Cost-effectiveness of prehabilitation of elderly frail or pre-frail patients prior to elective surgery (PRAEP-GO) versus usual care - Protocol for a health economic evaluation alongside a randomized controlled trial

Abstract

Background: Prehabilitation aims to improve patients' functional capacity before surgery to reduce perioperative complications, promote recovery and decrease probability of disability. The planned economic evaluation is performed alongside a large German multi-centre pragmatic, two-arm parallel-group, randomized controlled trial on prehabilitation for frail elderly patients before elective surgery compared to standard care (PRAEP-GO RCT). The aim is to determine the cost-effectiveness and cost-utility of prehabilitation for frail elderly before an elective surgery.

Methods: The planned health economic evaluation comprises cost-effectiveness, and cost-utility analyses. Analyses are conducted in the German context from different perspectives including the payer perspective, i.e. the statutory health insurance, the societal perspective and the health care provider perspective. Data on outcomes and costs, are collected alongside the ongoing PRAEP-GO RCT. The trial population includes frail or pre-frail patients aged ≥70 years with planned elective surgery. The intervention consists of frailty screening (Fried phenotype), a shared decision-making conference determining modality (physiotherapy and unsupervised physical exercises, nutrition counselling, etc.) and setting (inpatient, day care, outpatient etc.) of a 3-week individual multimodal prehabilitation prior to surgery. The control group receives standard preoperative care. Costs include the intervention costs, the costs of the index hospital stay for surgery, and health care resources consumed during a 12-month follow-up. Clinical effectiveness outcomes included in the economic evaluation are the level of care dependency, the degree of disability as measured by the WHO Disability Assessment Schedule 2.0 (WHODAS 2.0), quality-adjusted life years (QALY) derived from the EQ-5D-5L and the German utility set, and complications occurring during the index hospital stay. Each adopted perspective considers different types of costs and outcomes as outlined in the protocol. All analyses will feature Intention-To-Treat analysis. To explore methodological and parametric uncertainties, we will conduct probabilistic and deterministic sensitivity analyses. Subgroup analyses will be performed as secondary analyses.

Discussion: The health economic evaluation will provide insights into the cost-effectiveness of prehabilitation in older frail populations, informing decision-making processes and contributing to the evidence base in this field. Potential limitation includes a highly heterogeneous trial population.

Trial registration: PRAEP-GO RCT: NCT04418271; economic evaluation: OSF ( https://osf.io/ecm74 ).

Keywords: Cost-effectiveness analysis; Frailty; Health care economics; Health care evaluation mechanisms; Prehabilitation; Preoperative exercise; Trial-based health economic evaluation.

Fig. 1

Overview of planned evaluations and outcomes. Abbreviations: CEA – cost-effectiveness analysis; CUA – cost-utility analysis; ICU – intensive care unit; LCD – Level of Care-Dependency; LOS – length of stay; QALY – Quality Adjusted Life Years; SHI – statutory health insurance; WHODAS – World Health Organization Disability Assessment Schedule. Note: Further details on the outcomes to be evaluated can be found in subsequent sections and Table 2

Fig. 2

Overview of cost categories and respective types of data (A) used by adapted health economic perspective (B). Note: Detailed information on measurement and valuation of defined costs by perspective and type of analysis is available in the subsection “Measurement and valuation of resource use and costs” and in Additional file 1. Abbreviations: SHI – statutory health insurance

Fig. 3

Schematic Representation of Planned (A) Primary and Secondary Analyses, (B) Subgroup Analyses, and Sensitivity Analyses. Abbreviations: CCI – Charlson Comorbidity Index; ICER – incremental cost effectiveness ratio; ICUR – incremental cost utility ratio; ITT – intention-to-treat; SHI – statutory health insurance