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. 2025 Feb 6;134(4):1018–1028. doi: 10.1016/j.bja.2025.01.010

Home-based prehabilitation: a systematic review and meta-analysis of randomised trials

Filippo D'Amico 1, Sara Dormio 1, Giulia Veronesi 2,3, Fabio Guarracino 4, Katia Donadello 5, Gilda Cinnella 6, Riccardo Rosati 3,7, Nicolò Pecorelli 3,8, Gabriele Baldini 9,10,11, Marina Pieri 1,3,⁎, Giovanni Landoni 1,3, Stefano Turi 1; PREHAB study group
PMCID: PMC11947603  PMID: 39919985

Abstract

Background

Prehabilitation aims to enhance preoperative functional capacity through exercise, nutrition, and psychological programs. Home-based prehabilitation represents an alternative to hospital prehabilitation, with the advantage of not utilising hospital resources. This review aims to evaluate adherence and clinical effectiveness of home-based prehabilitation.

Methods

We searched PubMed, Cochrane, and Embase up to October 1, 2024 for randomised controlled trials comparing home-based prehabilitation with standard care. The primary outcome was the proportion of patients with postoperative complications. Secondary outcomes included protocol adherence, and 6-min walking test. We used risk ratios (RR) and mean differences to summarise the results. The risk of bias was assessed using RoB 2 tool.

Results

We included 29 randomised trials for a total of 3508 patients. Median adherence to home-based prehabilitation programs was 82%. Home-based prehabilitation reduced the proportion of patients with postoperative complications (508/1322 [38.4%] vs 578/1335 [43.3%], risk ratio 0.84, 95% confidence interval [CI] 0.72–0.98, P=0.02, I2=44%, low certainty). After home-based prehabilitation, 6-min walking test performance was better compared with control (MD 28.2 m (95% CI 9.5–46.9; P<0.01, I2=48). Preoperative depression (MD −0.65, 95% CI −0.87 to −0.43; P<0.001, I2=0%), postoperative anxiety (MD −0.50, 95% CI −0.75 to −0.25; P<0.001, I2=0%, low certainty) and length of hospital stays (MD −0.32 days, 95% CI −0.61 to −0.03; P=0.03, I2=45%, low certainty) were lower with home-based prehabilitation.

Conclusions

Home-based prehabilitation reduced the proportion of patients with postoperative complications, but with low certainty of evidence. It also improved preoperative functional capacity, reduced hospital stays, depression and anxiety scores, with good adherence to the intervention.

Systematic review protocol

PROSPERO (CRD42024591208).

Keywords: anaesthesia, exercise, home-based, prehabilitation, preoperative rehabilitation

Editor's key points.

  • •

    Home-based prehabilitation is a potential alternative to hospital-based programs, avoiding the use of hospital facilities. However, its clinical effectiveness remains uncertain.

  • •

    In this systematic review, the authors demonstrate that home-based prehabilitation reduces postoperative complications, improves functional capacity, and decreases depression and anxiety, with high adherence.

  • •

    Home-based prehabilitation represents a promising approach to improve perioperative outcomes. Further high-quality randomised studies with larger sample sizes are needed.

Every year, >300 million people require surgery.1 Patients undergoing surgery are at risk of postoperative complications. Despite advances in perioperative care and improvement of recovery-related outcomes, the incidence of postoperative complications generally remained high.2,3

Prehabilitation recently emerged as a novel strategy aiming at improving preoperative functional capacity and resilience to surgical stress.4 Prehabilitation focuses on enhancing patients' functional capacity through exercise, nutritional support, and cognitive or educational intervention, with the ultimate goal to improve patient outcomes.5,6 In clinical trials, prehabilitation interventions are extensively studied in orthopaedic, thoracic, and abdominal surgeries.6 Systematic reviews and meta-analyses show that the pooled effect estimates consistently indicated a reduction in complications, with relative effect sizes ranging from 0.33 to 0.88, supported by low to very low certainty evidence.7

However, implementing prehabilitation programs remains challenging as it requires funding, adequate facilities for exercising, and trained personnel.8 Additionally, many patients scheduled for surgery live far from the hospital, making it difficult for them to attend in-hospital supervised prehabilitation sessions. Home-based prehabilitation programs could represent an alternative for overcoming these issues, although patient adherence might be challenging.

