Research report: Impact of broadly targeted enhanced recovery after surgery protocols in hysterectomy versus other gynecologic surgeries

A broadly targeted Enhanced Recovery After Surgery (ERAS) pathway rolled out across six Iowa hospitals was associated with significantly lower opioid prescribing at discharge for gynecologic surgery patients, according to a retrospective chart review comparing hysterectomy patients with those undergoing other gynecologic procedures. The study, conducted under the "Billion Pill Pledge" ERAS initiative, examined surgeries performed between November 3, 2022 and April 4, 2024, and found that patient-reported prescription quantities after ERAS implementation were substantially lower than surgeon-estimated pre-ERAS prescribing levels for both patient groups. The research team, led by Tanya Li and colleagues, analyzed two cohorts: 63 patients who underwent hysterectomy and 30 patients who underwent other gynecologic surgeries, including cervical hysteroscopy, cesarean section, endometriosis excision or ablation, and sterilization procedures.

Before ERAS implementation, there was no significant difference in the mean number of opioid pills prescribed at discharge between the two groups. After the pathway was introduced, however, hysterectomy patients received a mean of 23 pills at discharge compared with 16 pills for other gynecologic surgeries, a statistically significant difference. The reduction in prescribing was notably uneven between the two procedure types.

The non-hysterectomy group saw a 40 percent decrease in prescribed pill counts following ERAS implementation, while the hysterectomy group achieved only a 14 percent reduction, a difference the authors report as statistically significant. This contrast suggests that while the broadly targeted pathway influenced prescribing across gynecologic surgery overall, hysterectomy patients continued to receive larger quantities of opioids at discharge than patients undergoing less invasive procedures. When the researchers compared patient-reported post-ERAS prescription quantities with surgeon-estimated pre-ERAS prescribing, the differences were significant for both groups.

For hysterectomies, patient-reported quantities averaged 23 pills versus a surgeon-estimated 27 pills before the pathway. For other gynecologic surgeries, the gap was wider: 16 pills reported after ERAS versus an estimated 29 pills before implementation. Despite the overall drop in prescribing, a substantial share of the opioids dispensed went unused.

On average, 55 percent of prescribed pills remained unused among hysterectomy patients and 65 percent among other gynecologic surgery patients, a difference that was not statistically significant. The authors emphasize that these high proportions of unused medication highlight the need for continued efforts to optimize postoperative opioid disposal practices, since excess pills retained in households pose ongoing risks for diversion and nonmedical use. The study sits within the broader context of the opioid epidemic in the United States, where postoperative prescribing has been recognized as a significant source of initial opioid exposure.

Midwestern states, including Iowa, have experienced substantial opioid-related morbidity and mortality, reflecting national trends of opioid misuse, diversion, and overdose. Excess postoperative prescriptions increase the availability of unused medications that are often stored at home, which is why reducing the quantity dispensed at discharge is considered a key lever for limiting community-level opioid exposure. The findings suggest that this broadly targeted approach may be associated with lower postoperative opioid prescribing in gynecologic surgery, with the largest absolute changes observed among non-hysterectomy procedures.

The authors caution that the analysis is a retrospective chart review with a relatively small sample, particularly in the non-hysterectomy group of 30 patients, and that the comparison of patient-reported post-ERAS quantities with surgeon-estimated pre-ERAS prescribing relies on estimates rather than direct measurements. As an observational study, it demonstrates associations between ERAS implementation and prescribing patterns rather than proving causation.

Subject of Research: Impact of a broadly targeted ERAS pathway on postoperative opioid prescribing in hysterectomy versus other gynecologic surgeries

Article Title: Impact of broadly targeted enhanced recovery after surgery protocols in hysterectomy versus other gynecologic surgeries

Article References: Li, T., Saroya, H., Lu, J., Pirzada, W. U., Shamith, S. F., Ramtin, S., & Ilyas, A. M. (2026). Impact of broadly targeted enhanced recovery after surgery protocols in hysterectomy versus other gynecologic surgeries. PLOS One, 21(10), e0360744. https://doi.org/10.1371/journal.pone.0360744

Image Credits: AI Generated

DOI: 10.1371/journal.pone.0360744

Keywords: ERAS, opioid prescribing, gynecologic surgery, hysterectomy, Billion Pill Pledge, postoperative pain, opioid epidemic, Iowa hospitals, retrospective chart review, opioid disposal, discharge prescriptions, Impact