Engage With Primary Care Providers By Chad M. Craig, MD, FACP E nhanced recovery programs surrounding surgery have the potential to assist with more than successful surgical outcomes alone. Enhanced Recovery Programs fall under the umbrella of Perioperative Surgical Homes, and integration of care between such programs and outpatient providers have the opportunity to strongly influence the trajectory of patients’ health beyond the surgical episode.1 An enormous amount of information is often gathered during the preoperative phase of care, including for example new diagnoses of anemia, type 2 diabetes mellitus, kidney disease, or cardiopulmonary disease. Such information is useful to the perioperative team, but often not reliably communicated during short-term transitions of care to rehabilitation facilities, or to outpatient primary care providers. This holds true for information gathered during the operative and post-operative periods as well, for example: a short run of atrial fibrillation intraoperatively that self-resolves and is of unclear clinical significance. At many hospitals there is a significant reliance on traditional discharge summaries from the index hospital stay, without verbal handoff of key information, or a reliable way to know if select information was reviewed and acted upon by a primary provider or specialist. Enhanced recovery programs have identified and bundled key interventions that are known to influence the success of surgical and patient outcomes.2 Functionality, pain, and quality-of-life are three key issues addressed in such programs, and this holds true for a wide range of surgical specialties: oncologic, orthopaedic, cardiovascular, and general surgery. These three issues are likewise of enormous importance to patients and primary care providers in the outpatient setting over the long term. Programs that optimize nutrition, and focus on healthy diets may translate in to long term healthy eating behaviors. Tobacco cessation programs, diabetes education, exercise, home safety, biofeedback and psychological health, and multimodal pain management programs are additional examples that have the potential to significantly impact how patients engage in and manage their longer term health. These are costly interventions and it would be a shame if we were to consider them one-and-done interventions surrounding the surgical episode. Many surgical-focused hospitals have invested enormous financial resources into programs to aide patients in achieving successful outcomes. Outpatient practices may not have the same resources, and could greatly benefit from information gathered by the former. Additionally, it often takes repeated clinical encounters with patients before unhealthy behaviors are altered, as for example with tobacco smoking cessation. From a longitudinal health viewpoint, one might view Enhanced Recovery Programs as similar to community health fairs: excellent opportunities to employ select highimpact health interventions, and change the trajectory of short and long term health. For large integrated health systems, the components and resources dedicated to Enhanced Recovery Programs will often overlap with the goals of other providers within the same system.3 However, within much of the United States patient care remains fragmented between multiple providers. For those 8 select centers that are optimizing patient care around the time of surgery and providing excellent outcomes through Enhanced Recovery Programs, there is a real opportunity for them to feedback that information and patient education strategies (where successful) with outpatient providers. This is especially true for geriatric patients, in whom medical comorbidity rates are high, and new medical issues are often identified in the setting of surgical stressors. A number of phone-based applications are increasingly offering an easy platform for such communication between providers. Proactive, goal-directed behavior that is often highlighted as part of Enhanced Recovery Programs, supports the concept of patients engaging in shared-decision making and playing an overall proactive role in their health.4 Patients should also proactively identify their support team before surgery, an overlooked area of importance highlighted by both patients and investigators alike in one study.5 The ASER ALERT • VOLUME 2, ISSUE 1 • aserhq.org transition home is identified frequently by patients as one of the most stressful periods of perioperative care,6 and having adequate resources identified proactively, as well as effective handoff to primary providers may aide in alleviating such anxiety. Engaging primary care providers directly in a consistent and systematic manner, during the preoperative and postoperative phases of care, is one practical strategy that may aide with such communication, and often yield additional pertinent health information not previously disclosed by patients. Additional strategies that ease the communication between Enhanced Recovery Program providers and primary outpatient providers would be welcome to this field. This is an area that would benefit from additional research, and no-doubt would be highly utilized in various health system structures throughout the country. n
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