A systematic review and evaluation of randomised controlled trials (RCT) evaluating only home-based prehabilitation was not previously performed. Hypothesising that home-based prehabilitation could increase the accessibility and dissemination of prehabilitation, this systematic review and meta-analysis of randomised studies aimed at evaluating adherence to home-based prehabilitation and its effect on postoperative complications.

Methods

This systematic review and meta-analysis of RCT was conducted following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines.9 The research question was formulated using the Population, Intervention, Comparison, Outcome (PICO) framework: among perioperative patients (P), did home-based prehabilitation (I), compared with standard care without prehabilitation (C), reduce the proportion of patients with postoperative complications (O)?

Eligibility criteria

Studies published in peer-reviewed journals comparing home-based prehabilitation with standard care in perioperative populations were included. Both cardiac and noncardiac surgeries were considered. Exclusions included observational studies, studies with overlapping populations, systematic and narrative reviews, and editorials.

Search strategy

Four researchers independently performed a comprehensive search of PubMed, the Cochrane Central Register of Controlled Trials, and Google Scholar to identify relevant studies from inception until September 12, 2024. We included relevant conference abstracts identified through database searches and major conference websites. No restrictions were applied regarding patient age or publication language and articles in languages not spoken by the authors were translated using professional translation services (Supplementary Material 1).

Study selection

Two authors independently assessed study eligibility evaluating titles and abstracts, using a standardised form. When present, discrepancies were resolved by a third senior investigator. The selection of the included articles was based on full-text reviews, with consensus reached among the authors in cases of disagreement.

Definition of home-based prehabilitation

We included RCT that compared prehabilitation exclusively conducted at home with standard care without prehabilitation. Prehabilitation programs were defined as unimodal interventions (consisting of exercise, nutrition, or cognitive/psychological training) or multimodal interventions (combining exercise, nutrition, cognitive/psychological training, or all three), performed for at least 7 days before surgery.6

Data collection

Study characteristics (first author, year of publication, country), sample size, setting, prehabilitation characteristics, adherence, strategies to improve compliance, and outcomes were extracted by two independent investigators. Study authors were contacted for missing outcomes of interest.

Outcome

The primary outcome was the proportion of patients with postoperative complications. Secondary outcomes were adherence to prehabilitation programs (expressed as percentage of patients compliant to the program), 6-min walking distance before surgery, change of 6-min walking distance measured before surgery and compared with baseline, length of hospital stay, and preoperative hospital anxiety and depression score (HADS).

We also collected data on the proportion of patients with major complications (defined as those rated ≥3 on the Clavien–Dindo classification10), on the comprehensive complication index, health-related quality of life, rate of hospital readmission, and emergency department visits after hospital discharge.

Statistical analysis

For dichotomous outcomes, the Mantel–Haenszel method was used to calculate risk ratios (RR) and odds ratios (OR), along with their 95% confidence intervals (CI), using Review Manager (version 5.4.1; Review Manager [RevMan] computer program, The Cochrane Collaboration, 2020). For continuous outcomes, mean differences (MD) and 95% CI were calculated using the inverse variance method.11 If only median and interquartile range (IQR) data were available, Wan's method was used to estimate the mean and standard deviation.12

The hypothesis of statistical heterogeneity was tested with a significance level set at two-tailed 0.05. The statistical heterogeneity hypothesis was evaluated by means of Cochran's Q test, with statistical significance set at the two-tailed 0.10 levels, whereas the extent of statistical consistency was quantified with Higgins and Thompson's I2.13 We used a random-effect model for primary and secondary outcomes. An unadjusted P-value <0.05 was considered as statistically significant. Sensitivity analyses were conducted by excluding specific studies based on predefined criteria to evaluate the robustness of the findings, without using meta-regression techniques. Sensitivity analyses were performed including only studies with low risk of bias, studies including patients at high risk of complications (defined as >40% of complications in the control group14), studies with prehabilitation programs longer than 2 weeks, studies with multimodal prehabilitation, studies with only exercise prehabilitation, studies with only nutritional prehabilitation, studies including exercise prehabilitation, and studies including nutritional prehabilitation.

