Personalized prehabilitation: a health promotion tool to improve surgical outcomes

Summary

Advances in the care of surgical patients emphasize the impact of social determinants of health (e.g., age, gender, income, education) on clinical outcomes and the relevance of personalized perioperative care, which can accelerate recovery and reduce complications. The importance of implementing patient-specific health promotion strategies preoperatively is discussed here, and a personalized prehabilitation paradigm that builds on perioperative practices designed to reduce complications and accelerate recovery within the Enhanced Recovery After Surgery (ERAS) approach is proposed. The selected actionable domains of health determinants in this paradigm highlight strategies to optimize surgical patients’ health and well-being, by identifying medical and nonmedical vulnerabilities, with the goal of improving surgical outcomes. This discussion will help centre perioperative optimization through health promotion as a core tenet of surgical care.

While postoperative rehabilitation is well-established, prehabilitation, which occurs before surgery, has yet to become commonly integrated across a range of surgical procedures and health institutions as part of the Enhanced Recovery After Surgery (ERAS) approach^1–3 owing to many potential barriers.⁴ Elective surgeries,⁵ and even some urgent inpatient surgeries,⁶ can have waiting periods ranging from a few days to several weeks, representing an underutilized opportunity to reduce risk factors for potential perioperative complications.^2,7 In this discussion, we emphasize the need for preoperative optimization across various surgical procedures and propose an evidence-based comprehensive personalized prehabilitation paradigm, placing importance on addressing modifiable and nonmodifiable determinants of health as well as interventions to act upon them.

Existing prehabilitation approaches

Several perioperative optimization programs are functional in centres across Canada (Table 1), including the Perioperative Program in Montréal and the Prehabilitation Unit in Toronto, and studies to date have shown their benefit in aiding recovery and reducing postoperative complications.⁷ While the existence of these programs is encouraging, many prehabilitation approaches remain limited to either a specific patient population, a single surgical procedure, or a narrow selection of interventions.^8–12 Failing to address the nonmedical needs of patients before surgery undermines patients’ experiences and leads to poor clinical outcomes, with associated health care costs.¹³ Personalized prehabilitation that addresses only medical comorbidities without considering socioeconomic characteristics may be insufficient for improving patient-centred surgical care.

Table 1.

Perioperative optimization programs in Canada

Province	Program	Target surgical patients	Prehabilitation interventions						Delivery
			Physical exercise	Nutritional support	Stress management	Lifestyle changes	Patient education	Comorbidity management
NS	Hip and Knee Pre-habilitation Program at many Nova Scotia Health sites	Hip and knee replacement surgery patients	•				•		Multidisciplinary team
Que.	Peri Operative Program (POP) Clinic at the Montreal General Hospital	Patients undergoing major surgery (e.g., cancer, spine, bariatric surgery)	•	•	•	•	•	•	Multidisciplinary team led by an anesthesiologist and comprising a kinesiologist, a nutritionist and a nurse psychoeducation specialist
	Vascular Surgery Prehabilitation Program at the Glen site, MUHC	Vascular surgery patients	•	•					Multidisciplinary team
	Cardiac Prehabilitation Program at the Richardson Hospital	Cardiac surgery patients at the Jewish General Hospital	•	•	•		•		Multidisciplinary team comprising a nurse, a kinesiologist, a nutritionist and a social worker
Ont.	Prehabilitation Program at the Toronto General Hospital	Patients undergoing major surgery or who are at risk	•	•	•	•	•	•	Multidisciplinary team (e.g., kinesiologist, psychologist and dietitian)
	Odette Cancer Centre Prehabilitation at the Sunnybrook Health Sciences Centre	Cancer surgery patients primarily	•	•	•	•		•	Multidisciplinary team comprising a hospitalist, an OT, a social worker, a dietitian, surgeons and nurses
	Prehab Program at the Oakville Trafalgar Memorial Hospital	Joint replacement surgery patients	•				•		PT or OT
Man.	Prehabilitation Clinic at the Concordia Hospital	Hip and knee joint replacement surgery patients	•	•		•	•		Multidisciplinary team comprising a PT/OT, a dietitian, a nurse and/or a social worker
Alta.	Prehabilitation Program at many Alberta Health Services sites	Patients awaiting any surgery	•	•	•	•			Multidisciplinary team comprising a dietitian, a PT/OT, a psychologist and/or a social worker
BC	Surgical Patient Optimization Collaborative at many BC sites	Patients undergoing major surgery	•	•	•	•		•	Multidisciplinary team

MUHC = McGill University Health Centre; OT = occupational therapist; PT = physiotherapist.

