ERAS thyroidectomy within the Italian DRG-based public health system: surgical efficiency is penalized

Enhanced Recovery After Surgery (ERAS) pathways safely reduce length of stay (LOS) and resource use in many surgical fields, but their economic impact in thyroidectomy within the Italian National Health Service (SSN) is unclear, particularly under Diagnosis-Related Group (DRG) rules that penalize early discharge. A decision-analytic model compared an ERAS-inspired thyroidectomy pathway-same-day discharge after hemithyroidectomy and 24-hour discharge after total thyroidectomy-with a conventional DRG-driven pathway based on ≥2 postoperative inpatient days. The analysis adopted a hospital/provider perspective over 30 days, using data from a high-volume endocrine surgery unit and contemporary ERAS literature. Outcomes included LOS, postoperative complications, 30-day readmissions, direct hospital costs, and contribution margin under current SSN tariffs (including early-discharge penalties) and under a neutral reimbursement scenario. In hemithyroidectomy (400 cases/year), ERAS reduced mean LOS from 2.6 to 0.33 days (-2.27 days; p