Abstract
Background
Although trimodal prehabilitation programs have demonstrated clinical benefits in oncologic surgery, evidence regarding their financial sustainability in public health systems of middle-income countries remains limited.
Objective
To assess the institutional budget impact and financial viability of implementing a trimodal prehabilitation program for oncologic surgical patients in a public regional hospital.
Methods
A five-year Budget Impact Analysis was conducted from the hospital perspective. The model incorporated an initial capital investment of CLP 24,773,549 and an annual operating cost of CLP 92,400,000, with a projected annual enrollment of 380 patients. Cost offsets were primarily driven by expected reductions in postoperative hospital length of stay, while reductions in major postoperative complications were incorporated as complementary clinical-economic indicators. A 10% annual discount rate was applied. Net present value (NPV) and internal rate of return (IRR) were calculated to assess financial performance.
Results
The estimated cost per treated patient was CLP 243,158, while projected annual cost offsets averaged CLP 287,000 per patient. The program generated an annual net benefit of approximately CLP 16,660,000. Over a five-year horizon, the discounted NPV was CLP 38,382,700, with an IRR of 43%. Sensitivity analyses demonstrated that financial viability was primarily dependent on the magnitude of hospital length-of-stay reduction.
Conclusion
Under base-case assumptions, implementation of a trimodal prehabilitation program in a public hospital setting appears financially sustainable, with projected returns exceeding the institutional discount threshold. These findings suggest that perioperative optimization strategies may represent an economically viable investment for resource-constrained health systems.
Keywords: Budget impact analysis, Financial feasibility, Oncologic surgery
Cancer remains the leading cause of death worldwide, accounting for nearly 10 million deaths annually [5, 11]. In 2022, approximately 20 million new cases were diagnosed globally, and projections suggest a continued increase toward 2030 and beyond [4]. In Chile, 59,876 new cases and 31,440 deaths were reported in 2022, with malignant tumors representing a substantial proportion of mortality, including in the Maule Region (Ministerio de Salud [17], Servicio de salud Maule [23]). The growing burden of cancer poses significant clinical and economic challenges, particularly within publicly funded healthcare systems [24].
Surgery remains the cornerstone of curative treatment for many solid tumors. However, postoperative complications, according to the Clavien-Dindo model [9], are frequent and contribute to prolonged hospitalization, intensive care utilization, readmissions, and increased mortality [7, 22]. Morbidity rates of up to 27.7% have been reported in general surgical populations, with higher rates observed in complex procedures [11, 24]. Patients experiencing major complications may incur costs several times higher than those without complications. Globally, the economic burden of cancer has been estimated at USD 1.16 trillion, while in Chile annual direct and indirect costs exceed one trillion Chilean pesos, approximately 1,160,000,000.00 US Dollars [10, 11]. Despite this impact, few surgical services systematically evaluate the financial consequences of postoperative morbidity [25].
Prehabilitation has emerged as a strategy aimed at improving patients’ functional reserve before surgery through multimodal interventions that typically include structured exercise, nutritional optimization, and psychological support [15, 16, 21]. Evidence suggests that trimodal prehabilitation may improve functional capacity, enhance perioperative recovery, and reduce postoperative complications in selected oncologic populations [2, 3, 14]. Reductions in complications ranging from 10% to 16% have been described, with some studies reporting even greater effects in high-risk patients [12, 20]. Programs have been implemented in Canada, the Netherlands, and the United Kingdom, with reported per-patient costs between CAD1,500 and £400 depending on program structure [6, 13].
In Chile, the National Cancer Law (Ministerio de salud [18]), and the National Cancer Plan (Ministerio de Salud [19]), promote comprehensive and equitable cancer care [10, 22]. Nevertheless, economic evaluations assessing the financial implications of implementing structured prehabilitation programs in middle-income public hospitals remain limited [8]. While clinical feasibility has been described locally, the budgetary consequences of systematic implementation have not been formally modeled.
Given the increasing incidence of cancer, the frequency of postoperative complications, and the resource constraints of public hospitals, estimating the financial impact of prehabilitation is relevant for institutional planning [25, 26]. A hospital-based budget impact analysis may provide decision-makers with structured information regarding projected costs and potential reductions in complication-related expenditure within a defined time horizon.
Objective
To evaluate the projected 5-year financial implications of implementing a trimodal prehabilitation program for oncologic surgery from a hospital provider perspective in a middle-income public healthcare setting.
Method
Study design
A hospital-based budget impact analysis (BIA) was conducted to estimate the financial implications of implementing a trimodal prehabilitation program for patients undergoing elective oncologic surgery. The analysis followed the methodological principles recommended for budget impact evaluations and was reported in accordance with the CHEERS 2022 statement [1].