Risk-of-bias and quality assessments

The risk of bias (RoB) for each included trial was assessed by two independent investigators using the revised Cochrane RoB 2 tool for randomised trials,15 with disagreements resolved through discussion with a third reviewer. Trials were considered to have low RoB only if all domains were assessed as at low RoB.

The overall quality of evidence for the primary outcome was evaluated using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach.16

The protocol was registered in the Prospective International Register of Systematic Reviews (PROSPERO) with the registration number CRD42024591208.

Results

The search strategy of electronic databases identified 29 RCT with a total of 3508 patients which met the inclusion criteria and were included (Fig. 1). Characteristics of major trials excluded are reported in Supplementary Table S1. Twelve studies were conducted in Europe,17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28 nine in America,29, 30, 31, 32, 33, 34, 35, 36, 37 five in Asia,38, 39, 40, 41, 42 and two in Australia.43,44 Studies were published between 2010 and 2023. Fourteen studies were performed in abdominal surgery,17,20,23,25,27,28,30,32, 33, 34,41,43, 44, 45 five in orthopaedic,18,19,21,38,39 five in major noncardiac,24,31,35, 36, 37 three in thoracic,26,29,40 one in cardiac,42 and one in spinal surgery.22 Except for the prehabilitation protocol, the treatment in both groups was similar, including the optimisation of preparatory comorbidities and adherence to the ERAS protocol recommendations. Of the 29 studies included in the meta-analysis, eight were at low risk of bias, 12 had some concerns, and nine were at high risk of bias, with the major cause of bias related to deviations from the intended intervention (Supplementary Fig. S1). Characteristics of included studies are reported in Table 1.

Fig 1.

Fig 1

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PRISMA flow diagram showing literature search results. PRISMA, Preferred Reporting Items for Systematic Reviews and Meta-Analyses.

Table 1.

Characteristics of the included studies. NR, not reported. ∗In all studies, clinicians, anaesthesiologists, care physicians, and data analysts were blinded. Participants and those administering prehabilitation protocols were not blinded because of the nature of the intervention.

