New digital-based prehab offers significant benefits for patients and hospitals
Professor Tara Rampal, Consultant Anaesthetist, looks at the important role digital prehabilitation can play in preparing patients for surgical procedures and what’s required to set up a digital prehab service.
Increasingly, the number of patients with frailty, sarcopenia, complex comorbidities and advanced age are being offered major surgical interventions. This leaves patients vulnerable to complications, which often translates to increased healthcare costs and utilisation, including total costs, hospital costs, care transition costs, primary care use, dental care use, emergency department use, unplanned hospital readmissions and hospitalisations.
However, there’s now a solution that offers the ability to boost theatre efficiency and the health of our population, while also lowering the pressure on clinicians and the hospital workforce.
It may sound too good to be true, but digital prehabilitation (prehab) offers this potential.
Four pillars of prehab
Prehab is a relatively new area of healthcare that focuses on improving the general health of patients before surgery / treatment as a way of helping their recovery and lowering the likelihood of complications. It’s a multidisciplinary and personalised intervention focused on four key pillars – prescribed exercise, nutritional optimisation, tailored psychological support and lifestyle modifications.
Prehabilitation should offer each patient a bespoke programme as every person takes a different perioperative journey. For example, some need support with psychological health while others will need help to boost their physical fitness. The intervention needs to be offered as a whole integrated intervention as each part complements the other.
Within prehab’s four pillars, the exercise components are the most studied – it may be aerobic exercise, resistance / strength training or a combination. The most crucial element is the personalisation – tailoring it to a patient’s clinical need such as the planned surgical date, their functional capacity and the time available.
The nutrition optimisation focusses mainly on adequate protein supplementation, deficiency recognition and education.
The psychological intervention ranges from talking therapies to cognitive behaviour therapy, focussing on anxiety, depression, acceptance of diagnosis and encouraging adherence to the prescribed exercise.
The fourth pillar, lifestyle modifications, focuses on active and empathetic support for smoking cessation, alcohol moderation, involving education and guidance.
The benefits of prehab
There’s increasing acceptance in the global clinical community, that prehab reduces post operative complications, decreases unplanned readmissions and improves patients’ health related quality of life.
For example, the UK’s Royal College of Anaesthetists believes “fitter patients who are able to improve their health and activity levels recover from surgery more quickly and with fewer complications. What you do in the time leading up to surgery can have a really big impact on your recovery and long-term health.” [1]
According to the Centre for Perioperative Care, a multidisciplinary initiative working to optimise patient outcomes, a quarter of a million people in the UK are at a higher risk from surgery – a number that’s set to rise.
Its research highlighted that while 12% of operations result in a complication, being inactive raises this risk four-fold. [2] However, preparing in advance of an operation – and in particular by taking exercise and following nutritional guidance to help build strength and fitness – halves the chances of suffering a complication.
“Pre-operative” time is a motivational opportunity for patients to increase their fitness. When faced with an operation, everyone wants a positive post-operative outcome with an early return to the baseline, if not better.
However, face-to-face prehab may preclude people who need it most, such as those from poorer socio-economic backgrounds, as it adds additional costs through travel, childcare costs, and inability to fit in a session during regular hours.
Digital prehab programmes
At QuestPrehab, based near London, we have successfully developed a technology-enabled method and platform that delivers highly personalised digital prehab programmes that also addresses these challenges.
We offer remote consultations followed by remote delivery using platforms such as Zoom or Teams. This offers multiple advantages such as flexibility of scheduling, psychological safety of working in a familiar environment and a contextual advantage for the practitioner to understand the wider social determinants of a patients’ health.
As the technology is scalable, the wide-scale delivery of prehab is possible to patients who get to enjoy improved healthcare and quality of life. At the same time, clinicians get to benefit from improved theatre efficiency and the lowering of pressure on medical staff.
During the past three years, we’ve worked with over 1,200 oncology patients. During that time, the reduction in 90-day surgical readmissions for urology patients fell 50% – and over 60% for colorectal cancer resections – as compared to published data in journals. [3]
When delivered digitally, prehab is often at a cost significantly lower than face-to-face service, but as valid in terms of patient experience. [4] There were additional savings, as improved health related quality of life led to earlier returns to work and less demand on social and primary care. [5]
A digital service does not have any geographical barriers, so patients living further afield from a hospital don’t miss out and it addresses health inequalities by decreasing the opportunity costs for patients. Properly administered, its impact extends beyond reduction in complications and readmissions and presents a real opportunity to positively impact the health of the population.
Three preconditions to incorporate digital prehab
To incorporate digital prehab as standard of care, clinicians need to accept three preconditions.
First and foremost, think beyond the operating theatres, hospital boundaries and organisational pathways. We must look at the patient journey, from the phone call to the GP to the presentation at the operating table. Perioperative prehab can be offered at any point, the earlier in the pathway the better.
We must adopt the flexibility of mind that interventions in the perioperative care pathway, in the cancer care pathway are not always deliverable in the hospital. There are fantastic cardiac rehabilitation and diabetes prevention models that have been successfully delivered in the community for years. Second, and in my opinion perhaps the most important point, is that the digital platform used should be accessible.
Simplicity is often the best way, with apps helping track compliance and adherence along with providing trustworthy resources for people. The Covid-19 pandemic has accelerated the acceptance of digital services and most of us like our apps to be concise, intervention specific, easy to navigate and integrated into our lives.
Lastly, while looking to guide our patients towards digital prehab platforms, we must acknowledge the privilege and the responsibility of the position of trust we have. We must guide them to services that have been acknowledged as offering an effective and impactful solution for the challenging problem of offering prehab. We also bear the responsibility of ensuring these solutions are cost effective to ensure we offer value-based interventions.
Key principles to incorporate multimodal prehab
To incorporate multimodal prehab into a healthcare system I believe there are four key principles that must be employed.
1. Remote / digital delivery
In our post-lockdown world, the vast majority of people appreciate the flexibility, accessibility, privacy and support offered by live streaming. Delivery into the home will mitigate the need to travel to a prehab unit, widening access to those who may not be able to attend the face-to-face in-hospital sessions.
2. The service must be highly personal
We are all a sum of our physical, psychological, social and familial experiences. Add to that the unique nature of clinical disease and treatment planned, it’s no surprise that evidence demonstrates that personalised interventions, such as tailored prehab programmes have far greater impact than generic advice and information. [6] An individualised plan within the framework of multimodal guidance will have the greatest benefit.
3. Clinically led and supported
To achieve meaningful and long-lasting results, you must offer an inter-professional programme allowing for multiple healthcare professionals to coordinate care to facilitate optimal use of the preoperative time and to embed behavioural change before surgery.
4. It must offer value for money
In order to be sustainable beyond its ‘pilot stage’ and to impact the greatest number of patients, any programme – and the interventions offered – must be cost effective.
As additional proof of concept of the effectiveness of a digital prehab service, QuestPrehab will soon become the first company in the world to deliver digital prehab programmes to China, helping pulmonary patients 5,700 miles away in two Shanghai hospitals. [7]
About the author
Professor Tara Rampal FRCA MBBS (https://tararampal.com) is a Consultant Anaesthetist with a keen interest in Perioperative Care and Population Health. She trained at the Barts and the London School of Anaesthesia where she was awarded the Excellence Award for Academic Achievement in 2008. She is the Founder of QuestPrehab, an award winning innovative digital prehab service, which aims to improve healthcare outcomes and health-related quality of life for patients in need of major medical intervention. She is passionate about the potential of digital tools in changing the healthcare landscape.
• To learn more about QuestPrehab and its programmes, please visit: https://questprehab.com
