Seems like weve written many, many columns on the impact of frailty on a variety of medical outcomes but the impact on surgical outcomes has been most striking. Our surgical colleagues often say to us Yes, I recognize when patients are frail. I tell them and their families that they are at greater risk for the surgery. What else am I supposed to do?
Several studies have demonstrated that hospital multidisciplinary teams, usually led by geriatricians or other healthcare professionals who focus on those with frailty, may have a positive impact on outcomes for hospitalized frail patients. But the missing piece has always been whether doing anything preoperatively to ready frail patients for surgery makes a difference.
A systematic review (McIsaac 2017) found that few interventions have been tested to improve the outcomes of frail surgical patients, and most available studies are at substantial risk of bias.
Now a new study (Howard 2019) adds to a slowly growing body of evidence that prehabilitation does, indeed, have a positive impact on surgical outcomes. The Michigan Surgical and Health Optimization Program (MSHOP) is a formal prehabilitation program that engages patients in 4 activities before surgery: physical activity, pulmonary rehabilitation, nutritional optimization, and stress reduction. Patients were referred to the program at the discretion of their surgeon, with at least 2 weeks between referral and the surgery. The program focused on walking (patients receive a pedometer to track steps), breathing (patients receive an incentive spirometer), nutrition and stress management. They also received advice on smoking cessation, if appropriate. A DVD and brochure with instructions and resources for each domain was provided to patients, as well as a way to log their participation. During their involvement in the program, patients receive emails, phone messages, and text message-based reminders to
Overall, 70% of MSHOP patients complied with the program. MSHOP patients had better physiologic reserve (demonstrated by better systolic and diastolic blood pressures and lower heart rate compared to the other groups one hour into surgery). There was a significant reduction in class 3 to 4 complications in the MSHOP group (30%) compared with the nonprehabilitation (38%) and emergency (48%) groups. Total hospital charges averaged $75,494 for the MSHOP group, $97,440 for the nonprehabilitation group, and $166,085 for the emergency group. That translates to an average savings of $21,946 per patient. The authors note this represents a significant cost offset for a prehabilitation program. They conclude a prehabilitation program should be considered for all patients undergoing surgery.
A significant limitation of this study is that it was not specifically a study of a frail population and there were no specific inclusion criteria for frailty. But a retrospective comparison of frailty data between groups (using psoas muscle size as a proxy for frailty) did identify a higher incidence of frailty in the MSHOP group. Therefore, those patients would have been expected to do worse. But this study demonstrates that surgical prehabilitation is beneficial in that these patients do not have the inferior outcomes and patients who completed prehabilitation had superior outcomes in some cases.
This was also not a randomized, controlled trial. Rather patients were referred at the discretion of their surgeon (hence, some likely selection bias) and groups were chosen for comparison by propensity score matching.
In our April 10, 2018 Patient Safety Tip of the Week Prepping the Geriatric Patient for Surgery we discussed some other preoperative programs for frail elderly patients. The Perioperative Optimization of Senior Health (POSH) study (McDonald 2018) looked patients who were undergoing elective abdominal surgery and were considered at high risk for complications (ie, older than 85 years or older than 65 years with cognitive impairment, recent weight loss, multimorbidity, polypharmacy, visual or hearing loss, or simply deemed by their surgeons to be at higher risk). Intervention patients received a multidisciplinary comprehensive preoperative evaluation that focused on cognition, medications, comorbidities, mobility, functional status, nutrition, hydration, pain, and advanced care planning.
Despite higher mean age and morbidity burden, older adults who participated in this interdisciplinary perioperative care intervention had fewer complications, shorter hospitalizations, more frequent discharge to home, and fewer readmissions than a comparison group. Though this was not a randomized, controlled trial (it was a before/after study design) and did not include a formal frailty measure, it is quite clear that most or all the intervention group patients were frail.
