EP123 - Enhanced Recovery is Associated With a Reduction in Health-Literacy Related Disparities in Postoperative Length of Stay

Purpose/Background: Limited health literacy (HL) has been linked to poorer health outcomes, yet effective strategies to improve care for these patients remain under investigation. Enhanced Recovery After Surgery (ERAS) protocols-standardized patient-centered perioperative pathways-are associated with shorter post-operative recovery and fewer complications after colorectal surgery. Whether ERAS influences post-operative length of stay (LOS) across HL levels remains unclear. We hypothesized that standardized colorectal ERAS care would be associated with a greater reduction in LOS for patients with low HL compared to intermediate-high HL, helping to mitigate LOS disparities.

Methods/Interventions: This was a retrospective study of patients undergoing elective colorectal resection at a tertiary care referral center from 2014 to 2023. Health literacy was assessed via the validated Brief Health Literacy Screen (BHLS). Demographic, perioperative and ERAS data was derived from prospectively maintained ERAS database. The primary outcome was post-operative LOS stratified by HL level and receipt of ERAS pathway perioperative care. ERAS and non-ERAS cohorts were 1:1 propensity score matched on age, sex, race, ASA status, procedure type (MIS vs open for colon vs rectal cancer). Multivariable Poisson regression, additionally adjusted for year of surgery, evaluated LOS by HL category and ERAS participation to account for temporal trends in ERAS use.

Results/Outcomes: Among 2,146 patients (1,073 non-ERAS and 1,073 ERAS) who underwent colorectal resection, 165 (7.7%) had low HL (BHLS≤9) and 1,981 (92.3%) had intermediate-high HL (BHLS>9). Low HL patients tended to be older (median age 66.4 vs 56.5 years, p< 0.01), more likely to be male (67.3% vs 49.7%, p< 0.01), with higher ASA scores (73.3% vs 64.1% with ASA ≥3). There was no significant difference in cancer type or procedure type between HL groups. Among patients in the non-ERAS cohort, median LOS was longer for low vs intermediate-high HL (6 vs 4 days, p=0.008). In the ERAS cohort, median LOS was similar: 3 days (IQR 3-6) for low and 3 days (IQR 2-6) for intermediate-high HL patients (p=0.46). Overall ERAS adherence averaged 81.5%, 80.3% vs. 81.6% for low and intermediate-high HL patients (p=0.231).

Multivariable analysis adjusted for patient, procedure specific factors and year of surgery demonstrated a significant interaction between ERAS and HL (p=0.001). Predicted LOS for non-ERAS patients was longer for low vs intermediate-high HL (8.9 vs 6.4 days), narrowing to 4.9 vs 4.4 days in the ERAS cohort. In a sensitivity analysis defining the ERAS cohort as patients with ≥75% protocol compliance, adjusted LOS in the non-ERAS cohort was 8.2 vs 6.0 days for low vs intermediate-high HL, while LOS in the ERAS cohort remained similar (4.8 vs 4.4 days).

Conclusion/Discussion: Standardized ERAS pathway care was associated with shorter post-operative LOS for all patients and reduced differences in LOS among low and intermediate-high HL patients. Although limited by a small sample size of low HL patients and retrospective study design, these findings suggest that structured, protocolized perioperative care may have the potential to help mitigate HL-related disparities in surgical recovery, warranting further study.

Figure 1: Median LOS by Health Literacy Levels and Enhanced Recovery After Surgery (ERAS)