Optimizing Pre-operative Health for Better Outcomes

Prehabilitation for improving surgical outcomes. Although nutritional status and physical strength have long been known to predict surgical outcomes, opinions varied about whether you could improve outcomes by addressing these factors. In the past decade, research has been undertaken to determine (1) which interventions improve outcomes; (2) which patients are candidates for intervention; and (3) which indicators measure improved status and correlate with improved outcomes. In addition, recent research has explored when the best time is to intervene – before surgery and/or treatment (i.e., prehabilitation) or after (i.e., rehabilitation).

Sarcopenia as a risk factor. Sarcopenia is the loss of muscle mass and strength as part of the aging process, but it is accelerated or attenuated in various circumstances. Some diseases, such as rheumatologic conditions and cancer, are associated with accelerated sarcopenia, while activity and nutrition intake are associated with slower decline. Because of the high incidence of sarcopenia and its effects on health and physical function, its causes and potential treatments have been explored. Today, most interventions involve increasing exercise and improving nutritional intake.1

There are several ways to measure muscle mass and strength, but many in clinical and research settings are using the 6-min walk test (6MWT) because it is easy to administer, it correlates with maximum oxygen consumption values and it measures the ability to undertake activities of daily living.2 Although research is in its infancy and gaps in evidence still exist, prehabilitation that includes nutrition, exercise and psychological support has been shown to be more effective than post-operative rehabilitation in maintaining functional capacity and reducing pulmonary complications.3

Candidates for prehabilitation. Measures that determine who benefits most from prehabilitation have not been clearly identified. There is enough evidence today, however, to say that preoperative assessments should consider functional status, comorbidities, cognition, social support, nutrition and medical conditions to identify who is most at risk for adverse events. Because prehabilitation requires at least three or four weeks to see results, the risk of delaying surgery also needs to be considered.

The best candidates for prehabilitation are those with compromised functional status. More complex scores from the Physiological and Operative Severity Score for the Enumeration of Mortality or Morbidity (POSSUM) and the American Society of Anesthesiologists Physical status scale strongly predict postoperative complications, but simple functional assessments also accurately predict poor outcomes, such as a low 6MWT distance, reduced ability to climb flights of stairs and low hand grip strength. Efforts to improve fitness has been shown to be effective in initial pilots, so further work is being done to understand which interventions are most effective in reducing post-operative complications. Patients with GI cancers are good candidates as they are often nutritionally depleted pre-operatively and carry a significant risk of complications.4

How prehabilitation works. Increased muscle strength and mass are associated with fewer complications, including pulmonary infections, poor wound healing and longer recovery times. Amino acids available from muscle are an important resource for wound healing and synthesis of other proteins involved in immunity, thereby making less opportunity for infection to occur. In addition, patients return to an anabolic state more quickly after having pre-operative conditioning. When looking to optimize recovery after an anticipated surgery or when treatment is expected to result in a significant catabolic period, they show that you cannot as effectively make up for catabolic losses after the fact (i.e., post-surgery) as you can by “pre-loading” muscles with prehabilitation interventions. It is therefore important to target prehabilitation interventions at improving fitness and muscle strength, which are known to correlate with fewer post-operative complications and speedier recovery.

What prehabilitation involves. Trials have studied exercise alone, nutrition alone and both exercise and nutrition. Although understanding the mechanisms is in its early stages, indications are that exercise and nutrition independently improve muscle mass and strength and contribute to better outcomes but that they have an even greater impact when applied together.

Older adults vary in their ability to engage in physical activity, but they maintain their functional status when they are as active as possible. Ideally, older adults should engage in at least 150 minutes per week of moderate-intensity activity. For additional benefit, they can engage in additional vigorous-intensity activity as well because there is a “dose response” with higher activity levels. In a prehabilitation program, however, the patient’s baseline condition must be taken into consideration, making the goal to increase activity, no matter where the baseline starts. In fact, the greatest benefit has been shown in those with baseline low level of fitness, even if improvements are small, because they are at the greatest risk for post-operative complications.

