“Prehabilitation” lowers length of stay, total cost for hospital patients

An inexpensive program to help surgery patients get physically and mentally ready for their upcoming operation may help reduce overall costs and get them home faster, according to new research published in the Journal of the American College of Surgeons.

"Prehabilitation,” as it's called, uses the weeks before surgery to encourage patients to move more, eat healthier, cut back on tobacco, breathe deeper, reduce their stress, and focus on their goals for after their operation.

In 2017, after its first test in surgery patients at the University of Michigan, the approach showed signs of reducing total medical costs related to the patient's care, and cutting their length of stay in the hospital, compared with similar Michigan Medicine patients who had surgery before the program began.

The current study included hundreds of patients in 21 hospitals across Michigan. It is based on data from 523 patients with traditional Medicare coverage who went through the “prehab” program, and more than 1,000 similar patients who did not.

The researchers found that prehab patients across the state left the hospital one day earlier and were more likely to go straight home rather than to a skilled nursing facility, compared with similar patients treated at the same hospital. Total costs for all care up to three months after surgery were nearly $3,200 less on average for those who went through prehab.

The study focused on the patients with the highest risk of complications after surgery because they had a combination of underlying health conditions beyond the problem that required surgery. Their median age was 70, and one in six qualified for federal disability benefits. All of them, and the patients they were compared with, were having one of 26 common operations.

The prehab patients' surgeons referred them to the program, called the Michigan Surgical and Health Optimization Program (MSHOP). The program was supported by a grant from the Centers for Medicare and Medicaid Services, and involved hospitals taking part in the MSQC quality improvement program.

Once enrolled, they received a call or electronic message from a member of the MSHOP team, and materials about the importance of better nutrition, tobacco cessation, engaging in positive thinking and goal setting, and reducing stress to their pre-surgery preparation. They also received a pedometer to track their steps, and an incentive spirometer to encourage them to practice taking deep breaths, to improve their lung function before and after surgery.

In all, 62 percent of them tracked their walking three or more times a week, entering them into their medical record or calling them in to a secure voicemail box. The program staff contacted patients who hadn't logged steps, to encourage them to do so. For those who tracked regularly, they took an average of 2,909 steps per day, and about 30 deep breaths on the spirometer.

The comparison group of patients was chosen to match the type of operation, and the hospital where they had surgery. Though the prehab patients were only in the program for an average of two and a half weeks before surgery, the program was associated with statistically significant changes in several measures.

In addition to the total cost and hospital length of stay differences, the patients in the program were less likely to need home health care after they went home, with 24 percent of the prehab patients receiving it compared with 29 percent of non-prehab patients. However, the prehab patients had about the same rates of nursing home stays, visits to emergency departments, and additional hospital stays after they left the hospital.

In a second new paper published in Annals of Surgery, the researchers propose that surgical teams adopt the same "positive psychology" approach to engaging with surgery candidates that patients in the study were taught.

Although prehab programs at many of the participating hospitals ended or scaled back when the study ended, the research team made MSHOP part of the standard of care for Michigan Medicine surgical candidates who have a higher than usual risk of complications. Blue Cross Blue Shield of Michigan supports the effort through a pilot payment project. A full kit of patient materials is available online.

In addition to incorporating more positive psychology aspects, such as having patients express their post-surgical goals and the steps they will take to try to reach them, the MSHOP program has evolved to allow patients to track steps using their smartphones and wearable activity trackers instead of providing pedometers. The program has even been integrated into the electronic portal that patients use, so that they can sync their step counts automatically from their device.

Surgical team members, from pre-op clinic staff to post-surgery rounding teams, are encouraged to work with MSHOP enrollees toward shared ownership of their surgical outcomes, and better wellbeing. As more hospitals and health systems engage in national programs that incentivize the wringing of more value out of healthcare dollars, such as the Accountable Care Organization programs offered by CMS, the researchers predict that the business case for offering prehab will grow.