Is Privatization the Key to The Expansion of Enhanced Recovery After Surgery (ERAS) to Rural Surgical Care—A Commentary on The Novel Start-Up, Goldfinch Health, and Their Early Reported Outcome Improvements in The State of Iowa

• Enhanced Recovery After Surgery (ERAS) improves surgical outcomes.
• Rural hospitals do not routinely practice enhanced recovery.
• Privatization of enhanced recovery may help bring it to rural hospitals.

Enhanced Recovery After Surgery (ERAS) programs are well-described, evidence-based approaches to improving outcomes after surgery [1-4]. In a recent meta-analysis of 42 randomized controlled trials, ERAS programs were associated with a significant reduction in length of stay (LOS), overall complications, total costs, and 30-day readmission rates.² Lau et. al. concludes that ERAS programs are an effective and valuable part of improving patient outcomes while accelerating recovery after surgery [2]. A study from the Nashville TVHS-Veterans Affairs hospital reported that the post-ERAS patient cohort experienced a reduction in inpatient and outpatient opioid consumption with a significant reduction in total days of opioid supply with no increase in hospital readmissions [3]. In a recent review, Echeverria-Villaloos et. al. objectively looked at the scientific evidence on the role of ERAS implementation in reducing postoperative opioid consumption and their potential association with decreasing long-term opioid use, dependency and addiction [5]. They concluded that there is a clear trend of ERAS programs limiting intraoperative and postoperative opioid use through guidelines to prevent chronic post-surgical pain and support weaning from opioid medications [5]. The American Society for Enhanced Recovery and Perioperative Quality Initiative Joint Consensus Statement on Persistent Postoperative Opioid Use concludes that “efforts to modify prescriber behaviors and health system characteristics are likely to have success in reducing persistent postoperative opioid use” [6]. In a recent retrospective study by the PRIMUM Group of 791 patients, the use of ERAS protocols in minimally invasive gynecologic procedures resulted in a 65% reduction in readmissions and a reduction in intra-operative opioid use and opioids prescribed for post-operative pain [7]. 

Despite the published successes in outcome improvement, the adoption of evidence-based ERAS pathways in routine clinical practice is slow [8]. This is certainly true in local, community, and district hospitals/surgery centers. Rural populations in the United States comprise 60 million people [9]. With the opioid epidemic continuing to devastate community public health [10], it is imperative that rural populations benefit from innovations in care models that provide, as Harrington et. al. states: “best health at best cost” [9]. However, it is clear that the “best health” provided by ERAS is not practiced in most hospitals, especially in rural communities.

A unique, private, start-up company, Goldfinch Health (Iowa City, IA), is helping bridge this gap between ERAS utilization and rural America (https://www.goldfinchhealth.com/), positioning hospitals serving rural communities to lead the United States healthcare system toward more standard adoption of enhanced recovery [11-13]. Their approach appears to harness an innovative combination of tech-enabled clinical navigation and opioid minimizing ERAS pathways [11,12]. By contracting with healthcare payers (i.e., insurance companies, corporations, unions, governments, etc.), they are efficiently able to make ERAS available to anyone, no matter their residence. The implementation of ERAS is currently dependent on institutional prioritization primarily located in academic medical centers [1,4]. Their services empower the patient by providing them with pre-operative education and nutrition, an ERAS dedicated nurse advocate, aid finding ERAS friendly surgeons, as well as post-operative follow-up/outreach from with nurse [11,13]. Ultimately, they help hospitals and physicians practice ERAS principles [11]. They were recently awarded the 2023 Health Value Award during The Healthcare Innovation Congress.¹¹ To date, and to the best of our knowledge, this is the first private company in the United States whose primary mission is to help surgical patients receive their care along an ERAS pathway.

