‘Prehabilitation’ Program Shown to Help Surgery Patients

Preparing patients for surgery usually involves sharing information about the upcoming procedure, reviewing vital signs and tests at a pre-op appointment, and providing specific instructions about medications and foods for the days or hours immediately before a patient is due to check in.

But a new study has found that getting patients to actively participate in their preparation for a longer period of time can lead to better outcomes.

This inexpensive program to help surgery patients get physically and mentally ready for their upcoming operation may help reduce overall costs and get them home faster, according to the research involving more than 1,500 patients in 21 hospitals across Michigan.

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The concept of “prehabilitation” 

“Prehabilitation,” as it’s called, uses the weeks before surgery to encourage patients to move more, eat healthier, cut back on tobacco, breathe deeper, reduce their stress and focus on their goals for after their operation.

After the approach was first tested at the University of Michigan in 2017, it showed signs of reducing total medical costs related to the patient’s care, and cutting their length of stay in the hospital, compared with patients at Michigan Medicine who did not go through the program.

The new study, published in the Journal of the American College of Surgeons in December 2019, confirms those results on a larger scale. The study looked at 523 patients with traditional Medicare coverage who went through “prehab”, and more than 1,000 similar patients who did not.

The latest study found that patients in the prehab program:

  • Left the hospital one day earlier than those that weren’t in the program, on average;
  • Were more likely to go straight home rather than to a skilled nursing facility, compared with similar patients treated at the same hospital;
  • Incurred an average of $3,200 less in total medical costs, up to three months after surgery;
  • Were less likely to need home health care after surgery (24% of prehab patients compared to 29% of non-prehab).

    However, the study found that prehab patients had about the same rates of nursing home stays, visits to emergency departments and additional hospital stays after they left the hospital.

    In a new paper in the Annals of Surgery, published in January 2020, the researchers proposed that surgical teams adopt the same “positive psychology” approach to engaging with surgery candidates that patients in the U-M study were taught.

    “Every time the prehab study has been studied, it’s found to increase the value of surgical care by improving care while reducing cost. This study cements the business case for hospitals to support it,” said Michael Englesbe, MD, who leads the U-M Department of Surgery team that published both studies. His comments were reported by Kara Gavin, media relations manager at the U-M Institute for Healthcare Policy and Innovation.

    “We also now recognize that prehab’s physical training may work partly because it empowers the patient to engage in their own recovery,” added Englesbe, a professor of surgery and director of the Michigan Surgical Quality Collaborative (MSQC). “Patient empowerment is the ‘secret sauce’ and we hope to harness it even more.”

    Study targeted high-risk patients 

    The new study focused on the patients with the highest risk of complications after surgery because they had a combination of underlying health conditions beyond the problem that required surgery. Their median age was 70, and one in six qualified for federal disability benefits. All of the patients in the study were having one of 26 common operations.

    Surgeons referred patients to the program, called the Michigan Surgical and Health Optimization Program or MSHOP. The program was supported by a grant from the Center for Medicare and Medicaid Services, and involved hospitals taking part in the MSQC quality improvement program.

    Once enrolled, prehab patients received a call or electronic message from a member of the MSHOP team, and materials about the importance of better nutrition, tobacco cessation, engaging in positive thinking and goal-setting, and reducing stress to their pre-surgery preparation.

    They also received a pedometer to track their steps, and a spirometer to encourage them to practice taking deep breaths, to improve their lung function before and after surgery.

    In all, 62% of the prehab patients tracked their walking three or more times a week, online or by phone, and the program staff contacted patients who hadn’t logged steps, to encourage them to do so.

    Though the prehab patients were only in the program for an average of two and a half weeks before surgery, the program was associated with statistically significant changes in several measures.

    Establishing a new standard of care 

    Although prehab programs at many of the participating hospitals ended or scaled back when the study ended, the U-M team has made MSHOP part of the standard of care for Michigan Medicine surgical candidates who have a higher than usual risk of complications. Blue Cross Blue Shield of Michigan supports the effort through a pilot payment project.  Access a full kit of online patient materials. 

    In addition to incorporating more positive psychology aspects, such as having patients express their post-surgical goals and the steps they will take to try to reach them, the MSHOP program now allows patients to track steps using their smartphones and wearable activity trackers. The data is then synced automatically from their device to the electronic patient record.

    Surgical team members, from pre-op clinic staff to post-surgery rounding teams, are encouraged to work with MSHOP enrollees toward shared ownership of their surgical outcomes, and better well-being.

    As hospitals and health systems continue to be incentivized for value-based care, Englesbe predicted that the business case for coordinating prehab programs will grow.

    Source: Michigan Medicine - University of Michigan 

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