Article Archive
March/April 2021

Clinical Matters: Prehabilitation
By Maura Keller
Today’s Geriatric Medicine
Vol. 14 No. 2 P. 28

Presurgical preparation pays off for older patients.

Ask most surgeons how much time and energy they spend counseling surgical patients to reduce stress, eat more healthfully, and exercise prior to surgery, and most will admit they spend very little. But a recent study at Michigan Medicine shows that a prescribed prehabilitation patient program, which includes physical as well as psychological tasks, has shown to improve postoperative outcomes in a variety of patients—including geriatric patients—undergoing major operations.

According to Michael Englesbe, MD, FACS, the Cyrenus G. Darling Sr., MD and Cyrenus G. Darling Jr., MD Professor of Surgery at the University of Michigan in the section of transplantation surgery, prehabilitation refers to preoperative wellness training that patients do prior to surgery. This is particularly important for older patients, who have challenges associated with frailty and poor nutrition.

Englesbe and his colleagues at Michigan Medicine recently published a paper in the Journal of the American College of Surgeons highlighting a recent study that shows training surgical patients to exercise, eat more healthfully, stop smoking, do lung exercises, and reduce stress makes these patients more physically and mentally prepared for their upcoming operations. In turn, these prehabilitation programs reduce the number of additional surgical procedures required and reduce expenses. Prehabilitation also increases postoperative functionality and, from a psychological standpoint, helps patients focus on their desired outcomes. They’re asked to record their own goals for life after surgery and life events they are looking forward to.

In turn, the prehabilitation study results show lower rates of postoperative complications, shorter hospital stays, and a quicker return to baseline functioning. And while these outcome improvements are proving beneficial for all patients, those who are older and at a higher risk of postoperative complications are experiencing the greatest impact.

 “We have not done enough science to understand exactly why it works, but we have shown that it definitely improves patient outcomes,” Englesbe says. “It is relatively intuitive that [a] patient should physically and psychologically prepare for a major event like surgery. This program adds structure to this preparation.”

At Its Core
Historically, the preparation a patient undergoes prior to surgery typically entails a series of preoperative appointments, lab work, and a final physical examination. But for the patients who enrolled in the Michigan Surgical and Health Optimization Program (MSHOP), their preoperative tasks were far different. Upon enrollment, each patient received individualized instruction on nutrition, exercise, smoking cessation, stress reduction, and incentive spirometry, as well as educational materials, a pedometer, and an incentive spirometer.

To determine the ideal candidates for the study, the research team used Medicare claims data from 2014 to 2017 to conduct the multicenter study at 21 Michigan hospitals. Patients and those in the control group were followed throughout the duration of their surgical hospitalizations and for 90 days postoperatively. And while Medicare beneficiaries were included in the experimental group, the program was offered to all patients regardless of their insurance status. In addition, the patients in the study had a median age of 70 and were primarily those who had the highest risk of complications after surgery.

As Englesbe explains, the program entailed physical activity (usually walking with daily increases in number of steps prior to surgery), nutrition counseling, smoking cessation, and positive psychological exercises to boost mindset. All of this was done at home before surgery. The goal for the length of participation was four weeks prior to surgery, although enrollment was allowed for patients who were having surgical procedures as soon as seven days from their enrollment date.

To motivate program participants throughout the program, patients also received daily reminders and feedback through automated texts, phone messages, or e-mails.

“We have been doing this for many years,” Englesbe says. “The most important outcome is that patients report that it has been an important part of their care, they feel empowered and engaged in their surgical outcomes, and it helps them make some positive progress during a scary time. The science has focused primarily on resource utilization such as the cost and use of nursing homes. This has been intentional because the primary goal of the research was to investigate the return on investment of the program.”

The comparison or control group included individuals who had the same operation at similar institutions and had a similar mix of risk factors. “This was a statewide pragmatic study so there’s likely some bias between the two groups,” Englesbe says.

In the Numbers
After delineating the number of potential MSHOP enrollees from 21 hospitals in Michigan, 569 patients met the study inclusion criteria, of which 523 patients were part of the final sample group along with 1,046 controls. The median length of enrollment in the program was 18 days. At the University of Michigan, they train patients having major inpatient surgery, excluding cardiac and orthopedic patients. Patients who are particularly fit were enrolled in the program.

During the program, 62% of enrollees were classified as “engaged,” which means they entered step counts three or more times per week for at least 50% of the weeks enrolled. For those patients who responded to the daily reminders to input their steps and spirometer readings, the median number of steps per day was 2,909, and the median number of breaths per entry from their spirometer use was 30. Patients also had a shared ownership of having positive surgical outcomes by tracking their numerical data, reporting that data, and also participating in the stress-reducing exercises.

The MSHOP patients experienced an average six-day hospitalization compared with the controls’ median seven-day length of stay. In addition, the MSHOP patients were more likely than controls to be discharged to home but less likely to be discharged to home with home health services after hospitalization. And these patients were also less likely to be discharged to skilled nursing facilities.

Although there were no differences between the control and the MSHOP patients in 90-day emergency department visits, hospital readmissions, or rates of nursing home stays, the postacute care payments were significantly lower for MSHOP patients in skilled nursing facilities and home health services.

As Englesbe explains, the study found that these Medicare beneficiary surgical patients in Michigan who participated in the prehabilitation program experienced shorter hospital stays and lower total episode payments. Because fewer procedures were necessary and the length of stay was reduced, the cost savings associated with these patients indicated they were better prepared both physically and mentally.

In addition, the study shows that while prehabilitation provides value for Medicare, hospital systems receive benefits as well from high-value surgical care. Here’s why: Shorter length of stay is paramount for hospital efficiency and resource use. In addition, changes in Medicare reimbursement have created additional pressure on hospitals to decrease patients’ lengths of stay.

And while prehabilitation programs are apropos for hospital systems, these types of programs will also work for a variety of medical settings including private offices, non-profit health care systems, and academic centers. The costs involved for prehabilitation programs also are nominal. For example, the MSHOP program cost approximately $70 per patient, which covered expenses for three full-time coordinators and a pedometer for each participant.

On the Horizon
What does the future hold for this program? According to Englesbe and study coauthors, including Charles Mouch, MD, and Mary Shen, MD, the future is bright thanks to two next steps. These include the integration with a posthabilitation program with the goal of getting people back to their baseline functional status as quickly as possible and creating lasting behavior health change. Indeed, the University of Michigan has made prehabilitation the standard of care for major inpatient general and thoracic surgery patients at Michigan Medicine who show higher than usual risk of complications. And the team is eager to apply its experience as a model for broad adoption of prehabilitation programs for all patients in Michigan.

In addition, the program has evolved to include technological enhancements such as the ability for patients to track and sync steps via a smartphone or wearable activity tracker rather than a pedometer.

“We are also looking to expand the program outside of the University of Michigan and the state of Michigan. The program has not taken hold outside of the small number of institutions in the state of Michigan, and we’re working hard to help support it and make it available to every patient having major surgery in state,” Englesbe says. “Other major academic institutions are starting to use a program like this, but it will take some time to fully disseminate into community-based care.”

Maura Keller is a Minneapolis-based writer and editor who writes about health care, business, technology, law, and other topics for regional and national publications.