Perspective and time horizon
The analysis was performed from the perspective of a public hospital provider in Chile. A 5-year time horizon was selected to capture both initial implementation costs and medium-term operational expenditures. Future costs were discounted at an annual rate of 10%, consistent with national public investment evaluation guidelines.
Target population
The modeled population included adult patients scheduled for elective oncologic surgery at a regional public hospital in the Maule Region. Annual demand projections were estimated using regional cancer incidence data and institutional surgical activity reports. Program capacity was determined according to projected staffing availability and infrastructure constraints.
Intervention
The intervention consisted of a structured trimodal prehabilitation program delivered prior to surgery, including:
Supervised physical exercise (aerobic and resistance training).
Individualized nutritional assessment and optimization.
Psychological support focused on coping strategies and perioperative stress management.
The program duration was four weeks on average, based on published clinical protocols. The comparator was usual preoperative care without structured prehabilitation.
Model structure
A deterministic financial model was developed to estimate:
Initial investment costs (infrastructure, equipment, training),
Annual operating costs (personnel, consumables, overhead),
Projected number of patients treated annually,
Expected reduction in major postoperative complications.
Clinical effectiveness was modeled as a proportional reduction in major postoperative complications based on conservative estimates from published literature. The number of complications avoided was calculated by applying the relative reduction to the projected annual surgical volume and baseline complication rates derived from the literature.
Costing approach
Costs were estimated in 2025 Chilean pesos (CLP). Capital costs were depreciated using the straight-line method according to national public sector accounting standards. Residual value assumptions were incorporated where applicable. Personnel costs were calculated using institutional salary scales. All cost inputs were obtained from hospital administrative records and publicly available national tariffs when required.
Outcome measures
The primary outcome was the cumulative 5-year net budget impact of implementing the program compared with usual care. A secondary outcome was the incremental cost per major postoperative complication avoided.
Sensitivity analysis
Deterministic one-way sensitivity analyses were conducted to explore uncertainty in key parameters, including:
Baseline complication rates.
Magnitude of complication reduction (10–20% range).
Program operating costs.
Annual patient enrollment.
Scenario analyses were performed under conservative and optimistic assumptions to assess financial variability.
Economic model specification
An institutional-level Budget Impact Analysis was conducted over a five-year time horizon from the perspective of a public regional hospital. The model estimated annual program costs, projected cost offsets derived from reductions in postoperative complications and hospital length of stay, and the resulting net financial impact.
Annual Net Benefit: The annual net financial benefit of the program was calculated as:
 |
Where:
Annual Savings represent the aggregated institutional cost offsets associated with reduced postoperative complications and shorter hospital stays.
Annual Program Cost includes personnel, operational, and allocated overhead expenses required to deliver the trimodal prehabilitation program.
Annual savings were estimated as:
 |
Where:
N = number of patients treated annually.
S = estimated average cost offset per patient.
Annual program costs were estimated as:
 |
Where:
C = cost per patient derived from institutional resource utilization and salary scales.
Net Present Value (NPV): To assess financial sustainability over time, discounted cash flow analysis was performed. The Net Present Value (NPV) was calculated as:
 |
Where:
CFt = net cash flow in year.
r = annual discount rate (10%).
T = time horizon (5 years).
The initial investment was incorporated as a negative cash flow at year 0.
Internal Rate of Return (IRR): The Internal Rate of Return (IRR) was calculated as the discount rate that satisfies:
 |
IRR represents the rate at which the present value of benefits equals the present value of costs.
Estimation of cost offsets
Reductions in postoperative length of stay were estimated based on published evidence of trimodal prehabilitation programs, with a conservative base-case assumption of a 3-day reduction (range: 2–5 days). The institutional cost per inpatient surgical day was obtained from hospital financial records and estimated at CLP 95,000 per day.
Cost savings per patient were calculated as:
 |
Using base-case assumptions:
 |
This value was rounded to CLP 287,000 to reflect additional minor resource savings associated with complication reduction.
The clinical parameters used in the model were derived from published randomized and observational prehabilitation studies. No local pilot implementation data were available; Therefore, results reflect modeled projections rather than empirical effectiveness estimates.
The parameters used and the target population of the study are presented in Table 1.
Table 1.
