Barriers and facilitators to the implementation of prehabilitation for elderly frail patients prior to elective surgery: a qualitative study with healthcare professionals.

BACKGROUND: Prehabilitation aims to enhance functional capacity before surgery, minimise complications and achieve a better postoperative outcome. This can be particularly useful for older, frail patients to better tolerate surgery. The aim of this study was to identify what barriers and facilitators healthcare professionals in Germany experienced in the implementation and delivery of the multimodal prehabilitation programme "PRAEP-GO" for (pre-)frail adults aged 70 years and older to inform the implementation of prehabilitation into standard care. METHODS: A nested descriptive qualitative study was conducted using semi-structured face-to-face interviews with healthcare professionals involved in the PRAEP-GO trial from the Berlin and Brandenburg region in Germany. Transcripts were analysed using Kuckartz' qualitative content analysis. Results were interpreted and synthesised using the Consolidated Framework for Implementation Research, a theoretical framework to allow their application to a more general context. RESULTS: A total of 14 interviews were conducted. Seven therapists (physio-, ergo-, sports therapy), five physicians and two employees from other professions with mainly administrative and organisational tasks in the project. All identified barriers and facilitating factors could be assigned to the themes of organisation, prehabilitation, cooperation and communication between healthcare professionals and with patients. Much optimisation potential was found regarding organisational aspects, e.g. addressing perceived staff shortages and optimising the patient pathway. Furthermore, it became apparent that communication and cooperation between professionals but also with patients need to be improved. More evidence regarding prehabilitation should be provided to convince professionals more. Prehabilitation should be multimodal and individualised, including the programme duration. Officially introducing prehabilitation into standard care would facilitate its delivery. DISCUSSION: These findings underscore the fact that successful implementation of prehabilitation programmes, such as PRAEP-GO, requires sufficient organisational infrastructure, human resources, access to knowledge, an adaptable and individualised programme design as well as good communication among professionals and with patients. The transferability of the findings is limited by the absence of nutritionists and resulting overrepresentation of other therapists in the sample. To further convince professionals and patients of the concept of prehabilitation, more research is needed to build a solid evidence base that will ensure greater awareness and, thus, more motivation and cooperation among professionals and patients. TRIAL REGISTRATION: Open Science Framework (osf.io/ksfgj).

Facilitators and barriers to the implementation of prehabilitation for frail patients into routine health care: a realist review.

BACKGROUND: Despite evidence supporting the effectiveness of prehabilitation as a new preoperative care pathway to optimise perioperative outcomes, its implementation into routine health care is widely pending. Frail patients might particularly benefit from prehabilitation interventions, but facilitating and hindering factors need to be considered in the implementation process. Thus, our aim was to derive a programme theory on what prehabilitation programmes work for frail patients in what circumstances and why. METHODS: Following Pawson's realist review approach, preliminary programme theories on facilitators and barriers were established. General and topic-specific databases were searched systematically for facilitators and barriers to the implementation of prehabilitation for frail patients. Articles were included if they dealt with multimodal prehabilitation programmes prior to surgery in a frail population and if they contained information on facilitators and barriers during the implementation process in the full text. Based on these articles, refined programme theories were generated. RESULTS: From 2,609 unique titles, 34 were retained for the realist synthesis. Facilitating factors included the individualisation of prehabilitation programmes to meet the patients' needs and abilities, multimodality, adaption to the local setting and health care system, endorsement by an ambassador and sharing of responsibilities among a multidisciplinary team. Central barriers for frail patients were transportation, lack of social support, and inadequate, overwhelming information provision. CONCLUSIONS: Implementing prehabilitation as a new care pathway for frail patients requires organisational readiness and adaptability to the local setting. On an individual level, a clear understanding of responsibilities and of the intervention's goal among patients and providers are necessary. Added attention must be paid to the individualisation to fit the needs and restrictions of frail patients. This makes prehabilitation a resource-intense, but promising intervention for frail surgery patients. TRIAL REGISTRATION: PROSPERO (CRD42022335282).

Concepts for exercise therapy in prehabilitation for elderly people with frailty or pre-frailty prior to elective surgery. A scoping review.

