Barriers to implementation of enhanced recovery after surgery (ERAS) by a multidisciplinary team in China: a multicentre qualitative study

Objective To explore the attitudes and barriers encountered in the implementation of enhanced recovery after surgery (ERAS) in China from the perspective of multidisciplinary team members. Design Based on Donabedian’s structure–process–outcome (SPO) model, a multicentre qualitative study using semistructured interviews was conducted. Setting From September 2020 to December 2020, the participants of this study were interviewed from six tertiary hospitals in Sichuan province (n=3), Jiangsu province (n=2) and Guangxi province (n=1) in China. Participants A total of 42 members, including surgeons (n=11), anaesthesiologists (n=10), surgical nurses (n=14) and dietitians(n=7) were interviewed. Results Multidisciplinary team (MDT) members still face many barriers during the process of implementing ERAS. Eight main themes are described around the barriers in the implementation of ERAS. Themes in the structure dimension are: (1) shortage of medical resources, (2) lack of policy support and (3) outdated concepts. Themes in the process dimension are: (1) poor doctor–patient collaboration, (2) poor communication and collaboration among MDT members and (3) lack of individualised management. Themes in the outcome dimension are: (1) low compliance and (2) high medical costs. The current implementation of ERAS is still based on ideas more than reality. Conclusions In general, barriers to ERAS implementation are broad. Identifying key elements of problems in the application and promotion of ERAS from the perspective of the MDT would provide a starting point for future quality improvement of ERAS, enhance the clinical effect of ERAS and increase formalised ERAS utilisation in China.


REVIEWER
Gramlich , Leah University of Alberta, Medicine REVIEW RETURNED 13-Sep-2021

GENERAL COMMENTS
Thanks for this paper. The rationale for using the donabedean approach -SPO -needs more justification and perhaps an acknowledgement of other potential approaches The lack of description of ERAS program characteristics/expectations within the programs (eg -do they use an evidence based care pathway, do they use implementation teams to review data and practices with change management approaches, do they use an audit system to inform practice change) is a gap The authors do not describe involvement of either patients or health system leaders -this is a gap that could be explained in the discussion The current evidence on barriers and enablers to ERAS care is not completely described based on the literature The process/approach to qualitative evaluation is not well described -eg how and whata themes were identified this needs a significant rewrite but it is important information

