Financial incentives for the deployment of Enhanced Recovery After Surgery (ERAS) in the SwissDRG inpatient prospective payment system: a national study

Enhanced Recovery After Surgery (ERAS) protocols integrate multimodal perioperative care to improve patient recovery and outcomes1. Initially introduced for colorectal surgery, ERAS has since expanded across surgical specialties, with studies demonstrating reduced length of stay (LoS), fewer complications, and cost-effectiveness, particularly when used in abdominal surgery2. Diagnosis-related groups (DRG) determine reimbursement in the Swiss healthcare system (SwissDRG), each DRG endorsing a resource utilization score called cost weight (CW)3. Under SwissDRG, short LoS outliers trigger financial deductions from standard reimbursements (inlier CW), potentially penalizing hospitals adopting ERAS due to its LoS-reducing effects3. This study investigated ERAS impact on LoS for patients treated at ERAS and non-ERAS hospitals in Switzerland, and financial implications from both the hospital and healthcare system perspectives. Data were collected from a national benchmarking database of Swiss hospitals. The registry collects anonymous routine discharge-level and revenue data according to the national tariff structure, as well as costs uniformly calculated on a national scale. Stays from January to December 2022 were selected based on DRG related to pathologies of the digestive organs and hepatobiliary system/pancreas, Supplementary materials. LoS and cost–revenue analyses were performed. For readmissions occurring within 18 days after discharge, the associated costs were consolidated into the initial stay and therefore included. Comparisons of outcomes in academic and non-academic ERAS (ERAS-A and ERAS-NA) and non-ERAS (non-ERAS-A and non-ERAS-NA) hospitals were performed using standard statistics, Supplementary materials. For means calculated from variables that were already means, no standard deviation was reported. In 2022, 248/278 (89.2%) hospitals contributed to the national benchmarking database, and 132 (53.2%) provided acute somatic care. The relevant DRG were found in 111/132 (84.1%) hospitals, of which 15 (13.5%) deployed ERAS (ERAS-A: n = 2 and ERAS-NA: n = 13), whereas 96 were non-ERAS hospitals (non-ERAS-A: n = 3 and non-ERAS-NA: n = 93). A total of 142 755 hospital stays were collected, Supplementary materials. Overall, ERAS hospitals had a higher low LoS outlier rate than non-ERAS hospitals (8.5% versus 7.1%, P < 0.001), and mean coverage rates were 93.5% for ERAS and 94.6% for non-ERAS (P < 0.001). A significantly higher mean revenue occurred in non-ERAS hospitals, but mean costs/case were significantly lower in ERAS hospitals. Comparison of hospitals of the same size and scope is summarized in Table 1. Comparison of hospitals of the same size and ERAS Implementation. †Non-academic hospitals totaling more than 2500 discharges per year. ERAS-A, enhanced recovery after surgery (ERAS) certified academic (A) hospitals deploying ERAS in their surgical department; ERAS-NA, enhanced recovery after surgery (ERAS) certified non-academic (NA) hospitals deploying ERAS in their surgical department; LoS, length of hospital stay; DRG, diagnosis-related groups. Comparison of hospitals of the same size and ERAS Implementation. †Non-academic hospitals totaling more than 2500 discharges per year. ERAS-A, enhanced recovery after surgery (ERAS) certified academic (A) hospitals deploying ERAS in their surgical department; ERAS-NA, enhanced recovery after surgery (ERAS) certified non-academic (NA) hospitals deploying ERAS in their surgical department; LoS, length of hospital stay; DRG, diagnosis-related groups. The present results corroborate the findings of several large-scale studies showing that ERAS programmes decrease the postoperative LoS of surgical patients4,5, and confirmed ERAS as an efficient perioperative management pathway, as these protocols reduce variability in care, streamline processes, and improve outcomes. The mean cost per stay in ERAS-A hospitals was over 3800 Euros lower compared to non-ERAS-A hospitals and 1220 Euros in non-academic hospitals. However, due to financial issues specifically related to SwissDRG, the short LoS in ERAS hospitals resulted in a reduced reimbursement amount, leading to a loss of revenue for ERAS hospitals. Although costs are significantly lower in ERAS hospitals, the mean margin per case remains negative, in part due to the adjusted (reduced) reimbursement amount. From a healthcare system point of view, the lower costs and reimbursement amounts induced by ERAS hospitals represent substantial savings. However, as less than 14% of hospitals deployed ERAS in Switzerland, the real cost-saving potential revealed by the present study remains unexploited. Despite differing reimbursement systems, comparable costs make the issue of missed saving opportunities of non-ERAS hospitals warrant further studies across healthcare settings. The present study highlights important disincentives for wider ERAS deployment and sustainability in Switzerland, despite undeniable clinical benefits and cost-saving opportunities. It is therefore mandatory to adapt payment mechanisms and compensate for the loss of revenue induced by high-performing ERAS hospitals. Ultimately, the healthcare system could unlock substantial savings while improving the quality of care. This study received no funding. G.-R.J. and F.G. contributed equally and share first authorship. Valérie Addor was chair of the ERAS Implementation Committee and member of the Executive Committee of the ERAS Society. She is a consultant for Encare. The other authors have no conflicts of interest or financial ties to disclose. Supplementary material is available at BJS Open online. Gaëtan-Romain Joliat (Data curation, Formal analysis, Methodology, Writing—original draft, Writing—review & editing), Fabian Grass (Data curation, Formal analysis, Methodology, Validation, Writing—original draft, Writing—review & editing), Joachim Marti (Conceptualization, Data curation, Formal analysis, Supervision, Validation, Writing—review & editing), Valérie Addor (Formal analysis, Validation, Writing—review & editing), Lucien Gardiol (Formal analysis, Methodology, Validation, Writing—review & editing), Charles André Vogel (Formal analysis, Methodology, Validation, Writing—review & editing), Nicolas Demartines (Formal analysis, Project administration, Validation, Writing—review & editing), and Fabio Agri (Conceptualization, Data curation, Formal analysis, Project administration, Supervision, Validation, Writing—review & editing)