Healthcare CEO dispels the myths surrounding ERAS

ERAS (enhanced recovery after surgery) was first introduced as a model of care in the late 1990s, and is increasingly earning the support of clinicians in a range of surgical treatment modalities.

The model, which uses a range of techniques to allow for faster post-operative recovery and mobilisation of patients, has been linked with a quicker return to function, reduced opioid usage, and lower infection rates. In turn, it has improved overall health outcomes and increased patient satisfaction.

Using minimally-invasive surgery, optimised anaesthetic techniques and outpatient rehabilitation care where needed, ERAS can also drastically reduce hospital stays and health expenditure for surgical procedures.

The model is particularly beneficial in the realm of joint replacement, where costs alone represent close to half of total benefit outlay for hospital services funded by private health insurers. For this reason, some have labelled ERAS care pathways a potential game changer for reducing health system expenditure.

Links to managed care

Despite the growth of its evidence base, there is still controversy in Australia surrounding the shift towards ERAS models of care.

In recent years, some have linked ERAS to US-style ‘managed care’, in which insurers decide where, how and by which doctors their members will be treated – a model that has been legislated against in Australia.

Given this comparison, some high-profile medical craft groups have backed a campaign to ‘send the eagle home’, expressing concerns with – what they perceive to be – US-style insurer influence sprouting in the Australian healthcare system.

An unfair comparison?

Chief Executive of Nexus Hospitals, Andrew Petering – a speaker at this year’s Short Stay Hospital Forum – believes this controversy is largely based on misinformation, and says the comparisons with managed care are unsubstantiated.

Mr Petering, who runs a national short stay hospital network of 28 facilities, highlights that one of the earliest privately funded short stay joint replacement programs in Australia was developed at a Nexus hospital in Melbourne. This involved orthopaedic surgeons, anaesthetists, physiotherapists, in conjunction with health insurer Medibank.

“The decision to use ERAS care pathways is a clinical decision for surgeons and does not involve a patient’s private health insurer. For the program at Vermont Private Hospital, we introduced an additional initiative to deliver the ERAS service along with a guaranteed zero out-of-pocket experience for the patient. This required significant engagement with insurers to cover medical gaps and make this model feasible,” claims Mr Petering.

“As this funding model has rolled out in a handful of other private hospitals in Australia, it has somehow led to a mindset amongst some elements of the healthcare sector that ERAS is an insurer-led initiative and therefore amounts to Managed Care. I can personally vouch for the fact that Medibank were at pains to ensure that they were not involved in the process of determining clinical pathways for individual patients.”

Statistics support  a broader roll-out of ERAS

ERAS pathways are an important development in the delivery of better clinical care. Whilst not suitable for every patient, ERAS models can offer improved outcomes and a better hospital experience for a large cohort of patients.

Given the potential to improve patient experience and sustainability of the health system overall, Mr Petering argues it is a model worth pursuing.
“We need to focus less on finding more funding to pay for healthcare, and focus more on ways to make quality healthcare more affordable,” he said.

The take-up of ERAS in offshore jurisdictions also indicates strong support from clinicians and reflects the mounting evidence of positive patient outcomes.

A growing body of studies have reviewed the impact of ERAS models, showing impressive results across a variety of measures. These include:

• 84 percent reduction in post-operative complications, with statistically significant reductions in a variety of conditions (including anaemia, haematoma, DVT, pain, nausea, urinary retention and hypotension) which are the primary causes of delaying discharge and /or readmission

• 10 percent improvement in pain and function

• 31 percent improvement in patient satisfaction rates compared with conventional surgery with patients being able to return home sooner.

A comparison of trends in reduced length of stay shows inpatient rehabilitation rates for joint surgery in the United States decreased from a peak of 35 percent in 2003 to 11 percent in 2009. In Ontario, Canada, rehabilitation rates dropped from 25 percent in 2009 to less than 10 percent in 2013.

These trends are in direct contrast to private inpatient rehabilitation in Australian private hospitals which increased from 31 percent in 2009 to 45 percent in 2016. These high rates of inpatient rehabilitation for joint replacement procedures are not supported by clinical evidence, failing to demonstrate improved functional outcomes compared to those discharged to community-based care.

So what is impeding the take-up of this surgical technique in Australia?

Perverse incentives could be to blame

Mr Petering accepts that meaningful change in healthcare is often slow and difficult and that the sector can be conservative and resistant to change. However, he believes perverse incentives may be to blame for the ERAS controversy.

He says these could be driven by entrenched behaviour, misinformation, and in some cases perverse financial incentives that perpetuate inefficient and wasteful practices. These include contractual arrangements put in place by private health insurers that encourage longer hospital stays and admissions for inpatient rehabilitation stays that may not be warranted.

“Ultimately, I believe we need to focus on what is in the best interests of patients first and foremost, and what is best for sustainability of the healthcare system overall. ERAS models have gained traction overseas because an increasing number of clinicians believe it delivers better outcomes for patients, improved patient satisfaction, and reduces overall costs of healthcare delivery”, he argued.

Airing more of his views on the ERAS controversy, Andrew Petering will present at the Short Stay Hospital Forum, hosted by Informa Connect.

This year’s event will be held on the 1st August at the Rendezvous Hotel Melbourne.

Learn more and register here.

Andrew Petering is Chief Executive of Nexus Hospitals. Nexus owns and operates 28 short-stay hospitals across Australia and provides over 175,000 procedures for patients every year. Mr Petering co-founded Nexus ten years ago with the acquisition of a single hospital in Melbourne and a corporate model focussed on genuine partnership with doctors and innovation in the delivery of optimised patient care.