The prehabilitation nutrition goals are to maximize net protein synthesis, particularly in muscle tissue. Carli, et al., at McGill University in Montreal, Quebec, Canada, recommends emphasizing adequate protein intake, aiming for at least 1.2-1.5 g protein/kg body weight. In addition, a bolus of 140 g carbohydrate 3 hours before and 10 g high quality protein immediately after exercise is recommended to increase muscle mass and strength.5

Progress has also been made in understanding how psychological stress impacts recovery. When adding strategies to relieve anxiety to a prehabilitation program, patients are more likely to continue with the program and experience better recovery. Psychological prehabilitation has been shown to improve immunity and surgical outcomes independently. In fact, simply believing that improving fitness aids recovery is correlated with better post-operative recovery. Cancer patients are especially likely to experience anxiety and depression, so cancer surgery prehabilitation should include psychological support to enhance physical function before and after surgery.6

Improved clinician understanding is also important when implementing prehabilitation. Clinicians do not always see the importance of these efforts because (1) they are not what has been done in the past; (2) the potential benefits are not appreciated; and (3) the effort by patients and clinicians may seem too great.7 More work needs to be done to make this easier for clinicians to prescribe and for patients to access and participate in prehabilitation.

Using digital tools to enable prehabilitation and rehabilitation. What if we could make it much easier for clinicians, patients and caregivers to prescribe and participate in these types of programs? With more tools available for delivering personalized assistance with exercise and nutrition recommendations, patients could avoid having to travel to rehab centers to follow the program and track their milestones. They can also use these tools to measure compliance with the recommendations and communicate with team members in real time to optimize results when the time frame is narrow. If there are only 3 or 4 weeks, getting information and additional resources to patients is essential to optimize effectiveness. Digital tools can enhance patient and team member experience so that patients can get the help they need when they need it. Whether it’s the right instructions or a delivery of supplies, any holdup can mean less chance to have the best post-operative outcome possible.

Datuit is dedicated to enabling clinical teams to deliver multi-disciplinary support to patients and caregivers. Its Care Plan Manager allows clinicians to help patients invite family and health professionals and enables real time communication among all the care team members so patients can get and review information and answers to questions. It also enables tools to work in the environment so that other content and service providers can be available to the entire care team. It also uses standards to aggregate medical data from EHRs and send data to providers using Direct, FHIR, eFax or its own secure messaging capabilities.

As healthcare moves into the digital age, many tools and platforms will be involved to support the data needs of provider organizations, payers, patients and families. Datuit’s SafeIX® Platform and Care Plan Manager care coordination tool helps patients and their care team members work together to measure outcomes and enable the best care possible.

1 Walston JD. Sarcopenia in older adults. Curr Opin Rheumatol 24(6):623-7 (2012). Accessed at https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4066461/.

2 Gillis C, Li C, Lee L, et al. Prehabilitation versus Rehabilitation: A Randomized Control Trial in Patients Undergoing Colorectal Resection for Cancer. Anesthesiology 121:937-47 (2014). Accessed at http://anesthesiology.pubs.asahq.org/article.aspx?articleid=1936479.

3 Pouwels S, Hageman D, Gommans LNM, et al. Preoperative exercise therapy in surgical care: a scoping review. J Clin Anesth 33:476-90 (2016). Accessed at http://www.jcafulltextonline.com/article/S0952-8180(16)30307-5/fulltext.

4 Feeney C, Hussey J, Carey M, et al. Assessment of physical fitness for esophageal surgery, and targeting interventions to optimize outcomes. Dis Esophagus 23(7):529-39 (2010). Accessed at https://academic.oup.com/dote/article-abstract/23/7/529/2329249/Assessment-of-physical-fitness-for-esophageal?redirectedFrom=fulltext.

5 Carli F, Scheede-Bergdahl C. Prehabilitation to Enhance Perioperative Care. Anesthesiology Clin 33:17-33 (2015). Accessed at https://academic.oup.com/dote/article-abstract/23/7/529/2329249/Assessment-of-physical-fitness-for-esophageal?redirectedFrom=fulltext.

6 Carli F, Gillis C, Scheede-Bergdahl C. Promoting a culture of prehabilitation for the surgical cancer patient. Acta Oncol 56(2):128-33 (2017). Accessed at http://www.tandfonline.com/doi/full/10.1080/0284186X.2016.1266081.

7 Herbert G, Sutton E, Burden S, et al. Healthcare professionals’ views of the enhanced recovery after surgery programme: a qualitative investigation. BMC Health Services Research 17:617 (2017). Accessed at https://bmchealthservres.biomedcentral.com/articles/10.1186/s12913-017-2547-y.