1
|
Sliwinski S, Faqar-Uz-Zaman SF, Heil J, Mohr L, Detemble C, Dreilich J, Zmuc D, Bechstein WO, Becker S, Chun F, Derwich W, Schreiner W, Solbach C, Fleckenstein J, Filmann N, Schnitzbauer AA. Predictive value of a novel digital risk calculator to determine early patient outcomes after major surgery: a proof-of-concept pilot study. Patient Saf Surg 2024; 18:13. [PMID: 38610002 PMCID: PMC11010393 DOI: 10.1186/s13037-024-00395-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2024] [Accepted: 03/28/2024] [Indexed: 04/14/2024] Open
Abstract
BACKGROUND A structured risk assessment of patients with validated and evidence-based tools can help to identify modifiable factors before major surgeries. The Protego Maxima trial investigated the value of a new digitized risk assessment tool that combines tools which can be easily used and implemented in the clinical workflow by doctors and qualified medical staff. The hypothesis was that the structured assessment and risk-grouping is predictive of short-term surgical quality reflected by complications and overall survival. METHODS The Protego Maxima Trial was a prospective cohort analysis of patients undergoing major surgery (visceral, thoracic, urology, vascular and gynecologic surgeries) as key inclusion criterion and the absence of an acute or acute on chronically decompensated pulmo-cardiovascular decompensation. Patients were risk-scored with the software (The Prehab App) that includes a battery of evidence-based risk assessment tools that allow a structured risk assessment. The data were grouped to predefined high and low risk groups and aggregate and individual scores. The primary outcome was to validate the predictive value of the RAI score and the TUG for overall survival in the high and low risk groups. Secondary outcomes were surgical outcomes at 90-days after surgery (overall survival, Clavien-Dindo (CD) 1-5 (all complications), and CD 3-5 (major complications)). The study was carried out in accordance with the DIN ISO 14,155, and the medical device regulation (MDR) at Frankfurt University Hospital between March 2022 and January 2023. RESULTS In total 267 patients were included in the intention to treat analysis. The mean age was 62.1 ± 12.4 years. Patients with a RAI score > 25 and/or a timed up and go (TUG) > 8 s had a higher risk for mortality at 90 days after surgery. The low-risk group predicted beneficial outcome and the high-risk group predicted adverse outcome in the ROC analysis (Area Under the Curve Receiver Operator Characteristics: AUROC > 0.800; p = 0.01). Risk groups (high vs. low) showed significant differences for 90-day survival (99.4% vs. 95.5%; p = 0.04) and major complications (16.4% vs. 32.4%; p < 0.001). CONCLUSION The proof-of-concept trial showed that a risk assessment with 'The Prehab App' may be viable to estimate the preoperative risk for mortality and major complications before major surgeries. The overall performance in this initial set of data indicated a certain reliability of the scoring and risk grouping, especially of the RAI score and the TUG. A larger data set will be required to proof the generalizability of the risk scoring to every subgroup and may be fostered by artificial intelligence approaches. TRIAL REGISTRATION Ethics number: 2021-483-MDR/MPDG-zuständig monocentric; The Federal Institute for Pharmaceuticals and Medical Devices/BfArM, reference number: 94.1.04-5660-13655; Eudamed: CIV-21-07-0307311; German Clinical Trial Registry: DRKS 00026985.