Target population and projected annual program eligibility
| Parameter | Value | Source/Assumption |
|---|---|---|
| Total population of Maule Region | 1,162,641 | Regional demographic data (8–10) |
| Proportion affiliated with FONASA | 86.7% | Regional health coverage data |
| Estimated annual cancer incidence (250 per 100,000) | 2,520 cases | Adjusted incidence rate (8–10) |
| Estimated proportion requiring surgical treatment | 40%* | Literature-based assumption |
| Estimated annual oncologic surgical candidates | 1,008 patients | Derived estimate |
| Expected enrollment in prehabilitation program | 380 patients | Institutional capacity projection |
*Assumption based on proportion of solid tumors managed surgically in public hospital settings
Results
The model assumed stable annual enrollment of 380 patients, constant per-patient costs throughout the five-year horizon, and consistent effectiveness in reducing postoperative complications and hospital length of stay. No major structural changes in institutional cost structures were considered. A 10% annual discount rate was applied in accordance with standard economic evaluation practices for middle-income settings. Postoperative length-of-stay reduction was conservatively estimated at 2–5 days, with a base-case assumption of 3 days.
Base-case financial results
The estimated initial investment required to implement the trimodal prehabilitation program was CLP 24,773,549. Annual operating costs were projected at CLP 92,400,000, primarily driven by personnel expenditures.
Under base-case assumptions, the estimated cost per patient was CLP 243,158. Projected cost offsets associated with reduced length of stay averaged CLP 287,000 per patient, resulting in an annual net benefit of approximately CLP 16,660,000.
Over the five-year time horizon, discounted cash flow analysis yielded a positive net present value (NPV) of CLP 38,382,700. The internal rate of return (IRR) was estimated at 43%, substantially exceeding the applied discount rate.
While the primary analysis focused on institutional budget impact driven by projected reductions in hospital length of stay, a complementary clinical-economic assessment was conducted to estimate the cost per major postoperative complication avoided. This secondary indicator provides additional context regarding the relationship between implementation costs and projected clinical benefits but should not be interpreted as the principal economic outcome of the study.
These findings suggest that, under base-case assumptions, the program is financially sustainable and potentially cost-saving for the institution.
The estimated investment needed to implement the program per patient is shown in Table 2.
Table 2.
Resource utilization and cost per patient in the trimodal prehabilitation program
| Component | Sessions per patient | Unit cost per session (CLP) | Cost per patient (CLP) |
|---|---|---|---|
| Kinesiology (exercise training) | 15 | 18,500 | 277,500 |
| Nutrition (individual consultation) | 6 | 16,000 | 96,000 |
| Psychological support | 3 | 14,000 | 42,000 |
| Initial multidisciplinary assessment | 1 | 20,000 | 20,000 |
| Total cost per patient | — | — | 435,500 |
*Unit costs derived from institutional salary scales and allocated overhead expenses
The annual budget impact of the program is summarized in Table 3.
Table 3.
Annual budget impact of the trimodal prehabilitation program
| Parameter | Value (CLP) |
|---|---|
| Patients treated per year | 380 |
| Cost per patient | 243,158 |
| Total annual program cost | 92,400,000 |
| Estimated savings per patient | 287,000 |
| Total annual savings | 109,060,000 |
| Net annual benefit | 16,660,000 |
*Chilean pesos
Clinical impact and cost per complication avoided
Assuming a 15% relative reduction in major postoperative complications and applying baseline rates derived from published literature, the program was projected to prevent approximately 85 major complications over five years.
The incremental cost per major postoperative complication avoided was estimated at CLP 3,122,353. These findings reflect the relationship between projected implementation costs and estimated clinical benefits in terms of complications avoided.
Sensitivity analysis
Deterministic one-way sensitivity analyses demonstrated that financial sustainability was particularly sensitive to the magnitude of postoperative length-of-stay reduction.
Under a conservative assumption of a 2-day reduction, the intervention did not achieve a positive NPV. At a 3-day reduction (base-case), financial viability was achieved, with the break-even threshold situated between 2 and 3 days. Greater reductions substantially increased projected returns.
Additional sensitivity analyses indicated that variations in baseline complication rates, magnitude of complication reduction (10–20%), annual enrollment, and personnel costs influenced economic outcomes; however, results remained within ranges considered manageable relative to institutional surgical expenditure.
Complementary financial assessment
As a complementary institutional appraisal, standard public-sector investment metrics were applied. The positive NPV and IRR indicate that projected cost offsets are sufficient to recover both initial investment and operational expenditures within the modeled horizon. These indicators are presented as institutional decision-support tools and should not be interpreted as a full societal economic evaluation.
The Fig. 1 shows the economic impact of the trimodal prehabilitation program.
Fig. 1.
Theoretical model of prehabilitation. Note: Image created by the authors and enhanced with the help of artificial intelligence
The discounted cash flow over the five-year horizon is presented in Table 4.
Table 4.
