Enhanced recovery programs (ERP), Enhanced Recovery After Surgery (ERAS), care pathways: call it what you may, the goal is all the same, viz. to standardize perioperative care and improve patient outcomes. It has been all about length of stay and complications, but additional metrics include patient-centered outcomes including return to activities of daily living and time to return to work.1

In their study, Nevo and colleagues provide us with a report card for their current ERP for esophagectomy patients.2 The take-home message from this study is that even a successful program must be evaluated regularly and modified appropriately to be optimized. Their synopsis is spot on and can be summarized in two words: “dynamic processes.” ERP resource requirements include: (1) recruit a multidisciplinary team, and design a program appropriate for your facility and your patients; (2) train staff and integrate into electronic medical records; (3) develop patient education material and purchase supplies; (4) coordinator to oversee and collect data for outcomes.1

In this time of health equity discussion, let us address the challenge of patient and institutional context in the implementation of ERPs. Is there equality in the application of these programs? Where do the challenges lie? A rural patient living 150 miles from the hospital may not have access to a visiting nurse or gas money to return to a hospital for a new postoperative complaint and thus may not be a suitable candidate for speedy discharge. The non-English-speaking patient may not understand the discharge instructions if only offered in English. The undomiciled patient may not have access to good hygiene, putting them at infection risk, a social determinant of health. When you want to study the impact of an intervention, you start with the one that will have the largest delta. So, let us consider esophagectomy with its average morbidity rate of 50% and apply the most challenging context of socially challenged populations: non-English-speaking, living below the poverty line, mentally ill. If you can implement the program successfully in this context, you know you can make a difference with your program and improve the value of your investment in time and resources.

So, where do we invest in the socially challenged context when implementing ERP for esophagectomy patients: (1) a nurse coordinator to run the show after being designed with input from the clinical team, (2) nurses for patient preoperative education and to place orders, (3) patient education material in multiple languages, (4) nurses to contact patients on postdischarge days 1, 3, and 7, and (5) a research coordinator or surgical sleuth to investigate the impact of the program and collect data as well as patient-centered outcomes. A modification of the program every few years should reflect medical innovations and fluxes in patient population. The relevant studies would start from the hypothesis that the implementation of ERP for esophagectomy patients improves patient outcomes in two ways. The primary specific aims should include return to activities of daily living, return to employment, discontinuation of postoperative pain medications, and quality-of-life parameters. The secondary aims should include improved length of stay and complication rates. This provides value creation for current and future patients.3 To deliver evidence-based treatment plans, the evidence must be there, and this means having value creation in research.

There are several lessons from this publication by Nevo et al.2 Discharging patients expediently is desirable for the patient and surgeon, as well as in terms of healthcare costs, but potential disaster must be averted when we are talking about complex operations such as esophagectomies or Whipple procedures. Postoperative leaks can occur after 6 days, and venothromboemboli after 60 days.4 ERPs are not one-size-fits-all proposals; however, with appropriate dedication of resources to nurses to check on patients post discharge, and liberal use of telehealth and smartphone apps for those with access to this technology, the value of ERPs can result in equity of care.

ERPs for complex procedures should benefit all patients, and continued revisions should address and incorporate the social determinants of health (SDH) of patients. SDH includes a lack of employment, income, stable housing, or food, and limited education.5 The goal of ERAS/ERP/care pathways is value improvement, so let us remember the context and we will see healthcare equality in the value of these programs. We will see true population health even for our most challenging surgical patients.