Collapse
Affiliation(s)
- Svenja Sliwinski
- Department for General, Visceral, Transplant and Thoracic Surgery, Frankfurt University Hospital, Goethe University Frankfurt/Main, Theodor-Stern-Kai 7, 60590, Frankfurt/Main, Germany
| | - Sara Fatima Faqar-Uz-Zaman
- Department for General, Visceral, Transplant and Thoracic Surgery, Frankfurt University Hospital, Goethe University Frankfurt/Main, Theodor-Stern-Kai 7, 60590, Frankfurt/Main, Germany
| | - Jan Heil
- Department for General, Visceral, Transplant and Thoracic Surgery, Frankfurt University Hospital, Goethe University Frankfurt/Main, Theodor-Stern-Kai 7, 60590, Frankfurt/Main, Germany
| | - Lisa Mohr
- Institute of Sports Medicine, Goethe University Frankfurt/Main, Frankfurt/Main, Germany
| | - Charlotte Detemble
- Department for General, Visceral, Transplant and Thoracic Surgery, Frankfurt University Hospital, Goethe University Frankfurt/Main, Theodor-Stern-Kai 7, 60590, Frankfurt/Main, Germany
| | - Julia Dreilich
- Institute of Sports Medicine, Goethe University Frankfurt/Main, Frankfurt/Main, Germany
| | - Dora Zmuc
- Department for General, Visceral, Transplant and Thoracic Surgery, Frankfurt University Hospital, Goethe University Frankfurt/Main, Theodor-Stern-Kai 7, 60590, Frankfurt/Main, Germany
| | - Wolf O Bechstein
- Department for General, Visceral, Transplant and Thoracic Surgery, Frankfurt University Hospital, Goethe University Frankfurt/Main, Theodor-Stern-Kai 7, 60590, Frankfurt/Main, Germany
| | - Sven Becker
- Department for Gynecology, Frankfurt University Hospital, Goethe University Frankfurt/Main, Frankfurt/Main, Germany
| | - Felix Chun
- Department for Urology, Frankfurt University Hospital, Goethe University Frankfurt/Main, Frankfurt/Main, Germany
| | - Wojciech Derwich
- Department for Vascular Surgery, Frankfurt University Hospital, Goethe University Frankfurt/Main, Frankfurt/Main, Germany
| | - Waldemar Schreiner
- Department for General, Visceral, Transplant and Thoracic Surgery, Frankfurt University Hospital, Goethe University Frankfurt/Main, Theodor-Stern-Kai 7, 60590, Frankfurt/Main, Germany
| | - Christine Solbach
- Department for Gynecology, Frankfurt University Hospital, Goethe University Frankfurt/Main, Frankfurt/Main, Germany
| | - Johannes Fleckenstein
- Institute of Sports Medicine, Goethe University Frankfurt/Main, Frankfurt/Main, Germany
- Pain Center, Hospital Landsberg am Lech, Landsberg am Lech, Germany
| | - Natalie Filmann
- Institute of Biostatistics and Mathematical Modeling, Goethe-University Frankfurt, Frankfurt/Main, Germany
| | - Andreas A Schnitzbauer
- Department for General, Visceral, Transplant and Thoracic Surgery, Frankfurt University Hospital, Goethe University Frankfurt/Main, Theodor-Stern-Kai 7, 60590, Frankfurt/Main, Germany.
| |
Collapse
|
2
|
Sliwinski S, Werneburg E, Faqar-Uz-Zaman SF, Detemble C, Dreilich J, Mohr L, Zmuc D, Beyer K, Bechstein WO, Herrle F, Malkomes P, Reissfelder C, Ritz JP, Vilz T, Fleckenstein J, Schnitzbauer AA. A toolbox for a structured risk-based prehabilitation program in major surgical oncology. Front Surg 2023; 10:1186971. [PMID: 37435472 PMCID: PMC10332323 DOI: 10.3389/fsurg.2023.1186971] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2023] [Accepted: 04/17/2023] [Indexed: 07/13/2023] Open
Abstract
Prehabilitation is a multimodal concept to improve functional capability prior to surgery, so that the patients' resilience is strengthened to withstand any peri- and postoperative comorbidity. It covers physical activities, nutrition, and psychosocial wellbeing. The literature is heterogeneous in outcomes and definitions. In this scoping review, class 1 and 2 evidence was included to identify seven main aspects of prehabilitation for the treatment pathway: (i) risk assessment, (ii) FITT (frequency, interventions, time, type of exercise) principles of prehabilitation exercise, (iii) outcome measures, (iv) nutrition, (v) patient blood management, (vi) mental wellbeing, and (vii) economic potential. Recommendations include the risk of tumor progression due to delay of surgery. Patients undergoing prehabilitation should perceive risk assessment by structured, quantifiable, and validated tools like Risk Analysis Index, Charlson Comorbidity Index (CCI), American Society of Anesthesiology Score, or Eastern Co-operative Oncology Group scoring. Assessments should be repeated to quantify its effects. The most common types of exercise include breathing exercises and moderate- to high-intensity interval protocols. The program should have a duration of 3-6 weeks with 3-4 exercises per week that take 30-60 min. The 6-Minute Walking Testing is a valid and resource-saving tool to assess changes in aerobic capacity. Long-term assessment should include standardized outcome measurements (overall survival, 90-day survival, Dindo-Clavien/CCI®) to monitor the potential of up to 50% less morbidity. Finally, individual cost-revenue assessment can help assess health economics, confirming the hypothetic saving of $8 for treatment for $1 spent for prehabilitation. These recommendations should serve as a toolbox to generate hypotheses, discussion, and systematic approaches to develop clinical prehabilitation standards.