VERSION 1 -AUTHOR RESPONSE
Reviewer: 1 Dr. Martin HUBNER, CHUV Lausanne 1. The manuscript is overly descriptive and much too long. Despite the qualitative nature, hrouping of answers in form of tables and comparisons between professions would be helpful for understanding, joy of reading and shortening of the manuscript.
Response: Thank you very much for this good suggestion. According to your suggestion, we simplified the content of the results and made tables of all quotes, namely Table 2 to Table 5 of the attached "Main Document-marked copy ".
2. What are next steps? This should be stated in the conclusion which is currently more than vague.
Response: Thank you for such detailed advice. According to your suggestion, we described our next plan in detail. They are the highlights in lines 486-490 of the attached "Main Document-marked copy ".
The specific content is as follows: More quality improvement research, evaluation and audit will be needed to improve the application effect of ERAS in the future. We hope that this study provides a starting point for future quality underpinnings in that good structure should promote good process and good process should promote good outcomes, which is conducive to guiding the effective improvement of medical quality. Error! Reference source not found. Therefore, the approach of Donabedian is valuable in conceptualizing and organizing medical quality evaluation, Error! Reference source not found. and has been widely adopted in the research of ERAS quality evaluation. Error! Reference source not found. In this qualitative interview study, the SPO model was used to analyze the barriers of structure, process, and outcome that potentially affect the implementation of ERAS programs. Response: Thank you for such detailed advice. We have added this part to the sample of the method.
They are the highlights in lines 166-168 of the attached "Main Document-marked copy ". The specific content is as follows: surgical nurses and 7 dietitians; 9 were excluded: 2 for poor quality of recording, 2 for schedule clash, 5 for data saturation.
6. To what extent can the results be generalized to the world or at least to the rest of China?
Response: Thank you for such detailed advice. According to your suggestion, we described our expected influence in China. They are the highlights in lines 481-483 of the attached "Main Document-marked copy ". The specific content is as follows: This study is a multicentre qualitative study, and all hospitals included belong to the southern region of China. Therefore, our results can partially reflect the application status of ERAS in the southern region.
7. some details on ERAS implementation should be given: implementation process, year of implementation in the centers, fields of surgery implemented; provide institutional protocol as online appendix; provide some data on compliance in the different centers.
Response: Thank you for such detailed advice. According to your suggestion, we have uploaded supplementary material including the implementation process, year, surgical field, compliance, and institutional protocol. The institutional protocol we signed in September is the Chinese version. If you need the English version, we will re-sign the institutional protocol later. underpinnings in that good structure should promote good process and good process should promote good outcomes, which is conducive to guiding the effective improvement of medical quality. Error! Reference source not found. Therefore, the approach of Donabedian is valuable in conceptualizing and organizing medical quality evaluation, Error! Reference source not found. and has been widely adopted in the research of ERAS quality evaluation. Error! Reference source not found. In this qualitative interview study, the SPO model was used to analyze the barriers of structure, process, and outcome that potentially affect the implementation of ERAS programs.
2. The lack of description of ERAS program characteristics/expectations within the programs (eg -do they use an evidence based care pathway, do they use implementation teams to review data and practices with change management approaches, do they use an audit system to inform practice change) is a gap.
Response: Thank you for such detailed advice. According to your suggestion, we have added the description of ERAS program characteristics/expectations within the programs. They are the highlights in lines 370-373 of the attached "Main Document-marked copy ". The specific content is as follows: Although medical staff implement the ERAS programs under the guidance of the ERAS guidelines, we found that the audit system has not been established or perfected, many feedback problems cannot be effectively resolved, causing MDT members to face many barriers in the process of implementing ERAS.
3. The authors do not describe involvement of either patients or health system leaders -this is a gap that could be explained in the discussion.
Response: Thank you for such detailed advice. According to your suggestion, we have provided supplementary explanations for this part of the content. They are the highlights in lines 468-473 of the attached "Main Document-marked copy ". The specific content is as follows: Finally, this study did not interview members of all disciplines involved in the implementation of ERAS, such as pharmacists and rehabilitation doctors. In addition, the attitudes and opinions of health system leaders and patients play a vital role in the application and development of ERAS. In the future, we will further expand the types of research objects and improve the research content.
4. The current evidence on barriers and enablers to ERAS care is not completely described based on the literature.
Response: Thank you for such detailed advice. According to your suggestion, we have added key references on barriers and enablers to ERAS care. They are the highlights in lines 558-570, 574-577, 587-590, 595-610, 613-627 and 631-634 of the attached "Main Document-marked copy ".
5. The process/approach to qualitative evaluation is not well described -eg how and whata themes were identified. this needs a significant rewrite but it is important information.
Response: Thank you for such detailed advice. According to your suggestion, we described the collection and analysis of the data in the method in detail. They are the highlights in lines180-235 of the attached "Main Document-marked copy ". The specific content is as follows:

Data collection
Interviewees were categorized by location of work site (i.e., Sichuan, Jiangsu or Guangxi Province) and role (i.e., surgeon, anaesthesiologists, surgical nurse and dietitian

Data analysis
The recorded interview was transcribed verbatim within 24 hours by member of the research team. Transcribed scripts were assigned a unique code in the order of interviews, and names were removed to align with confidentiality. Data analysis followed an thematic approach of induction and explanation, Error! Reference source not found. applying principles of constant comparison to analyze differences across cases. Error! Reference source not found. Main concepts and themes within the data were identified through a combination of open coding and thematic analysis. Error! Reference source not found. Error! Reference source not found. The research team repeated line-by-line reading of the transcripts. Following familiarization, the research team manually did open coding, drawing on their rich clinical experiences, and recorded these codes on the margin of the printed transcript. Error! Reference source not found. These codes were subsequently grouped according to the SPO model. Through clustering and integration of codes, themes of each dimension were determined. Themes were considered for inclusion in this report if they were prominent.
Prominent themes were further explored in context through in-depth reading and refined until saturation was reached. Error! Reference source not found. To ensure reliability, the research team met regularly to review the coded data, verify its relevance to main themes, discuss the