Discounted cash flow over 5-year horizon (10% discount rate)
| Year | Net Cash Flow (CLP) | Discounted Value (CLP) |
|---|---|---|
| 0 | -24,773,549 | -24,773,549 |
| 1 | 16,660,000 | 15,145,455 |
| 2 | 16,660,000 | 13,768,596 |
| 3 | 16,660,000 | 12,516,906 |
| 4 | 16,660,000 | 11,379,915 |
| 5 | 16,660,000 | 10,345,377 |
| Total NPV | — | 38,382,700 |
Results of the one-way sensitivity analysis are shown in Table 5.
Table 5.
One-way sensitivity analysis varying length-of-stay reduction
| LOS Reduction (days) | Annual Net Benefit (CLP) | Estimated NPV (5 years, 10%) |
|---|---|---|
| 2 days | -20,200,000 | Negative |
| 3 days (base-case) | 15,900,000 | 38,000,000 |
| 5 days | 88,100,000 | > 300,000,000 |
Discussion
This study conducted a hospital-level Budget Impact Analysis of implementing a trimodal prehabilitation program for oncologic surgical patients, with reduction in postoperative length of stay serving as the primary economic driver. Estimation of cost per complication avoided was included as a complementary indicator to contextualize projected clinical benefits.
Under base-case assumptions, the program generated a positive net present value over five years and an internal rate of return substantially exceeding the applied discount rate. These findings suggest that projected reductions in length of stay and postoperative morbidity are sufficient to offset implementation and operating costs, supporting the financial sustainability of the intervention from an institutional perspective.
Sensitivity analysis demonstrated that economic viability was highly dependent on the magnitude of length-of-stay reduction. While a 2-day reduction did not yield a positive NPV, the base-case 3-day reduction achieved financial feasibility, indicating a break-even threshold between 2 and 3 days. Larger reductions substantially improved projected returns, underscoring the importance of effective implementation and outcome monitoring.
Although prehabilitation has been extensively studied in high-income countries, formal economic evaluations, particularly within middle-income public health systems, remain limited. By modeling financial sustainability within a Latin American public hospital context, this study provides institution-specific evidence to inform managerial decision-making in resource-constrained environments.
Limitations
Several limitations should be acknowledged. First, the model relied on assumptions regarding reductions in postoperative complications and length of stay derived from published evidence; actual effectiveness may vary by setting. Financial sustainability was particularly sensitive to the magnitude of length-of-stay reduction, highlighting the importance of implementation fidelity and patient case-mix. Second, the analysis was deterministic and did not include probabilistic sensitivity analysis, limiting full characterization of parameter uncertainty. Third, the hospital perspective excluded broader societal costs and benefits, potentially underestimating the overall economic value of the intervention.
Additionally, the model assumed stable annual enrollment and consistent performance over the five-year horizon, which may not fully reflect real-world variability. Finally, as the analysis was conducted within a single institution, generalizability to other hospitals or health systems may be limited.
Future research should incorporate probabilistic sensitivity analyses, cost-utility approaches including quality-adjusted life years (QALYs), and multicenter implementation studies to enhance external validity.
Conclusion
Within the assumptions of this institutional Budget Impact Analysis, implementation of a trimodal prehabilitation program for oncologic surgical patients appears financially sustainable in a public hospital setting. The projected positive net present value and internal rate of return suggest that perioperative optimization may represent a viable economic strategy in resource-constrained health systems. Further research incorporating broader economic perspectives and uncertainty analyses is warranted to confirm and extend these findings.
Acknowledgements
All authors wrote this article directly, and AI was used for review and suggestions for adjustments to wording and syntax.
Author contributions
All authors contributed to the development of this research.
Funding
All authors declare that they did not receive funding for the development of this research or for its publication.
Data availability
The authors declare that the database on which this manuscript is based is detailed extensively in the Zenodo repository DOI 10.5281/zenodo.18650218. On the other hand, the prices associated with the financial calculations can be verified, based on the National Health Fund and Institutional Care Model, available at [https://share.google/qdJDNDUDcguTIlP8X](https://share.google/qdJDNDUDcguTIlP8X).
Declarations
Ethics approval and consent to participate
Not applicable.
Consent for publication
All authors have reviewed this manuscript and give their consent for its publication.
Competing interests
The authors declare no competing interests.
Footnotes
Publisher’s note
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Data Availability Statement
The authors declare that the database on which this manuscript is based is detailed extensively in the Zenodo repository DOI 10.5281/zenodo.18650218. On the other hand, the prices associated with the financial calculations can be verified, based on the National Health Fund and Institutional Care Model, available at [https://share.google/qdJDNDUDcguTIlP8X](https://share.google/qdJDNDUDcguTIlP8X).