Prehabilitation and preparation for surgery: has the digital revolution arrived?

Codesigning an E-Health Intervention for Surgery Preparation and Recovery

Surgery is a significant part of healthcare, but its demand is increasing, leading to challenges in managing patient care. Inefficient perioperative practices and traditional linear models contribute to adverse outcomes and patient anxiety. E-health interventions show promise in improving surgical care, but more research is needed. The purpose of this study was to involve patients and healthcare workers during the design phase of an e-health intervention that aims to support the perioperative care of elective surgery preparation and recovery. This study used an Information Systems Research Framework to guide collaborative codesign through semistructured interviews and cocreation workshops. Semistructured interviews collected insights on the perioperative journey and e-health needs from healthcare workers and consumers, resulting in the creation of a patient surgery journey map, experience map, and a stakeholder needs table. Collaborative work between consumers and healthcare workers in the cocreation workshops identified priority perioperative journey issues and proposed solutions, as well as prioritizing application software needs, guiding the development of the wireframe. The development of an e-health application aimed at supporting surgery preparation and recovery is a significant step toward improving patient engagement, satisfaction, and postsurgical health outcomes.

Digital health and medical technology for perioperative sarcopenia optimisation and prehabilitation - Where to go from here?

Sarcopenia has been shown to cause poorer outcomes in surgical oncology. With the advancement of artificial intelligence technology, body composition analysis can be obtained with ease. Given the lead time between cancer diagnosis and surgery, selected patients at risk of complications secondary to sarcopenia may be amenable to prehabilitation. The COVID-19 pandemic has led to the rapid adaptation of digital health and medical technology. Our perspective piece will review the current available evidence and propose innovative ways to incorporate technology into physical and nutritional prehabilitation.

Opportunities to optimise care and choice in joint replacement surgery using a digitally delivered, holistic PreHab pathway

PURPOSE

To describe the implementation and evaluation of a hospital-initiated, community-based, digital prehabilitation program (My PreHab Program: MPP) for adults referred for elective joint replacement.

METHODS

MPP was implemented July 2022 and comprises a personalised digital health screen that guides the provision of self-management resources. Adults (>18 years) referred and accepted, or already waitlisted, for total knee/hip replacement surgery were eligible. Individuals requiring category 1 (urgent) or emergency surgery and those without a mobile phone were excluded. Implementation and intervention outcome measures (program adoption, equity of reach, fidelity, acceptability, appropriateness, feasibility, engagement, preliminary surgical outcomes) were explored via study-specific measures and hospital records.

RESULTS

Of those invited (N = 689), 77.8% participated. Participants and non-participants were similar in key demographic variables except regional invitees were more likely to participate than metropolitan (88.0% vs 75.4%, p = .002) and non-participants tended to be older (median age = 69.0 vs 64.0, p = .005). Participants reported on average four modifiable risk factors: most commonly chronic pain (79.1%), obesity (57.3%), and frailty (40.9%). Most participants (80.4%) reviewed all resources provided and reported action/intention to address issues identified (90.9%). Participants perceived MPP as acceptable (3.2/5), appropriate (3.3/5), and feasible (3.4/5). Early trends for participants progressing to surgery (n = 33) show a reduced length of stay (MPP = 4.3, baseline = 5.3 days).

CONCLUSION

MPP demonstrated high adoption, fidelity, and participant engagement. It is acceptable, appropriate and feasible and has the potential to be scaled-up digitally at low-cost. Modifiable risk factors were prevalent and early indications suggest this preoperative intervention may benefit both patients and the healthcare system.

The use of technology in cancer prehabilitation: a systematic review

Aim

This review aimed to evaluate the effectiveness and feasibility of cancer prehabilitation programs delivered through technological enablers compared to conventional face-to-face interventions.

Methods

A systematic review was conducted, searching PubMed, Embase, and CINAHL for studies published from inception to February 6, 2024. Studies were included if they involved adult cancer patients in primary research, utilized technology for prehabilitation, and assessed functional, psychological, and quality of life outcomes.

Results

Sixteen studies were included, encompassing wearables, apps, teleprehabilitation, and virtual reality. All studies reported feasibility, but challenges included technical issues, lack of supervision, and non-compliance. Effectiveness depended on intervention rigor and technology type. Wearables offered objective monitoring but faced compliance issues. Videoconferencing provided supervision and could mitigate compliance concerns. Multimodal programs and intervention-specific outcome measures were recommended.

Conclusion

Technology-based prehabilitation programs seem feasible, but effectiveness depends on intervention design and technology employed. Future research should focus on developing robust evidence to guide clinical practice and explore the potential of integrated technological solutions.

Systematic review registration

PROSPERO, identifier CRD42022376028.

Digital health coaching to improve patient preparedness for elective lower limb arthroplasty: a quality improvement project

Major surgery carries high risks with comorbidities, frailty and health risk behaviours meaning patients are often unprepared for the physiological insult. Since 2018, the Prepwell programme at South Tees Hospitals NHS Foundation Trust has supported patients to improve their preoperative health and fitness. In April 2020, the face-to-face service was suspended due to the pandemic, leading to the team implementing a three-tiered remote digital support pathway, including digital health coaching via a mobile phone application.

