Actionable Factors Fostering Health Value Generation and Scalability of Prehabilitation: A Prospective Cohort Study

Abstract

Importance: Prehabilitation has potential for improving surgical outcomes as shown in previous randomized controlled trials. However, a marked efficacy-effectiveness gap is limiting its scalability. Comprehensive analyses of deployment of the intervention in real-life scenarios are required.

Objective: To assess health outcomes and cost of prehabilitation.

Design: Prospective cohort study with a control group built using propensity score-matching techniques.

Setting: Prehabilitation Unit in a tertiary-care university hospital.

Participants: Candidates for major digestive, cardiac, thoracic, gynecologic, or urologic surgeries.

Intervention: Prehabilitation program, including supervised exercise training, promotion of physical activity, nutritional optimization, and psychological support.

Main outcomes and measures: The comprehensive complication index, hospital and intensive care unit length of stay, and hospital costs per patient until 30 days after surgery. Patients were classified by the degree of program completion and level of surgical aggression for sensitivity analysis.

Results: The analysis of the entire study group did not show differences in study outcomes between prehabilitation and control groups (n=328 each). The per-protocol analysis, including only patients completing the program (n=112, 34%), showed a reduction in mean hospital stay [9.9 (7.2) vs 12.8 (12.4) days; P =0.035]. Completers undergoing highly aggressive surgeries (n=60) additionally showed reduction in mean intensive care unit stay [2.3 (2.7) vs 3.8 (4.2) days; P =0.021] and generated mean cost savings per patient of €3092 (32% cost reduction) ( P =0.007). Five priority areas for action to enhance service efficiencies were identified.

Conclusions and relevance: The study indicates a low rate of completion of the intervention and identifies priority areas for re-design of service delivery to enhance the effectiveness of prehabilitation.

FIGURE 1

Patients’ workflow: ET-based and PA-based programs. After a first baseline assessment, patients were assigned either to the program promoting physical activity (PA-based) or to the intervention additionally scheduling hospital-based supervised exercise training sessions twice or 3 times per week (ET-based). Subsequently, all candidates of the intervention group attended weekly face-to-face sessions during the prehabilitation program. A postintervention evaluation was scheduled before surgery and a final assessment of all cases was done at 30 days after surgery. The care in the control group (usual care) is displayed at the bottom of the figure. ER indicates emergency room.

FIGURE 2

Average costs per patient and cost structure of prehabilitation and matched controls for 3 groups of patients. Solid bars correspond to prehabilitation and hatched bars to controls. Prehabilitation in the entire study group (n=328) did not show cost reductions (left). Patients completing the program (n=112) (central), presented showed an 18% reduction in costs (P=0.140) with prehabilitation. The third group (right), completers undergoing highly aggressive surgical procedures (n=60) showed statistically significant cost savings, 32% (P=0.007).

FIGURE 3

Impact of program adherence and prehabilitation in patients undergoing highly surgical aggression on hospital costs per patient. The figure presents 3 different simulations assessing the impact of completing the program (left panel, blue), prehabilitation of patients undergoing highly aggressive surgeries (central panel, red) and completers undergoing highly aggressive surgeries (right panel, green) on hospital costs. The x axis indicates the relative frequencies of completers, prehabilitation of patients undergoing highly aggressive surgeries and completers undergoing highly aggressive surgeries in each sample, whose proportion was gradually increased from 0% to 100% in each model. The y axis indicates the difference of hospital costs per patient between prehabilitation and controls. Detailed information on costs analysis is provided in the Online Supplementary Material (Table 8bS, Supplemental Digital Content 1, http://links.lww.com/SLA/E177).