The authors of a recent investigation found that when patients participate in a prehabilitation program, there can be benefits related to shorter length of stay and lower total episode payments after surgery.1

Usually, procedures are scheduled around the surgeon’s timeframe, says Michael Englesbe, MD, FACS, professor of surgery and liver transplant surgeon at the University of Michigan.

Surgeons and centers put a lot of effort into ensuring patients completed the required lab tests and other assessments, but less effort is put into empowering patients to be part of the outcome of their care, Englesbe says.

“We do a couple of tests. The next time surgeons have time in their schedule, we schedule the surgery,” he says. “Instead, we could be empowering patients to exercise, to have their own outcome.”

Scheduling surgery should include the time patients need for prehabilitation before the procedure. “We hashed out the idea that the timing and surgery should be centered around the patient,” Englesbe says. “We should develop programs to prepare patients.”

The University of Michigan Medicine program has been following this philosophy for more than seven years. The program also has been studied for several years in Michigan with a partnership across the state.

Other research has revealed benefits to prehabilitation programs, too. For instance, one recent study of prehabilitation programs to improve exercise capacity before gastrointestinal cancer surgery revealed the programs improve exercise capacity, but do not affect length of stay or rate of postoperative complications.2 The authors of another study found that a prehabilitation exercise program in spinal stenosis surgery patients resulted in improved preoperative ranges of motion, leg pain intensity, lumbar extensor muscle endurance, and walking capacities.3

“Now, prehabilitation is standard of care at my institution,” Englesbe says. “Prehabilitation seems to be good for patients. It’s good business, and it costs payers [and] Medicare less money.”

There are four components to the University of Michigan prehabilitation program:

Smoking cessation. “We try to help every smoker to quit smoking, and we are not always successful,” Englesbe says.

Exercise/activity. Patients monitor their exercise activities, including tracking steps. The program encourages patients to increase their number of steps every day, starting with 30 days before the procedure until the day of the procedure.

“Some people can’t walk and can do other activities,” Englesbe says. “But they should have a specific time designated every day to do some activity in anticipation of the operation.”

This component includes nutrition. Patients are encouraged to improve their perioperative nutrition. Initially, patients met with a dietitian, but that proved too costly to be sustainable.

Incentive spirometer. The program provides training on how to use the incentive spirometer machine, which helps patients take deep breaths to open their airways. The idea is to prevent fluid or mucus from building up in the lungs. Patients like using the machine, Englesbe notes. “We’re not sure of the data on this, but patients like it, so we accepted it in our program,” he adds.

Positive psychology. The program focuses on positive psychology or stress management to help patients bring an optimistic mindset to their operation.

Often, patients are anxious before a surgical event. Positive psychology can help them take some control of that. “Anxious patients don’t do as well,” Englesbe notes.

The program focuses on teaching visualization and provides reading materials. Other techniques can include helping patients set goals of care, identify the best positive outcomes, practice deep breathing exercises, and other stress management methods. “We’ve created a pragmatic program, largely designed in partnership with patients to see what they need,” Englesbe reports.

Starting a prehabilitation program in a surgery center faces a buy-in challenge among physicians: “It’s hard to change behavior and clinical practice among doctors,” Englesbe acknowledges. “If you do something fancy with a bunch of technology, it gets complicated really quick.”

Some payers might provide incentives for physicians to focus on prehabilitation, but this trend is in its early stages. Payers need to see more evidence that the program can save money, which is what Englesbe’s research shows.

“No one would argue this isn’t good for patients, but the study also shows it saves money,” he says. “We work with a payer in Michigan to incentivize physicians or hospitals to do the work; we don’t pay them all that much, but it’s enough to change the practice.” For instance, the study showed that patients who went through the program received care that was $1,500 cheaper. These savings were attributed mainly to the reduced need for nursing home care, Englesbe says.1

Patients also enjoy the program because it gives them a way to be empowered and participate in their care. “We’re working hard to develop this program across the state of Michigan and beyond,” Englesbe says.

A national model that is similar in its practice and goals is Strong for Surgery, developed by the American College of Surgeons. (Editor’s Note: To learn more about this program, please read this article from the January 2019 issue of Same-Day Surgery, at this link: http://bit.ly/30WwgJt.)

“In the future, prehabilitation for surgery will be the standard of care, but it takes a long time to get there,” Englesbe says. “The point is that the more we can do to prepare patients for their operations physically and psychologically, the better.”

REFERENCES

  1. Mouch CA, Kenney BC, Lorch S, et al. Statewide prehabilitation program and episode payment in Medicare beneficiaries. J Am Coll Surg 2019; Dec 5. pii: S1072-7515(19)32217-3. doi: 10.1016/j.jamcollsurg.2019.10.014. [Epub ahead of print].
  2. Lau CSM, Chamberlain RS. Prehabilitation programs include exercise capacity before and after surgery in gastrointestinal cancer surgery patients: A meta-analysis. J Gastrointest Surg 2019; Nov 25. doi: 10.1007/s11605-019-04436-1. [Epub ahead of print].
  3. Marchand AA, Suitner M, O’Shaughnessy J, et al. Feasibility of conducting an active exercise prehabilitation program in patients awaiting spinal stenosis surgery: A randomized pilot study. Sci Rep 2019;9:12257.