A Call for Engagement with the Surgical Patient

As new healthcare systems develop to include integrated health delivery networks focusing on patient outcomes, we are witnessing a shift from an emphasis on diseasecentered care to patient-centered care, encouraging patient involvement in their own medical treatment plan. Even as reimbursement models similarly transition from a traditional fee-for-service to value-based delivery, it is imperative to consistently prioritize optimal patient outcomes. Hospital systems have focused on quality initiatives to ensure improved patient outcomes via error reduction, implementation of clinical practice guidelines, and a teambased multidisciplinary approach to medical care. We have also witnessed a departure from a traditional patriarchal approach to medicine, with an increasing emphasis on including patients as partners in their healthcare journey. Indeed, in general medicine, there is a well-established link between patient engagement with medical care (eg diet, exercise, and medication adherence) and improved outcomes from conditions such as cardiac disease, diabetes, and hypertension. Actively recruiting patients to participate in their perioperative health care may prove challenging, but available evidence suggests it may lead to drastically improved outcomes and lower overall healthcare costs. In light of this evidence, we advocate for further study of patient engagement in surgery in order to identify avenues for improvement. Our analysis reveals that a number of surgical programs have already employed variations of patient engagement standards. As one of the first incentivized surgical programs, the Comprehensive Care for Joint Replacement is the first bundled payment program sponsored by Centers for Medicare and Medicaid Services (CMS). This plan targeted approximately 800 hospitals and proposed a bundle payment for all perioperative care involved in joint replacement care for up to 90 days, including readmissions, prolonged stays, rehab, physical therapy, and medications. Participating hospital systems that reduce costs and improve outcomes receive bonus reimbursements, and low-achieving hospitals may actually receive reduced payments. In response to incentives for lower readmissions and complications, several joint replacement programs have implemented aggressive measures to target patient education to improve patient understanding of perioperative care and thereby avoid increased readmission rates and unfavorable outcomes. These patient education targets include endorsing discussions with case management prior to every case, providing online tools for patient education about rehabilitation, and identifying high-risk patients with modifiable risk factors such as weight control or smoking cessation and formally addressing these prior to and following surgery. Early postoperative follow-ups are conducted via telephone to provide additional postoperative guidance and to identify patients who may be at risk for early readmission. Other programs utilizing patient engagement to improve outcomes are (i) enhanced recovery after surgery (ERAS) and (ii) the perioperative surgical home (PSH). ERAS programs use preoperative education to improve nutrition, to increase focus on preand postoperative pain management to limit opioid use, and to initiate early dieting and mobilization. Studies have found these implementations reduce length of stay and improve outcomes, and at the heart of these programs is the education and engagement of the patient into these practices. The PSH is a continuum of perioperative care led by physician anesthesiologists. Using similar methods to the ERAS protocol but led by the anesthesia team, the goal of the PSH is to limit opioids during and after the hospital stay, improve postoperative care, limit hospital length of stay, and improve patient-related surgical and anesthetic complications. The core of the experience is the shared decision-making and engagement of the patient with the hospital staff. Given these obvious early successes in improving outcomes through increased patient engagement, these new models of healthcare provision are likely to be the standard in which future medical and surgical care will be delivered. In recognition of the success of these programs,