METHODS

Patients scheduled for elective lower limb arthroplasty were offered 8 weeks of digital health coaching preoperatively. Following consent, participants were assigned a personal health coach to set individual behaviour change goals supported by online resources, alongside a digitally delivered exercise programme. Participants completed self-assessment questionnaires at Entry to, and Exit from, the programme, with outcome data collected 21 days postoperatively. The primary outcome was the change in Patient Activation Measure (PAM).

RESULTS

Fifty-seven of 189 patients (30.2%) consented to referral for digital health coaching. Forty participants completed the 8-week programme. Median PAM increased from 58.1 to 67.8 (p=0.002). Thirty-five per cent of participants were in a non-activated PAM level at Entry, reducing to 15% at Exit with no participants in PAM level 1 at completion. Seventy-one percent of non-activated participants improved their PAM by one level or more, compared with 45% for the whole cohort. Median LOS was 2 days, 1 day less than the Trust's arthroplasty patient population during the study period (unadjusted comparison).

CONCLUSIONS

Digital health coaching was successfully implemented for patients awaiting elective lower limb arthroplasty. We observed significant improvements in participants' PAM scores after the programme, with the largest increase in participants with lower activation scores at Entry. Further study is needed to confirm the effects of digital health coaching in this and other perioperative groups.

Multimodal prehabilitation service for patients with colorectal cancer: the challenges of implementation

Prehabilitation has been shown to improve outcomes for patients undergoing major surgery; benefits include reductions in length of hospital stay and postoperative complications. Multimodal prehabilitation programmes lead to improved patient engagement and experience. This report describes implementation of a personalised multimodal prehabilitation programme for patients awaiting colorectal cancer surgery. We aim to highlight the successes, challenges and future direction of our programme.Patients listed for colorectal cancer surgery were referred for initial prehabilitation assessment. The prehabilitation group were assessed by specialist physiotherapists, dieticians and psychologists. An individualised programme was developed for each patient, aiming to optimise preoperative functional capacity and enhance physical and psychological resilience. Clinical primary outcome measures were recorded and compared with contemporaneous controls. For those undergoing prehabilitation, a set of secondary functional, nutritional and psychological outcomes were recorded at initial assessment and on completion of the programme.61 patients were enrolled in the programme from December 2021 to October 2022. 12 patients were excluded as they received less than 14 days prehabilitation or had incomplete data. The remaining 49 patients received a median duration of 24 days prehabilitation (range 15-91 days). The results show statistically significant improvements in the following functional outcome measures after prehabilitation: Rockwood scores, maximal inspiratory pressures, International Physical Activity Questionnaire Score and Functional Assessment of Chronic Illness - Fatigue Score. There was a lower postoperative complication rate in the prehabilitation group when compared with a control group (50% vs 67%).This quality improvement project has 3 Plan-Do-Study-Act (PDSA) cycles. PDSA 1 demonstrates prehabilitation can be successfully imbedded within a colorectal surgical unit and that patients are grateful for the service. PDSA 2 provides the project's first complete data set and demonstrates functional improvements in patients undergoing prehabilitation. The third PDSA cycle is ongoing and aims to refine the prehabilitation interventions and improve clinical outcomes for patients undergoing colorectal cancer surgery.

Systematic development and feasibility testing of a multibehavioural digital prehabilitation intervention for patients approaching major surgery (iPREPWELL): A study protocol

Improving outcomes for people undergoing major surgery, specifically reducing perioperative morbidity and mortality remains a global health challenge. Prehabilitation involves the active preparation of patients prior to surgery, including support to tackle risk behaviours that mediate and undermine physical and mental health and wellbeing. The majority of prehabilitation interventions are delivered in person, however many patients express a preference for remotely-delivered interventions that provide them with tailored support and the flexibility. Digital prehabilitation interventions offer scalability and have the potential to benefit perioperative healthcare systems, however there is a lack of robustly developed and evaluated digital programmes for use in routine clinical care. We aim to systematically develop and test the feasibility of an evidence and theory-informed multibehavioural digital prehabilitation intervention 'iPREPWELL' designed to prepare patients for major surgery. The intervention will be developed with reference to the Behaviour Change Wheel, COM-B model, and the Theoretical Domains Framework. Codesign methodology will be used to develop a patient intervention and accompanying training intervention for healthcare professionals. Training will be designed to enable healthcare professionals to promote, support and facilitate delivery of the intervention as part of routine clinical care. Patients preparing for major surgery and healthcare professionals involved with their clinical care from two UK National Health Service centres will be recruited to stage 1 (systematic development) and stage 2 (feasibility testing of the intervention). Participants recruited at stage 1 will be asked to complete a COM-B questionnaire and to take part in a qualitative interview study and co-design workshops. Participants recruited at stage 2 (up to twenty healthcare professionals and forty participants) will be asked to take part in a single group intervention study where the primary outcomes will include feasibility, acceptability, and fidelity of intervention delivery, receipt, and enactment. Healthcare professionals will be trained to promote and support use of the intervention by patients, and the training intervention will be evaluated qualitatively and quantitatively. The multifaceted and systematically developed intervention will be the first of its kind and will provide a foundation for further refinement prior to formal efficacy testing.