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December 19, 2024
At the 2023 Annual Conference for the American Society for Enhanced Recovery and Perioperative Medicine (ASER PM), four themes really stood out:
- What’s next for Enhanced Recovery After Surgery (ERAS)
- Data, Data, Data
- Remote Monitoring and Digital Health to accelerate ERAS success
- Patient-Reported Outcomes (PROs) for ERAS
1. What’s Next for Enhanced Recovery After Surgery (ERAS)
In the opening session, Dr. Matthew McEvoy, President of ASER PM, introduced a theme that would resonate for the event: where does ERAS go from here?
Enhanced Recover After Surgery (ERAS) has been around for almost 30 years now. ERAS pathways and their associated evidence are fairly well established. Although we can always do better with compliance, the nuts and bolts of how to do ERAS successfully are pretty well understood.
We are now seeing health systems with established ERAS programs look to expand the time period for optimizing the patient journey. Acronyms such as Enhanced Prehab Anticipating Surgery (EPAS) and Enhanced Health After Surgery (EHAS) are springing up as healthcare teams look to do more for patients beyond the acute perioperative episode.
Expanding on this further, Dr. TJ Gan, Founding President of ASER PM and Chair of Anesthesiology at MD Anderson, outlined the next four trends he sees in the evolution of ERAS:
- Prehabilitation and optimization for high-risk patients
- Improving patient experience and functional outcomes (e.g. PROs/PROMs)
- Optimizing existing pathways and developing new pathways
- Leveraging digital health, AI and innovation to enhance ERAS
Unsurprisingly many of these topics showed up throughout the event.
2. Data, Data, Data
Numerous experts impressed on the audience the importance of collecting both leading and lagging indicators of ERAS success.
Leading indicators were primarily compliance with ERAS process measures. For instance, Wazim Narain, Director of Data Analytics of Northwell Health, shared examples of the ERAS compliance dashboards his team provided when he previously worked at Memorial Sloan Kettering Cancer Center:
The Vanderbilt University Medical Center clinical informatics team, led by Dr. John Wanderer, Associate CMIO, and in partnership with Dr. McEvoy, Co-Director of ERAS, advocated for tracking lagging indicators over time via outcomes dashboards: length of stay, readmissions, surgical site infections, and more:
Of course, a common question among attendees: what do you do if you don’t have a robust clinical informatics team at your disposal? There doesn’t seem to be a good answer for that just yet unfortunately.
Certainly ERAS compliance and clinical outcomes are not new concepts for many folks experienced with ERAS. So what’s emerging when it comes to tracking outcomes?
Days Alive at Home 30 Days After Surgery (DAH30) was introduced as a relatively new measure to consider tracking. It’s not completely new as it’s been around in healthcare for some time, however it’s not commonly tracked. Essentially DAH30 is the number of days the patient spent at home after surgery but within the first 30 days post-surgery - however, if the patient dies at any point in those 30 days, the value is 0. The idea is this provides a more holistic assessment of a successful surgical recovery. In other words: if a patient has a short length of stay but still dies at home soon after, how good is that outcome, really?
3. Remote Monitoring and Digital Health to Accelerate ERAS Success
Dr. Ashish Khanna, Director of the Perioperative Outcomes and Informatics Collaborative at Atrium Health, explored how healthcare can learn from aviation. In the same way that aircrafts use flight recorders to not make assumptions about flight safety, shouldn’t healthcare also do monitoring to accurately understand patient health status?
In particular, Dr. Khanna, whose work has focused on real-time patient monitoring on hospital wards, advocated that evaluating monitoring technologies in an unrealistic study setting is not good enough - technology such as monitoring must happen in real world settings. For example, what if a patient on a monitor starts walking the hallways - does the monitoring still work?
Importantly, Dr. Khanna’s team recently published research that shows that increased post-op mobilization (based on data from wearables) was associated with shorter hospital length of stay and fewer post-op complications. Just more data supporting the importance of getting patients ambulating early after surgery!
What about using technology to engage patients pre-op and post-discharge? Dr. Traci Hedrick, Chief of General Surgery at UVA Health System, explored how this is an important opportunity to address because data shows there is a correlation between increased travel distance for patients and worse outcomes.
For instance, work done by Dr. Hedrick’s team using wearables found a clear association between increased pre-op walking and decreased post-op complications. In fact, adding mobility/activity data to the NSQIP risk calculator made the model even more predictive of post-surgical risk of readmissions.
Looking at post-discharge monitoring using Digital Health platforms, Dr. Hedrick identified four key benefits:
- Enable early discharge
- Early detection of surgical complications
- Better communication between patients and providers
- Improved patient engagement
Digital Health was even recognized on the awards podium as Cheryl Crisafi, Cardiac ERAS nurse leader at Baystate Health, won the Overall Abstract Award for her research poster on "Use of a Digital Platform to Foster Patient Engagement and Collect Patient Reported Outcomes to Customize Care". Cheryl’s team at Baystate Health implemented a digital care journey platform to automate delivery of ERAS patient education, collect PROs, and remotely monitor patients after surgery - leading to reductions in length of stay, ED visits and readmissions. Click here for more details on how Cheryl and Baystate designed and implemented this digital platform.
4. Patient-Reported Outcomes (PROs) for ERAS
As patient engagement and patient-centered outcomes become increasingly valued by CMS and payers, it’s a natural extension for ERAS programs to collect PROs/PROMs as well. Dr. McEvoy called out the QoR-15 and WHODAS 2.0 in particular as PROMs to consider collecting for ERAS programs. For more on collecting PROMs for ERAS, click here for the 2018 ASER PM <> POQI recommendations on the topic.
But beyond collecting PROs/PROMs, how do you use those scores to improve patient care? Dr. McEvoy explained the importance of understanding the Minimum Clinically Important Difference (MCID) for specific PROM surveys - in other words, understanding the smallest improvement in PRO/PROM scores considered worthwhile by a patient.
For example, research shows that an improvement/decline of 6% for QoR-15 and 5% for WHODAS 2.0 is meaningful for patients. So if an intervention such as ERAS can improve patient recovery at least this much, then that’s a material improvement for the patient experience.
Looking ahead to ERAS in 2024
ERAS is bigger than ever before and it won’t be long before it is truly the standard of care in North America. With the right technology and change management strategies, health systems can leverage ERAS to be a strategic tool to improve quality and patient safety, while also keeping staff satisfaction high.
Interested in further exploring how digital patient engagement can amplify ERAS success?
Download our white paper to learn how you can leverage technology to deliver standardized ERAS patient education, improve patient compliance, decrease opioid use, and reduce high cost services like readmissions, length of stay and ED visits.
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