Collapse
Affiliation(s)
- Svenja Sliwinski
- Department of General, Visceral, Transplant and Thoracic Surgery, University Hospital Frankfurt, Goethe University Frankfurt/Main, Frankfurt/Main, Germany
| | - Elisabeth Werneburg
- Department of General, Visceral, Transplant and Thoracic Surgery, University Hospital Frankfurt, Goethe University Frankfurt/Main, Frankfurt/Main, Germany
| | - Sara Fatima Faqar-Uz-Zaman
- Department of General, Visceral, Transplant and Thoracic Surgery, University Hospital Frankfurt, Goethe University Frankfurt/Main, Frankfurt/Main, Germany
| | - Charlotte Detemble
- Department of General, Visceral, Transplant and Thoracic Surgery, University Hospital Frankfurt, Goethe University Frankfurt/Main, Frankfurt/Main, Germany
| | - Julia Dreilich
- Institute of Sports Medicine, Goethe University Frankfurt/Main, Frankfurt/Main, Germany
| | - Lisa Mohr
- Institute of Sports Medicine, Goethe University Frankfurt/Main, Frankfurt/Main, Germany
| | - Dora Zmuc
- Department of General, Visceral, Transplant and Thoracic Surgery, University Hospital Frankfurt, Goethe University Frankfurt/Main, Frankfurt/Main, Germany
- Institute of Sports Medicine, Goethe University Frankfurt/Main, Frankfurt/Main, Germany
| | - Katharina Beyer
- Department of General, Visceral and Vascular Surgery, Campus Benjamin Franklin, Charité-Universitätsmedizin Berlin, Berlin, Germany
- German Association for General and Visceral Surgery (DGAV), Surgical Work Force for Perioperative Medicine, Berlin, Germany
| | - Wolf O. Bechstein
- Department of General, Visceral, Transplant and Thoracic Surgery, University Hospital Frankfurt, Goethe University Frankfurt/Main, Frankfurt/Main, Germany
| | - Florian Herrle
- German Association for General and Visceral Surgery (DGAV), Surgical Work Force for Perioperative Medicine, Berlin, Germany
- Romed Klinik Prien am Chiemsee, Klinik für Allgemein- und Viszeralchirurgie, Prien am Chiemsee, Germany
| | - Patrizia Malkomes
- Department of General, Visceral, Transplant and Thoracic Surgery, University Hospital Frankfurt, Goethe University Frankfurt/Main, Frankfurt/Main, Germany
| | - Christoph Reissfelder
- German Association for General and Visceral Surgery (DGAV), Surgical Work Force for Perioperative Medicine, Berlin, Germany
- Department of Surgery, Universitätsmedizin Mannheim, Medical Faculty Mannheim, University of Heidelberg, Mannheim, Germany
| | - Joerg P. Ritz
- German Association for General and Visceral Surgery (DGAV), Surgical Work Force for Perioperative Medicine, Berlin, Germany
- Helios Clinics Schwerin, Department for General and Visceral Surgery, Schwerin, Germany
| | - Tim Vilz
- German Association for General and Visceral Surgery (DGAV), Surgical Work Force for Perioperative Medicine, Berlin, Germany
- Department of General, Visceral, Thoracic, and Vascular Surgery, University Hospital Bonn, Bonn, Germany
| | - Johannes Fleckenstein
- Institute of Sports Medicine, Goethe University Frankfurt/Main, Frankfurt/Main, Germany
- Department of Pain Medicine, Hospital Landsberg am Lech, Landsberg am Lech, Germany
| | - Andreas A. Schnitzbauer
- Department of General, Visceral, Transplant and Thoracic Surgery, University Hospital Frankfurt, Goethe University Frankfurt/Main, Frankfurt/Main, Germany
- German Association for General and Visceral Surgery (DGAV), Surgical Work Force for Perioperative Medicine, Berlin, Germany
| |
Collapse
|
3
|
Faqar-Uz-Zaman SF, Sliwinski S, Detemble C, Filmann N, Zmuc D, Mohr L, Dreilich J, Bechstein WO, Fleckenstein J, Schnitzbauer AA. Study protocol for a pilot trial analysing the usability, validity and safety of an interventional health app programme for the structured prehabilitation of patients before major surgical interventions: the PROTEGO MAXIMA trial. BMJ Open 2023; 13:e069394. [PMID: 37019492 PMCID: PMC10439343 DOI: 10.1136/bmjopen-2022-069394] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2022] [Accepted: 03/14/2023] [Indexed: 04/07/2023] Open