Study Country Type of surgery Prehabilitation modality Number of patients Prehabilitation intervention(s) Duration Adherence (%) Blinding details∗
An and colleagues 202138 Korea Orthopedic Unimodal 36 Exercise 3 Weeks 90 Single-blinding
Bausys and colleagues 202328 Lithuania Gastric Multimodal 122 Exercise, nutritional, psychological 4 Weeks NR Single-blinding
Jensen and colleagues 201520 Denmark Urology Unimodal 107 Exercise 2 Weeks 59 Single-blinding
Ferreira and colleagues 202129 Canada Thoracic Multimodal 114 Exercise, nutritional, psychological 4 Weeks 84.9 Single-blinding
Fulop and colleagues 202117 Hungary Colorectal Multimodal 149 Exercise, nutritional, psychological 4 Weeks NR Single-blinding
Gillis and colleagues 201430 Canada Colorectal Multimodal 77 Exercise, nutritional, psychological 4 Weeks 78 Single-blinding
Gillis and colleagues 201631 Canada Colorectal Unimodal 43 Nutritional 4 Weeks 93.7 Single-blinding
Grant and colleagues 201718 UK Orthopaedic Unimodal 18 Exercise 8 Weeks 100 Single-blinding
Heiman and colleagues 202126 Sweden Breast Unimodal 400 Exercise 4 Weeks 53 Single-blinding
Huang and colleagues 201239 Taiwan Orthopaedic Unimodal 243 Exercise 2–4 Weeks 80 Single-blinding
Humeidan and colleagues 202132 USA Major surgery Unimodal 268 Cognitive 10 Days 96.8 Single-blinding
Jahic and colleagues 201819 Bosnia Orthopaedic Unimodal 20 Exercise 6 Weeks 100 Single-blinding
IJmer-Hemink and colleagues 202124 Netherlands Major surgery Unimodal 102 Nutritional 3 Weeks NR Single-blinding
Kim and colleagues 200933 Canada Colorectal Unimodal 21 Exercise 4 Weeks 74 Single-blinding
Liu and colleagues 202040 China Thoracic Multimodal 73 Exercise, nutritional, psychological 2 Weeks 100 Single-blinding
López-Rodríguez-Arias and colleagues 202145 Spain Colorectal Multimodal 20 Exercise, nutritional, psychological 4 Weeks NR Single-blinding
Matassi and colleagues 201421 Italy Orthopaedic Unimodal 21 Exercise 6 Weeks 79.4 Single-blinding
McIsaac and colleagues 202236 Canada Major surgery Unimodal 182 Exercise 3 Weeks 61 Single-blinding
Milios and colleagues 201943 Australia Prostatectomy Unimodal 100 Exercise 5 Weeks 92 Single-blinding
Minnella and colleagues 201844 Canada Esophagogastric Multimodal 51 Exercise, nutritional, psychological 4 Weeks 63 Single-blinding
Nielsen and colleagues 201022 Denmark Spinal surgery Unimodal 24 Exercise 6–8 Weeks 85 Single-blinding
Onerup and colleagues 202223 Sweden Colorectal Unimodal 668 Exercise 2 Weeks 63 Single-blinding
Peng and colleagues 202141 China Colorectal Unimodal 213 Exercise 2 Weeks 92 Single-blinding
Rampam and colleagues 202235 US Major surgery Unimodal 104 Exercise 3–8 Weeks 41 Single-blinding
Santa Mina and colleagues 201834 Canada Prostatectomy Unimodal 86 Exercise 4 Weeks 68.4 Single-blinding
Satoto and colleagues 202142 Indonesia Cardiac surgery Unimodal 24 Exercise 2 Weeks NR Single-blinding
Triguero-Cánovas and colleagues 202327 Spain Colorectal Multimodal 44 Exercise, nutritional, psychological 2 Weeks NR Single-blinding
Vlisides and colleagues 201937 USA Major surgery Unimodal 52 Cognitive 7 Days NR Single-blinding
Waller and colleagues 202225 UK Abdominal Multimodal 22 Exercise, nutritional, psychological 2 Weeks 84 Single-blinding
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Adherence

We found a median adherence to home-based prehabilitation programs of 82.0% (IQR: 64.3–92.0%), with data on adherence reported in 22 studies. Daily phone calls were used in one study,41 weekly calls were used in eight studies,23,25,30,31,34,35,40,44 while in five studies patients were contacted at different and predefined time points.20,26,28,39 Daily video call supervision was implemented in two studies,38,42 while home visits were conducted during the program in one study.33 Nine studies utilised logbooks,17,20,24,29,33,36,40,41,44 while videos were used in four studies as part of the instructional materials.34,36,41,45 Educational individualised lessons were part of the adherence strategy in four studies.17,28,30,39 Activity trackers or smartwatches were used in two studies to monitor exercise activity and provide feedback.25,35 Diaries were used for self-reporting exercises and activities, with participants instructed to maintain daily logs in 17 studies.17,20, 21, 22,24,26,28, 29, 30, 31,33,34,36,41,43, 44, 45

Characteristic of the home-based prehabilitation programs

Out of the 29 studies, 16 utilised exclusively exercise as prehabilitation intervention18, 19, 20, 21, 22, 23,26,33, 34, 35, 36,38,39,41, 42, 43 while nine utilised exercise with other interventions (multimodal prehabilitation).17,25,27, 28, 29, 30,40,44,45 Two studies focused on cognitive interventions,32,37 and two on nutritional interventions only.24,31

