Is Community-based Prehabilitation Feasible and Does it Improve Elective Surgery Outcomes?

Surgery is an important part of healthcare, with over 2.5 million operations  performed each year in Australia alone. However, one in five patients experience a complication after surgery, which significantly impacts patient health, leads to longer hospital stays and a higher chance of being readmitted to hospital. Many of these risks can be greatly reduced, if not completely prevented by getting as healthy as possible before surgery – a concept known as Prehabilitation (PreHab).

Health Translation SA’s is partnering with CALHN to help facilitate this exciting project  led by Prof Jane Andrews.  Together we are working with consumers, primary care and hospital providers to design and pilot a PreHab program for patients awaiting non-urgent elective surgery.

Background Information

Surgery is a critical component of healthcare systems. One third of the global disease burden, and two-thirds of cancers and injuries are managed by surgery. This equates to approximately 2.5 million surgical procedures per year in Australia alone.  However, post-operative complications are major but under-recognised cause of morbidity and mortality in patients undergoing surgery. Approximately 20% of these patients experience post-operative complications and death within 30 days of surgery ranks as the 3rd leading cause of death worldwide. Post-operative complications directly affect patients, increase length of hospital stay, rates of avoidable re-admissions, and direct health system costs.  Such complications are predicted to increase 10% annually in Australia if changes to current practice are not made.  In fact, the term “the hidden pandemic” has been recently used to describe the predicted scenario where life-improving and life-saving surgery will be less safe, or unaffordable, or both without addressing these issues now.

The risk of many post-operative complications can be greatly reduced, via a variety of management and treatment options optimising preparation for surgery.

Optimal surgical care starts well before the operation. It includes choosing wisely when to operate, in whom to operate and determining whether any factors can be optimised before operation. In the elective surgery space, the first two aspects usually receive due consideration. However, current systems do not routinely ensure preoperative optimisation occurs.  Currently, any pre-operative optimisation occurs via  a specialised preoperative anaesthetic clinic (when it does occur) within 1-2 weeks of surgery. Whilst there is some value in this, many aspects of optimisation need to be identified and addressed over a longer time period.  For example, smoking cessation is best 4 or more weeks prior to surgery and more weight loss is likely to be achieved over a longer period. This need to push back preoperative surgical optimisation timelines has led us to propose that “PreHabilitation” or PreHab (getting healthy before surgery) should commence at the time of referral for consideration of non-emergency elective surgery so optimisation(s) can commence earlier.

Perioperative timeline. Adapted from ANZCA (2019)

While previous studies have proven value in single preoperative interventions, such as smoking cessation, no-one has reported on the feasibility, acceptability and outcomes of a global PreHab approach. In this study we will codesign and pilot test a community-based prehabilitation program for patients referred for elective (planned) surgery.

This is a novel, pragmatic approach if successful, is highly likely to yield significant health gains not only to people undergoing surgery, but also to others in whom surgery may no longer be needed due to PreHab and also to others reaping the benefits of a heightened GP and community awareness of health maintenance issues and resources.

• From a system basis, this will reduce overall length of stay, via reduced complications. This will improve care costs and access to care as more cases can be done in the same bed base. Patients are also likely to have better individual outcomes from their surgery and from durable changes to lifestyle factors. Only a small engagement in such a program will yield measurable system level benefits.
• From a consumer viewpoint, this program will directly empower potential patients to take agency for their own health outcomes. It will support them to access care they need but may not be receiving in the community care setting while awaiting outpatient review. It will make their waiting time active rather than passive, improve their health literacy and make them real partners in their healthcare provision.