Effect of Enhanced Recovery After Surgery on Racial Inequalities in Prescribing Practices for Autologous Breast Reconstruction

Abstract

Background

Enhanced recovery after surgery (ERAS) pathways have improved surgical outcomes and reduced narcotic needs. This study evaluated racial differences in our institution's opioid prescribing practices in autologous breast reconstruction before and after ERAS implementation.

Methods

This was a retrospective review of consecutive patients undergoing autologous breast reconstruction from 2013 to 2021, pre-ERAS and after ERAS implementation. Primary outcomes were morphine milligram equivalents (MME) for intravenous (IV) and oral (PO) narcotics peri- and postoperatively. Secondary outcomes included infection, delayed wound healing, and need for reoperation.

Results

Of 163 patients, 150 met inclusion criteria. The pre-ERAS group comprised 65 patients (35% Black, 65% White), and the ERAS group included 85 patients (44% Black, 54% White). Pre-ERAS, Black patients received more IV narcotics than White patients, 814 versus 505 MME (p < 0.05). There was no difference between inpatient and outpatient PO MME (p > 0.05). ERAS decreased IV MME 10-fold (p < 0.05) and decreased inpatient PO MME approximately 3-fold (p < 0.05). Nevertheless, racial differences existed in IV narcotics (80 vs. 58 MME; p <0.05) and inpatient PO narcotics (93 vs. 59 MME; p < 0.05). Black race was a significant positive predictor in univariate and multivariate analyses for IV MME in both pre-ERAS and ERAS.

Conclusion

Black patients unexpectedly received more IV narcotics pre-ERAS. Although ERAS decreased inpatient opioid administration, racial differences persisted; Black patients also received more PO narcotics, contrary to literature findings of systemic pain undertreatment. Standardized protocols alone may be inadequate to address complexities of postoperative pain.

Keywords

breast reconstruction - opiates - racial inequalities

Note

ERAS USA 2021.

ASRM 2022 Poster Presentation.

Publication History

Received: 02 December 2024

Accepted: 01 June 2025

Article published online:
03 July 2025

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