Enhanced Recovery: A Team Approach to Managing Postoperative Ileus - Episode 3

Goals of ERAS Protocols Under Value-Based Care

Raoul Concepcion, MD: Declan, what are the goals? What would the goals of an ERAS program be? You’re setting this up in the new medical school, right?

Declan Fleming, MD: Well, ultimately the goal is to shepherd the patient through his or her recovery from surgery in as timely a fashion as possible, with as few problems as possible. Now, to do that, again, you have to get a large number of people involved. As we’ve all said, there are so many people that touch the patients as they go through the process. Anyone can disrupt or redirect the process. And so, everyone has to be on the same page. I don’t think any of us can emphasize that enough.

I love what was said—about revisiting. Again, you’ve got to audit what you’re doing because there will be successes to see which will encourage people; but there will also be a lot of variations away from the protocol. Unless you recognize that and go back to try to readdress that and ask people, “Why aren’t we doing this? What’s the reason behind this?”, you have no possibility of going forward. Essentially, that’s one of the hallmarks of value-based medicine—looking critically at what we’re choosing to do, seeing if it works, and seeing how that affects the outcome. And ultimately, of course, that affects cost and value to the patients and to society.

Raoul Concepcion, MD: Right, that’s the basic definition of value-based care—outcomes divided by cost, obviously in this budget neutral area that we are in. But the outcomes have to be measurable.

Declan Fleming, MD: Absolutely.

Raoul Concepcion, MD: Traci, when you are monitoring your data and monitoring your programs, what sort of metrics are you guys looking at in Virginia?

Traci Hedrick, MD, MS, FACS, FACRS: I think it’s very important to establish a database or some type of way you can monitor the outcome. The primary thing we look at is length-of-stay. You’ll find, in most enhanced recovery programs, that’s the primary outcome. You can’t look at length-of-stay without looking at readmission rates. It doesn’t help anybody if you get them out of the hospital sooner only to have them come back 24 hours later.

You also want to look at complications. At Virginia, we reduced our postoperative complications by half, and that was primarily due to reductions in ileus and surgical site infections, which has also been demonstrated time and time again. In addition to that, you want to look at patient satisfaction. We use HCAHPS (Hospital Consumer Assessment of Healthcare Providers and Systems) scores. There are other types of patient-reported outcomes that you could look at. And then, we look at costs. We started in colorectal. We have gone, now, to gynecology, thoracic, hepatobiliary, and we’re starting orthopedics next week. In all of those, we’ve demonstrated substantial reductions in cost. In thoracic, we were just reviewing the data recently. It was $10,000 per-patient reduction in 30-day total costs. When you calculate by the number of patients in the hospital, that can be a substantial reduction.

Raoul Concepcion, MD: So, as you look at various specialties, obviously one of the things that we’ll have a big discussion on is postoperative ileus. But when you look into some of the non-anastomotic specialties where we don’t have a gastrointestinal anastomosis, obviously, like joint replacement, thoracotomies, or radical prostatectomies, what are some of the commonalities as you develop programs for those individual surgical subspecialties that really do equate across the board for all specialties?

Traci Hedrick, MD, MS, FACS, FACRS: I think one of the primary tenets is pain control. There are huge side effects to opioids beyond just ileus, which is the primary thing that we worry about in gastrointestinal surgery. There is the potential for abuse, or the delirium in the elderly orthopedic patient, potentially in thoracic surgery. So, I think that’s one of the primary tenets. But, all of the rest of enhanced recovery is really just common-sense things that affect patients’ satisfaction. It’s the right thing to do for the patients, and that equates to improved outcomes in most all specialties that have been investigated.

Transcript edited for clarity.