Prehabilitation programs lasted a median of 4 weeks (IQR 2–4 weeks), with exercise sessions ranging from 3 to 7 days per week, with each session lasting from 30 to 60 min. Aerobic exercise was the most frequent type of exercise used, reported in 15 studies.17,20,22,23,25, 26, 27, 28, 29, 30,34,36,38,40,42 Three studies included inspiratory muscle training as part of the aerobic regimen.22,39,41 Resistance training was featured in seven studies,25,28, 29, 30,38,40,44 and resistance bands were provided in six studies.25,29,30,38,40,44 Some studies provided participants with specific exercise-intensity thresholds to reach during exercise. Specifically, three studies provided exercise targets based on the Borg scale and on heart rate.30,34,40 Other studies provided participants with exercise tools such as respiratory training devices,23,40 a step trainer,20 and a cycle ergometer.33

Eleven studies included a nutritional intervention in the context of a multimodal prehabilitation program,17,25,27, 28, 29, 30,40,44,45 while two as unimodal nutritional prehabilitation.24,31 All studies included dietary supplements when necessary; three studies provided supplements directly to patients,27,28,31 while one study provided complete meals.24 Eleven studies provided psychological, cognitive, or educational support,17,20,24,29,30,32,37,39, 40, 41,45 with two of them providing compact disks29,45 and two offering specific mobile applications.32,37

Primary outcome

Nineteen studies (2657 patients) reported data on the primary outcome with a reduction in the proportion of patients with postoperative complications in the prehabilitation group vs the control group (508/1322 [38.4%] vs 578/1335 [43.3%], RR 0.84, 95% CI 0.72–0.98, P=0.02, I2=44%, with low certainty of evidence; Fig. 2, Supplementary Fig S2) with a relative risk reduction of 11.2% and a number needed to treat of 21. Sensitivity analyses confirmed these results, especially if multimodal home-based prehabilitation was used (94/338 [27.8%] vs 130/322 [40.4%], RR 0.70, 95% CI 0.54–0.90, P<0.01), if prehabilitation lasted longer than 2 weeks (221/786 [28.1%] vs 269/766 [35.1%], RR 0.80, 95% CI 0.68–0.94, P<0.01) and in high-risk surgery (383/684 [56.0%] vs 443/710 [62.4%], RR 0.77, 95% CI 0.61–0.98, P=0.03) (Supplementary Table S2, Supplementary Figs. S3–S11).

Fig 2.

Fig 2

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Effect of home-based prehabilitation on the proportion of patients with postoperative complications. CI, confidence interval.

Secondary outcomes

At baseline, performance on the 6-min walking test in the prehabilitation and control group was similar (MD 1.6 m, 95% CI −3.4 to 6.6 m, P=0.53, I2=0%). After home-based prehabilitation, patients performance on the 6-min walking test was higher than that observed in the control group (MD 28.2 m, 95% CI 9.5–46.9 m, P<0.001, I2=48%, Fig. 3, with low certainty of evidence; Supplementary Fig. S12; nine studies included) and improved before surgery, compared with baseline (MD 10.6 m, 95% CI 0.2–21.1 m, P=0.05, I2=0%, with low certainty of evidence; Supplementary Figs. S13 and S14; five studies included).

Fig 3.

Fig 3

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Effect of home-based prehabilitation on the 6-min walking distance measured before surgery. CI, confidence interval; sd, standard deviation.

Anxiety and depression scores (HADS) were lower in the home-based prehabilitation group (preoperative depression: MD −0.65, 95% CI −0.87 to −0.43, P<0.001, I2=0%, with low certainty of evidence; Supplementary Figs S15 and S16, four studies included; 2-month postoperative anxiety MD −0.50, 95% CI −0.75 to −0.25, P<0.001, I2=0%, with low certainty of evidence; Supplementary Figs. S17 and S18, three studies included).

In addition, we find a reduction in length of hospital stays in the prehabilitation group compared with control (MD −0.3 days, 95% CI −0.61 to −0.03 days, P=0.03, I2=45%, Supplementary Figs. S19 and S20; with low certainty of evidence; with 18 studies included).

Healthcare cost data are reported in Supplementary Material 2. The other secondary outcomes were comparable between the two groups (Table 2, Supplementary Figs. S21–S30).