Abstract
INTRODUCTION Major surgery is associated with a high risk for postoperative complications, leading to an increase in mortality and morbidity, particularly in frail patients with a reduced cardiopulmonary reserve. Prehabilitation, including aerobic exercise training, aims to improve patients' physical fitness before major surgery and reduce postoperative complications, length of hospital stay and costs. The purpose of the study is to assess the usability, validity and safety of an app-based endurance exercise software in accordance with the Medical Device Regulation using wrist-worn wearables to measure heart rate (HR) and distance. METHODS AND ANALYSIS The PROTEGO MAXIMA trial is a prospective, interventional study with patients undergoing major elective surgery, comprising three tasks. Tasks I and II aim to assess the usability of the app, using evaluation questionnaires and usability scenarios. In Task IIIa, patients will undergo a structured risk assessment by the Patronus App, which will be correlated with the occurrence of postoperative complications after 90 days (non-interventional). In Task IIIb, healthy students and patients will perform a supervised 6 min walking test and a 37 min interval training on a treadmill based on HR reserve, wearing standard ECG limb leads and two smartwatches, which will be driven by the test software. The aim of this task is to assess the accuracy of HR measurement by the wearables and the safety, using specific alarm settings of the devices and lab testing of the participants (interventional). ETHICS AND DISSEMINATION Ethical approval was granted by the Institutional Review Board of the University Hospital of Frankfurt and by the Federal Institute for Pharmaceuticals and Medical Products (BfArM, reference number 94.1.04-5660-13655) on 7 February 2022. The results from this study will be submitted to peer-reviewed journals and reported at suitable national and international meetings. TRIAL REGISTRATION NUMBERS European Database on Medical Devices (CIV-21-07-037311) and German Clinical Trial Registry (DRKS00026985).
Collapse
Affiliation(s)
- Sara Fatima Faqar-Uz-Zaman
- Department for General, Visceral, Transplant and Thoracic Surgery, Hospital of the Goethe University Frankfurt Surgery Centre, Frankfurt am Main, Germany
| | - Svenja Sliwinski
- Department for General, Visceral, Transplant and Thoracic Surgery, Hospital of the Goethe University Frankfurt Surgery Centre, Frankfurt am Main, Germany
| | - Charlotte Detemble
- Department for General, Visceral, Transplant and Thoracic Surgery, Hospital of the Goethe University Frankfurt Surgery Centre, Frankfurt am Main, Germany
| | - Natalie Filmann
- Institute of Biostatistics and Mathematical Modeling, Goethe University Frankfurt, Frankfurt am Main, Germany
| | - Dora Zmuc
- MCL Medical Center Ljubljana, Ljubljana, University Medical Centre Ljubljana, Ljubljana, Slovenia
| | - Lisa Mohr
- Department of Sports Medicine and Exercise Physiology, Institute for Sports Science, Goethe University Frankfurt, Frankfurt, Germany
| | - Julia Dreilich
- Department of Sports Medicine and Exercise Physiology, Institute for Sports Science, Goethe University Frankfurt, Frankfurt, Germany
| | - Wolf O Bechstein
- Department for General, Visceral, Transplant and Thoracic Surgery, Hospital of the Goethe University Frankfurt Surgery Centre, Frankfurt am Main, Germany
| | - Johannes Fleckenstein
- Department of Sports Medicine and Exercise Physiology, Institute for Sports Science, Goethe University Frankfurt, Frankfurt, Germany
- Pain Centre, Klinikum Landsberg am Lech, Landsberg am Lech, Germany
| | - Andreas A Schnitzbauer
- Department for General, Visceral, Transplant and Thoracic Surgery, Hospital of the Goethe University Frankfurt Surgery Centre, Frankfurt am Main, Germany
| |
Collapse
|