According to press-releases and Goldfinch Health, in October 2022, Iowa’s Attorney General, Tom Miller, launched “The Billion Pill Pledge” alongside Goldfinch Health [11-13]. The mission of this pledge is to “remove a billion leftover opioids” [11,12]. Using money received in opioid settlements, Iowa used this bill to start a collaborative approach to “prevent opioid addiction before it begins” [11,12]. Attorney General Miller explained that the “the opioid settlements [provided Iowa] a new path forward in preventing future addiction” [11]. This program’s goal was to “extend support to rural communities and, especially, to those within these communities who are at-risk or who have already been harmed by the opioid epidemic” [11]. Based on information provided by Goldfinch Health, at the one-year anniversary of the program, twelve community hospitals caring for rural surgery patients have joined the initiative and started to have key aspects of ERAS with Goldfinch Health (pre-habilitation, multi-modal analgesia, minimally invasive surgery, and post-surgery care nurse support) added to their surgical care, no matter the procedure.  They report that, over the course of the first 1200 patients, a marked improvement in opioid need and output has been appreciated. Early data has demonstrated a provider opioid prescribing reduction of 70%, the need for opioid refills reduced by 90%, and a readmission rate less than 2% across all procedures.  Regarding pill reduction, they report that 85% of patients in the Iowa state program require 10 or fewer opioid pills throughout surgical care/recovery with 30% not requiring any opioids throughout. The average number of opioids taken from start to recovery for these first 1200 patients is reported as 6.8 pills. If these data are projected over traditional, non-ERAS care, the quantity of opioid tablets avoided amounts to over one million pills every 4 years in these communities.

While there have been pitfalls in United States healthcare privatization, few companies have looked to privatize a product that empowers the patient and help ensure they receive evidence-based healthcare. Privatizing enhanced recovery in a way that gives companies, health insurance corporations, hospitals, and governments the ability to provide evidence-based innovations like ERAS to their employees/patients/constituents may be the answer to ERAS’ slow adoption. Early reported data from the “The Billion Pill Pledge” is impressive and warrants a continued look as the progress is reported in the state of Iowa. However, it must be appreciated that this data is early, non-randomized, and likely, underpowered for strong conclusions. Nevertheless, it demonstrates a trend toward real and significant opioid reduction in patients that likely would not have been provided this evidence-based care. Concrete conclusions should not be made with this summary of reported data; however, this impressive early data supports the need for future studies investigating Goldfinch Health’s impact on length of stay, return to work, opioid use, and patient satisfaction. 

In conclusion, the adoption of ERAS programs in rural hospitals and surgery centers is crucial in providing optimal healthcare to rural populations. As the opioid epidemic continues to impact communities across the United States, rural areas must not be left behind. The innovative approach of Goldfinch Health and its early successes in the state of Iowa suggest that privatization may indeed be a key to expanding ERAS in rural surgical care.

1. King AB, Alvis BD, McEvoy MD (2016) Enhanced recovery after surgery, perioperative medicine, and the perioperative surgical home: current state and future implications for education and training. Curr Opin Anaesthesiol 29: 727-732.
2. Christine SM, Lau RSC (2016) Enhanced Recovery After Surgery Programs Improve Patient Outcomes and Recovery: A Meta-analysis. World Journal of Surgery 1: 899-913.
3. Alvis BD, Amsler RG, Leisy PJ, Feng X, Shotwell MS, et al. (2021) Effects of an anesthesia perioperative surgical home for total knee and hip arthroplasty at a Veterans Affairs Hospital: a quality improvement before-and-after cohort study. Can J Anaesth 68: 367-375.
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5. Echeverria-Villalobos M, Stoicea N, Todeschini AB, Fiorda-Diaz J, Uribe AA, et al. (2020) Enhanced Recovery After Surgery (ERAS): A Perspective Review of Postoperative Pain Management Under ERAS Pathways and Its Role on Opioid Crisis in the United States. Clin J Pain 36: 219-226.
6. Kent ML, Hurley RW, Oderda GM, Gordon DB, Sun E, et al. (2019) American Society for Enhanced Recovery and Perioperative Quality Initiative-4 Joint Consensus Statement on Persistent Postoperative Opioid Use: Definition, Incidence, Risk Factors, and Health Care System Initiatives. Anesth Analg 129: 543-552.
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9. Harrington RA, Califf RM, Balamurugan A, Brown N, Benjamin RM, et al. (2020) Call to Action: Rural Health: A Presidential Advisory From the American Heart Association and American Stroke Association. Circulation 141: e615-e644.
10. Shaver C, Johnson JA, Greenhill, RC, Nadimidla S (2021) Comparative Analysis of State Level Health Policy Support for Opioid Abuse Mitigation in Rural America. Journal of Health and Human Services Administration 44: 137-161.
11. Newland BG, Shelton RAJ (1970) The preparation of α- and β-titanium tribromide. Journal of the Less Common Metals 22: 369-372.
12. https://iowacapitaldispatch.com/2023/04/11/company-new-state-program-can-cut-post-surgery-opioid-use-by-7
13. https://www.ketv.com/article/iowa-billion-pill-pledge-program-aims-to-reduce-need-for-opioids-post-surgery/4304