Table 2.

Primary and secondary outcomes. CCI, Comprehensive Complication Index; CI, confidence interval; HADS, hospital-related anxiety and depression score.

Outcomes Number of studies Prehabilitation group event/N of patients (%) Control group event/N of patients (%) Risk ratio 95% CI Prediction interval I2 (%) P-value Certainty
Primary outcome
Proportion of patients with postoperative complications 19 508/1322 (38.4) 578/1335 (43.3) 0.84 [0.72–0.98] 0.70–1.01 44 0.02 ⨁⨁◯◯ Low
Secondary outcomes
Mortality 5 6/542 (1.1) 12/577 (2.1) 0.55 [0.21–1.46] 0.21–1.45 0 0.23
Major complications 12 134/988 (13.6) 131/1012 (12.9) 1.02 [0.77–1.34] 0.76–1.36 9 0.91
Emergency department visit 3 18/130 (13.8) 25/122 (20.5) 0.68 [0.40–1.19] 0.39–1.17 0 0.18
Hospital readmission 8 56/556 (10.1) 55/550 (10.0) 1.05 [0.72–1.53] 0.71–1.54 5 0.79
Prehabilitation groupN of patients Control group
N of patients 		Mean difference
Length of hospital stay (days) 18 1305 1310 −0.3 [−0.61 to −0.03] −0.65 to 0.05 45 0.03 ⨁⨁◯◯ Low
Six-min walking distance (m) 9 368 351 28.2 [9.5–46.9] 5.45–50.95 48 <0.01 ⨁⨁◯◯ Low
Six-min walking test change, baseline to preoperative (m) 5 163 154 10.6 [0.2–21.1] 0.15–21.05 0 0.05 ⨁⨁◯◯ Low
Six-min walking test (2 months follow-up) 3 147 139 37.7 [−8.1 to 83.5] −23.58 to 98.98 79 0.11
Six-min walking test change (baseline to 2 months follow-up) 2 92 83 49.2 [−40.9 to 139.3] −75.97 to 174.37 93 0.28
HADS anxiety (preoperative) 5 284 270 −0.65 [−1.69 to 0.40] −2.07 to 0.77 84 0.23
HADS depression (preoperative) 5 284 270 −0.65 [−0.87 to −0.43] −0.87 to −0.43 0 <0.01 ⨁⨁◯◯ Low
HADS anxiety (2 months follow-up) 3 148 139 −0.50 [−0.75 to −0.25] −0.75 to −0.25 0 <0.01 ⨁⨁◯◯ Low
HADS depression (2 months follow up) 2 104 97 −0.64 [−1.53 to 0.24] −1.52 to 0.24 0 0.15
Quality of life 2 78 79 0.03 [−0.03 to 0.08] −0.03 to 0.08 0 0.32
CCI 5 670 695 −2.83 [−8.64 to 2.97] −10.51 to 4.85 75 0.34
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Discussion

Home-based prehabilitation significantly reduced the proportion of patients developing postoperative complications when pooling 29 RCTs with a 16% relative risk reduction, with low certainty of evidence. These findings were reinforced when multimodal programs were used and with programs lasting longer than 2 weeks. Additionally, adherence to the home-based prehabilitation program was high (>75%) and performance on the 6-min walking test was better in patients treated with home-based prehabilitation; similarly, depression and anxiety scores were lower in the home-based prehabilitation compared with control group.

The finding of this meta-analysis provides severable valuable information to facilitate implementation and dissemination of home-based prehabilitation programs. Notably, we observed that home-based prehabilitation programs exhibit high adherence rates (82%). These data on adherence are even more noteworthy when compared with the adherence rates previously reported for overall (both in-hospital and home-based) prehabilitation protocols of 70%.7 Therefore, home-based prehabilitation protocols could represent a suitable and impactful solution in settings lacking exercise facilities. Additionally, many surgical patients live far from the hospital, and home-based protocols enable these patients to participate in prehabilitation protocols without time and costs required for frequent travels. Moreover, home-based prehabilitation protocols could reduce the need for dedicated trained personnel and costs.