One small randomized trial of prehabilitation in high-risk patients (age >70 years and/or American Society of Anesthesiologists score III/IV) undergoing elective major abdominal surgery has recently been completed (Barberan-Garcia 2018).The researchers randomized 71 patients to the control arm and 73 to intervention. Prehabilitation covered 3 actions: motivational interview; high-intensity endurance training, and promotion of physical activity. The intervention group enhanced aerobic capacity, reduced the number of patients with postoperative complications by 51%, and the rate of complications (P = 0.001).
A small randomized clinical trial in Canada (Minnella 2018) compared prehabilitation with a control group. Intervention consisted of preoperative exercise and nutrition optimization. Participants were adults awaiting elective esophagogastric resection for cancer. Compared with the control group, the prehabilitation group had improved functional capacity (measured by change in 6-minute walk distance) both before surgery and after surgery.
But a larger randomized study is ongoing (McIsaac 2018). This is a single-center, parallel-arm randomized controlled trial of home-based exercise prehabilitation versus standard care among consenting patients >60 years having elective cancer surgery (intra-abdominal and intrathoracic) and who are frail (Clinical Frailty Scale >4). The intervention consists of > 3 weeks of exercise prehabilitation (strength, aerobic and stretching). The primary outcome is the 6 min walk test at the first postoperative clinic visit. Secondary outcomes include the short physical performance battery, health-related quality of life, disability-free survival, complications and health resource utilization.
Hopefully the ongoing McIsaac study will provide definitive answers about utility of prehabilitation in preparing the frail geriatric patient for surgery.
One other program weve previously mentioned is the American College of Surgeons Strong for Surgery program. This program is intended to optimize patients overall status prior to surgery and provides a toolkit with checklists. Strong for Surgery empowers hospitals and clinics to integrate checklists into the preoperative phase of clinical practice for elective operations. The checklists are used to screen patients for potential risk factors that can lead to surgical complications, and to provide appropriate interventions to ensure better surgical outcomes. The checklists in the Strong for Surgery Toolkit target eight areas known to be influential determinants of surgical outcomes:
2. Glycemic Control
3. Medication Management
4. Smoking Cessation
5. Safe and Effective Pain Management after Surgery
8. Patient Directives
Its certainly logical that optimizing patients prior to surgery might improve outcomes. We are finally beginning to validate that concept and identifying the components of such prehabilitation programs that lead to success.
Some of our prior columns on preoperative assessment and frailty:
McIsaac DI, Jen T, Mookerji N, et al. Interventions to improve the outcomes of frail people having surgery: A systematic review. PLOS One 2017; Published: December 29, 2017
Howard R, Yin YS, McCandless L, et al. Taking Control of Your Surgery: Impact of a Prehabilitation Program on Major Abdominal Surgery. J Amer Coll Surg 2019; 228(1): 72-80 Published online: October 22, 2018
McDonald SR, Heflin MT, Whitson HE, et al. Association of Integrated Care Coordination With Postsurgical Outcomes in High-Risk Older AdultsThe Perioperative Optimization of Senior Health (POSH) Initiative. JAMA Surg 2018; Published online January 3, 2018
Barberan-Garcia A, Ubrι M, Roca J, et al. Personalised Prehabilitation in High-risk Patients Undergoing Elective Major Abdominal Surgery: A Randomized Blinded Controlled Trial. Ann Surg 2018; 267(1): 50-56
Minnella EM, Awasthi R Loiselle S-E, et al. Effect of Prehabilitation on Functional Capacity in Esophagogastric Cancer Surgery. JAMA Surgery 2018; Online First June 13, 2018
McIsaac DI, Saunders C, Hladkowicz E, et al. PREHAB study: a protocol for a prospective randomised clinical trial of exercise therapy for people living with frailty having cancer surgery. BMJ Open. 2018; 8(6): e022057. Published online 2018 Jun 22
American College of Surgeons. Strong for Surgery. Updated November 2018
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