Comprehensive personalized prehabilitation

The comprehensive personalized prehabilitation paradigm presented in Figure 1 focuses on the surgical patient and their set of sociodemographic determinants of health, and it aims to facilitate the formulation and institution of suitable prehabilitation programs. Sociodemographic determinants of health, such as age, gender, income, and education, are of particular importance, as they have consistently been proven to have direct and indirect effects on health outcomes,¹³ but are not always considered in preoperative assessment. Furthermore, in hopes of instigating multimodal yet targeted prehabilitation programs, the paradigm considers 6 broad but actionable domains: physical activity and functional capacity, diet and nutrition, cognition and mental health, habits, patient autonomy, and comorbidity. These domains are linked to established surgical prehabilitation interventions that are broadly deemed important in the practice of medicine yet are rarely included systematically as components of preoperative optimization. Combining this paradigm with existing health screening tools may help identify domains in which patients could benefit from patient- and procedure-specific prehabilitation approaches to improve surgical outcomes. Indeed, once a patient vulnerability is identified in one domain, the corresponding prehabilitation intervention can be initiated (e.g., an exercise prescription,⁸ a nutritional plan,⁷ a psychoeducation booklet,⁶ a smoking cessation program,¹² or an improved diabetes management strategy¹⁷).

Fig. 1.

A paradigm for personalized prehabilitation.

For instance, most frail patients who are referred for coronary bypass and valvular surgeries engage in minimal physical activity as they wait for surgery and often have several medical comorbidities such as diabetes.⁸ Prehabilitation strategies concentrating on physical activity and medical treatment of comorbidities might be effective prehabilitation in this patient population. Furthermore, despite diet and nutrition being a significant predictor of outcomes in patients undergoing major abdominal surgery, less than half of malnourished patients undergo nutritional screening and almost one-quarter do not receive nutritional supplementation,⁹ demonstrating a missed opportunity for nutritional prehabilitation. Moreover, patients with epilepsy who require surgery to achieve freedom from seizures sometimes experience adverse effects on cognition postoperatively; reinforcing existing function preoperatively via cognitive prehabilitation may help these patients prepare for cognitive deficits that could arise following surgery.^10,11 Additionally, educating patients and encouraging lifestyle changes through supportive interventions such as computer-based smoking cessation programs¹² represents another opportunity to improve surgical outcomes given that habits such as smoking can increase the risk for important surgical complications.¹² Ultimately, patient autonomy is at the heart of this paradigm, as actively engaging patients in their care through prehabilitation can help mitigate the fear and anxiety associated with waiting for surgery. Advancing the standard of surgical care to incorporate personalized prehabilitation (Figure 1) will not only improve its scope and quality, but will also help empower patients to act for their health and render clinical care more inclusive. By supporting patients in preparing for surgery and considering their unique health characteristics, surgical care will become increasingly personalized, preventative, and proactive.

Implementation

Personalized prehabilitation should be viewed as an investment as opposed to a liability. The implementation of comprehensive personalized prehabilitation programs requires resources, multidisciplinary collaboration, complex organization-wide logistical efforts, and patient engagement. Existing screening tools (e.g., for smoking and food insecurity) can be used in a preoperative clinic. Hospitals may need to provide staff with additional training on perioperative optimization. Depending on the patient, the intervention(s) will require varying time investments and follow-ups. However, according to a recent systematic review,¹⁴ optimized preoperative care may ultimately save resources. For example, in a recent randomized controlled trial, health economic analysis showed that prehabilitation for heart valve surgery is likely to be cost-effective in preventing postoperative pulmonary complications and increasing quality-adjusted life years.¹⁵ Furthermore, preliminary Canadian data demonstrate a potential overall positive cost benefit for prehabilitation, with a mean saving of $10 000 per patient with cancer across a cohort of 63 patients, although further analyses are needed to make a more definitive conclusion.¹⁶

While socioeconomic parameters such as education and income are difficult to act upon directly, it is important to assess and address the common challenges associated with low education and/or income. One example is producing versions of medical information brochures adapted to various levels of literacy and in multiple languages. Another example is expanding the use of telehealth services where appropriate, which can alleviate the financial burden of travelling to health care centres for certain pre- and postoperative appointments. In Canada and beyond, distance from and access to care are determinants of health, and ensuring that urban and remote communities alike can benefit equitably from prehabilitation via innovative uses of technology and culturally sensitive care will be of primary importance. Partnering with local communities is perhaps the key to achieving this goal, as it has, for example, already been implemented to improve the care that Indigenous people receive for diabetes in Canada.¹⁷ Nevertheless, further research is needed on ways to mitigate the effects of socioeconomic status in preoperative optimization.

Conclusion

This discussion emphasized the need for preoperative optimization across a range of procedures and presented an evidence-based comprehensive personalized prehabilitation paradigm to highlight the importance of incorporating patient variability across modifiable and nonmodifiable health determinants. Beyond pilot testing within diverse surgical populations, this paradigm can be advanced by integrating it into surgical training and tracking its implementation across Canada in national registries as well as made more accessible with telehealth platforms and community partnerships. It is hoped that this discussion will contribute to reframing health promotion within surgical care, ultimately strengthening our health systems.