Our results are consistent in both magnitude and direction with previous meta-analyses which did not exclusively focus on home-based programs. Zhang and colleagues46 in their meta-analysis found that prehabilitation enhanced performance in the 6-min walking test (SMD 1.30, 95% CI 0.30–2.29) and reduced postoperative complications in colorectal cancer patients (OR 0.53, 95% CI 0.40–0.69).46 Similarly, Santa Mina and colleagues47 in a meta-analysis of RCTs reported a reduction in length of hospital stay with prehabilitation (−0.39 days, 95% CI −0.76 to −0.029 days).47 Treanor and colleagues48 in their meta-analysis further supported these benefits, demonstrating a reduction in post-surgery complications (OR 0.25, 95% CI 0.10–0.66) and hospital stay (MD −4.18, 95% CI −5.43 to −2.93) in lung cancer patients. However, Hughes and colleagues49 found a significant reduction in overall complications with prehabilitation (OR 0.63, 95% CI 0.46–0.87), but did not observe significant improvements in the length of hospital stay or in 6-min walking test.49

Our finding that home-based prehabilitation significantly reduces the proportion of patients who develop postoperative complications is of paramount importance and underscores the critical role of prehabilitation in enhancing surgical outcomes. Optimising patients' physical and functional status before surgery improves their immediate postoperative recovery and potentially reduces the burden on healthcare systems. These findings suggest that a home-based intervention, which minimises the need for hospital facilities, can lead to substantial improvements in patient outcomes and overall healthcare efficiency. Regrettably, only five out of the 29 studies provide mortality data, revealing a notable lack of reporting in this area, which limits our conclusions. Similarly, even if prehabilitation is likely associated to permanent lifestyle changes, no study reported long-term outcomes so far.

Patients randomised to the prehabilitation had a higher performance status compared with controls, indicating that prehabilitation effectively enhances functional capacity. We selected the 6-min walking test as a functional capacity measure in our meta-analysis because of its robust validation and its ability to reflect global improvements in physical performance. In fact, the 6-min walking distance (and its variation after prehabilitation) has been associated with pulmonary function, health-related quality of life, maximum exercise capacity, postoperative complications, and survival.50,51 Our data showed that home-based prehabilitation improves the 6-min walked distance by 25 m, which can be considered clinically relevant as it is above the range of the minimal clinically important difference of 20 m, as previously reported.52

Among patient-reported outcomes, we found a significant reduction in depression immediately after prehabilitation protocols, and anxiety reduction at the 2-month follow-up. Reduction in depression and anxiety are among the most important outcomes from the patient perspective.53, 54, 55

Patients randomised to prehabilitation had a reduction in length of hospital stay of −0.3 days. Although this reduction may not appear clinically significant on an individual level, its systematic implementation could yield substantial cost savings for healthcare systems. The cost of a single day of hospital stay is estimated at ∼$3025 US dollars,56 suggesting that even a modest reduction in hospital stay can result in considerable economic advantages. Indeed, length of hospital stay is a main target for quality improvement activities.

Several strengths and limitations should be acknowledged. Home-based prehabilitation proved to be feasible and effective in terms of observed, clinician-reported, and patient-reported outcomes. This review provides a comprehensive and contemporary synthesis of evidence about the impact of home-based prehabilitation on key patient-centred outcomes. Pooling together the results of several home-based prehabilitation programs and focusing exclusively on RCTs, we improved the precision of the treatment effect estimates. Moreover, the well-defined research question, evaluated in a clearly defined population, with a specific intervention and comparator, on well-defined endpoints facilitates the interpretation of these results. Finally, we reported several sensitivity analyses, detailed prehabilitation protocols and strategies used to enhance adherence, ensuring a robust evaluation.

