As the saying goes, “An ounce of prevention is worth a pound of cure.” The healthcare industry continues to place more emphasis on preventive care, which can help reduce healthcare costs and improve patients’ quality of life. Another preventive concept, known as prehabilitation, is also gaining traction as a way to help patients who undergo surgical procedures recover faster.
Prehabilitation is defined as any physical or lifestyle preparation that happens before surgery and is designed to help patients regain function in less time. Patients who undergo surgery frequently follow a rehabilitation program after surgery to promote recovery but starting this program before the procedure may help further accelerate recovery time. Prehabilitation prepares the body to endure a major stressor (such as surgery) despite lengthy downtime during the initial recovery process.
A 2017 study published in the Journal of Bone & Joint Surgery looked at the associations between preoperative physical therapy and post-acute care utilization in total joint replacements found that “the use of perioperative physical therapy was associated with a 29 percent decrease in the use of any post-acute care services.” Findings also indicated a significant cost reduction, resulting largely from reduced payments to skilled nursing facilities and home healthcare. Other studies such as this 2017 review of prehabilitation programs in abdominal cancer surgery, have shown promising results and generated media attention.
Patient behavior is one of the primary determinants of health and well-being—an association that holds true when it comes to post-surgical recovery times and adhering to practices and behaviors that promote healing. Prehabilitation includes the following four main components:
Prehabilitation is about treating patients in their entirety and not just one piece of the puzzle. It is also just one component of the patient journey from pre-surgery to perioperative and post-surgical recovery. However, beginning the surgical journey in the best physical, nutritional, and psychological condition possible can help lead to better surgical outcomes and faster recovery times for patients. Preparing for surgery through prehabilitation can also help foster relationships between the care team and the patients and their families prior to surgery. This can help build trust, lead to better care management, and, in the long-term, better outcomes for the patient and the healthcare system.
Once the need for surgery is identified, patients should have a pre-op assessment. This type of holistic patient visit takes into account the four pre-op factors identified above and can be a powerful indicator of outcomes. Often seen as fitting hand-in-hand with prehabilitation, a frailty assessment is a powerful tool to identify a patient’s increased risk for complications and other adverse events. Patients identified as being frail have increased LOS, morbidity, mortality, surgical site infections, costs, and admissions to skilled nursing and other acute-care facilities.
Just as it’s advisable to be well prepared for any major event, such as an athletic competition or an important exam, the reasoning for prehabilitation stems from the idea that surgery is a major stress event that requires both physical and mental preparation. While there is little consensus on when the point of care for a patient begins, the prehabilitation phase can serve as a starting as soon as the care team identifies the need for surgery, up until the surgery takes place.
A robust prehabilitation program ideally starts four to six weeks prior to surgery, depending on many factors, such as the type of surgery, the patient’s fitness, and how far in advance the surgery is identified. However, studies have shown that even one encounter prior to surgery can have a positive effect on outcomes. While prehabilitation has shown promising results in a variety of patients and situations, its effectiveness is closely tied to successful care management over the pre-, peri-, and postoperative phases of the patient’s journey and has both short- and long-term ramifications.
Providing coordinated care throughout the prehab period is particularly important. Health systems can glean important insights about care best practices if they are able to effectively follow the patient journey and capture relevant data throughout. To do so, some health systems have a nurse or patient guide that helps patients navigate the journey four to six weeks out from the surgical encounter through to the recovery phase. Regular interaction with a patient leverages some of the principles of adaptive leadership in optimizing care management. Any healthcare encounter is an opportunity to close gaps in care and optimize the patient’s health in order to improve outcomes, and the pre-operative encounter can be an especially important opportunity.
The biggest factor impacting surgical outcomes is complications, often related to poor chronic disease management (most commonly diabetes). Helping patients meet their short-term and intermediate goals can also influence their longer-term outcomes. For example, a patient with well controlled blood sugar reduces his risk of post-op infections, thus improving outcomes such as LOS, and morbidity, and cost-per-case, as well as hastening recovery times. Although the majority of studies are in the surgical population, there is likely benefit in these prehabilitation concepts in all types of patients with complex medical conditions.
Colorectal cancer is the second most prevalent cancer, and surgery is the only remedial option for the more than 100,000 patients diagnosed each year. However, according to a 2019 article in BMC cancer, “as many as 50 percent of patients experience postoperative complications, and are associated with higher morbidity and mortality rates, lower quality of life, and increased expenditure in healthcare.” These complications have been closely tied to the four components mentioned above: preoperative functional capacity, nutritional state, psychological state, and optimization of medical complications.
While most clinicians have focused on patient outcomes following surgery, targeting behavior changes and rehabilitation, a 2017 study at McGill University targeted improved outcomes through prehabilitation efforts, looking specifically at improved walking capacity. The study concluded that a “structured multi-modal prehabilitation program improved walking capacity before and after surgery for colorectal cancer.”
A related study at McGill University that compared prehabilitation results to rehabilitation in post-surgical colorectal cancer patients was cited in an article by Kaiser Health News, showing that “eight weeks after surgery, 84 percent of prehab patients’ performance on a six-minute walking test had recovered to or over their baseline measurements compared with 62 percent of rehab patients.” While much of the available research seems to suggest a positive correlation between prehabilitation and improved outcomes, there’s a general consensus that a larger body of research is needed. However, there are still compelling reasons to integrate prehabilitation efforts into the surgical care continuum, while continuing to stay abreast of the latest ongoing research recommendations and conclusions.
Accurately measuring both short- and long-term patient outcomes relates to the ability of health systems to measure patient adherence to a plan. An analytics platform can help clinicians determine the optimal time for prehabilitation intervention. An analytics system can also help synthesize data from a myriad of sources that can alter the course of patient recovery.
Data sources might include patient visits outside the system, patient-reported outcome measures (PROMS), claims data, as well as data about diet and exercise from sources such as wearables or wellness centers. A robust analytics platform and solution makes it possible to provide more holistic care by ingesting data and making sense of these disparate pieces that aren’t otherwise captured.
In addition to the powerful Health Catalyst Data Operating System (DOS™), Health Catalyst also offers a suite of advanced applications, including Community Care, which can help clinicians identify care gaps and understand how to close them. There are also a number of surgical applications that consolidate these different sources of information into a central and robust platform that provides organizations with actionable data.
In order to measure the success of prehabilitation efforts, clinicians can set long-term outcome goals with process improvements during the prehab period that apply to multiple types of patient cohorts. With the increasing number of metrics that clinicians and health systems are trying to measure, adding more to this list can seem impossible. However, additional data provides an opportunity to leverage the work that improvement teams have done or improve process metrics that other teams are already working on. For instance, many health systems that Health Catalyst works with have improved their management of diabetes. This improvement can be further leveraged by a team looking to implement and measure prehabilitation efforts can further leverage this improvement.
While a number of studies show promising results of prehabilitation efforts, this is only one part of providing holistic treatment to patients that accounts for preventive care, perioperative best practices and postoperative rehabilitation. When patients are prepared for surgery by optimizing pre-existing medical conditions, physical fitness, nutritional status, and psychological support, early studies have shown a positive correlation with better outcomes.
Although more research is needed, prehabilitation is part of a coordinated care effort. Health systems can also leverage the improvement work on process metrics in coordination with prehabilitation efforts. Prehabilitation is one more component that can help lead to better care management in the short term and, in the long run, lead to better outcomes for both the patient and the healthcare system.
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