days; p<0.001) and variable costs by €1,079 per patient, again without compromising safety. However, DRG penalties reduced the margin by €481 per case, resulting in an annual loss of approximately €289,000 despite substantial real-resource savings. Overall, ERAS reduced mean LOS by 2.1 days and variable costs by €1,190 per patient across 1,000 procedures. ERAS thyroidectomy is clinically safe and markedly reduces LOS and hospital costs, but current SSN DRG rules penalizing early discharge blunt or reverse its financial benefits for public hospitals, particularly for total thyroidectomy. These findings highlight a structural mismatch between surgical efficiency and reimbursement incentives and support revising thyroidectomy tariffs to reward evidence-based early discharge. Because this is a model-based economic evaluation, these results should be interpreted as scenario-based evidence rather than as definitive real-world cost-accounting estimates.