The heterogeneity of patient populations, including studies conducted in various surgical settings, may introduce bias. Prehabilitation regimens were largely unsupervised, and almost one-quarter of studies did not report data on adherence. Also, a significant knowledge gap remains regarding the optimal design and structure of home-based prehabilitation programs. Moreover, given the nature of the intervention, blinding (both for the intervention and for the patients) was not feasible. Additionally, the observed heterogeneity of the prehabilitation intervention(s) among the included studies (type of prehabilitation, type of regimen including duration, and the intensity of exercise prescription), and the variability in reporting outcomes, make these results difficult to be clearly interpreted. The generalisability of the results to real-world settings may be limited, as the included studies are characterised by tightly controlled conditions and significant resource allocation per patient. This may not fully reflect the feasibility and effectiveness of home-based prehabilitation in standard care pathways or in less controlled, real-world scenarios. Larger, multicentre trials are needed to address these limitations and provide more generalisable evidence.57,58

Conclusions

Home-based prehabilitation, compared with standard care, reduces the proportion of patients with postoperative complications and depressive and anxious symptoms, while improving the 6-min walking test, with low certainty of evidence. Multimodal interventions and programs lasting longer than 2 weeks demonstrate a higher likelihood of effectiveness. Home-based protocols are feasible and can be a valuable resource for implementing prehabilitation in settings with limited resources or when patients are unable to access in-hospital facilities. Further randomised studies with large sample sizes are warranted.

Authors’ contributions

Conceptualisation: FDA, GL

Data collection: FDA, GC, RR, NP

Formal analysis: FDA, SD, GV, FG, KD, GB, MP, GL, ST

Methodology: FDA, GL

Original draft preparation: FDA, GB, MP, GL, ST

Validation: all authors

Manuscript review and editing: SD, GV, FG, KD, GC, RR, NP

Have read and agreed to the published version of the manuscript: all authors.

Funding

The European Union - Next Generation EU - NRRP M6C2 - Investment 2.1 Enhancement and strengthening of biomedical research in the NHS. Project code: PNRR-MCNT2-2023-12378183.

CUP code: C43C24000390007.

Declaration of interest

The authors declare that they have no conflicts of interest.

Handling Editor: Jonathan Hardman

Footnotes

Appendix A

Supplementary data to this article can be found online at https://doi.org/10.1016/j.bja.2025.01.010.

Contributor Information

Marina Pieri, Email: pieri.marina@hsr.it.

PREHAB study group:

Giulia Brizzi, Benedetta Chiodi, Giuseppe Ferrara, Sara Fiorito, Giovanni Guarnieri, Rosalba Lembo, Francesca Misceo, Cristina Nakhnoukh, Anita Nutta, Federico Oliva, Francesco Puccetti, Beatrice Righetti, Enrica Ronca, Filippo Sanfilippo, and Marta Veneziano

Appendix.

Collaborators: Giulia Brizzi1, Benedetta Chiodi2, Giuseppe Ferrara3, Sara Fiorito2, Giovanni Guarnieri4, Rosalba Lembo2, Francesca Misceo5, Cristina Nakhnoukh2, Anita Nutta2, Federico Oliva2, Francesco Puccetti6, 7, Beatrice Righetti2, Enrica Ronca2, Filippo Sanfilippo8 and Marta Veneziano2

1Department of Cardiothoracic Anaesthesia and ICU, Azienda Ospedaliero-Universitaria Pisana, Pisa, Italy.

2Department of Anaesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy.

3Department of Intensive Care, University Hospital of Foggia, Foggia, Italy.

4Division of Pancreatic Surgery, Pancreas Translational and Clinical Research Centre, IRCCS San Raffaele Scientific Institute, Milan, Italy.

5Department of Thoracic Surgery, IRCCS San Raffaele Scientific Institute, Milan, Italy.

6Department of Gastrointestinal Surgery, IRCCS San Raffaele Scientific Institute, Milan, Italy.

7School of Medicine, Vita-Salute San Raffaele University, Milan, Italy.

8Department of General Surgery and Medico-Surgical Specialties, School of Anaesthesia and Intensive Care, University of Catania, Catania, Italy.

Appendix A. Supplementary data

The following is the Supplementary data to this article:

Multimedia component 1
mmc1.docx (921KB, docx)

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