BACKGROUND: Frailty is a state of reduced functional capacities in older people that can be reversed through multimodal therapy concepts. The effect of preoperative prehabilitation on frailty has been examined, but the heterogeneity of exercise regimens has prevented conclusive evidence. This scoping review analyses prehabilitation interventions, particularly exercise methods, published in trials for prefrail and frail elderly patients. METHOD: We identified studies evaluating prehabilitation for frail elderly using the framework of Arksey and O'Malley. Five scientific databases were searched until March 2022. Articles were screened by two independent reviewers. Data extraction included, but was not limited to, study design, intervention protocol of the prehabilitation including exercise therapy and additional interventions, and safety of the reported exercise concepts. RESULTS: Nineteen studies were included, offering an insight into the utilized prehabilitation concepts for exercise. All study interventions were based around exercise programs, potentially with complementary interventions. Twelve studies based their exercise programs on a combination of endurance and strength training. Breathing exercises were prescribed in five studies, flexibility routines in five, and one study included balance training. Further interventions included nutritional counselling/supplementation in nine studies, smoking/alcohol cessation in five, in addition to two physiological and three medical/pharmaceutical interventions. DISCUSSION: Prehabilitation for the frail elderly is safe and feasible. The general concept of prehabiliation for frail patients is promising. An exercise program should focus on improving the patient's endurance and strength, considering the positive effects that can be provided by breathing exercises and other additional interventions, such as nutritional support or lifestyle counselling.

Cost-effectiveness of prehabilitation prior to elective surgery: a systematic review of economic evaluations.

BACKGROUND: Prehabilitation aims at enhancing patients' functional capacity and overall health status to enable them to withstand a forthcoming stressor like surgery. Our aim was to synthesise the evidence on the cost-effectiveness of prehabilitation for patients awaiting elective surgery compared with usual preoperative care. METHODS: We searched PubMed, Embase, the CRD database, ClinicalTrials.gov, the WHO ICTRP and the dissertation databases OADT and DART. Studies comparing prehabilitation for patients with elective surgery to usual preoperative care were included if they reported cost outcomes. All types of economic evaluations (EEs) were included. The primary outcome of the review was cost-effectiveness based on cost-utility analyses (CUAs). The risk of bias of trial-based EEs was assessed with the Cochrane risk of bias 2 tool and the ROBINS-I tool and the credibility of model-based EEs with the ISPOR checklist. Methodological quality of full EEs was assessed using the CHEC checklist. The EEs' results were synthesised narratively using vote counting based on direction of effect. RESULTS: We included 45 unique studies: 25 completed EEs and 20 ongoing studies. Of the completed EEs, 22 were trial-based and three model-based, corresponding to four CUAs, three cost-effectiveness analyses, two cost-benefit analyses, 12 cost-consequence analyses and four cost-minimization analyses. Three of the four trial-based CUAs (75%) found prehabilitation cost-effective, i.e. more effective and/or less costly than usual care. Overall, 16/25 (64.0%) EEs found prehabilitation cost-effective. When excluding studies of insufficient credibility/critical risk of bias, this number reduced to 14/23 (60.9%). In 8/25 (32.0%), cost-effectiveness was unclear, e.g. because prehabilitation was more effective and more costly, and in one EE prehabilitation was not cost-effective. CONCLUSIONS: We found some evidence that prehabilitation for patients awaiting elective surgery is cost-effective compared to usual preoperative care. However, we suspect a relevant risk of publication bias, and most EEs were of high risk of bias and/or low methodological quality. Furthermore, there was relevant heterogeneity depending on the population, intervention and methods. Future EEs should be performed over a longer time horizon and apply a more comprehensive perspective. TRIAL REGISTRATION: PROSPERO CRD42020182813.

[The Frail Patient in a Fictitious Case Study]. / Der fraile Patient: fiktives Fallbeispiel.

Various limitations in everyday life can indicate a frailty syndrome. These limitations are not always directly visible and result from a wide variety of domains. Fried et al. described these limitations of different domains as frailty syndrome. This syndrome can be acutely worsened by different influencing factors. One major risk factor is an upcoming anesthesia and surgery. Frailty is associated with a significantly increased risk of peri- and postoperative complications. To avoid acute deterioration due to anesthesia and surgery, the concept of prehabilitation was developed. The aim is to specifically address the respective deficits and to develop an individual training concept together with the patient. Prehabilitation can significantly improve the risk of complications and the outcome of frail patients. In this context, it is important to establish routine screening in order to detect a frailty syndrome in everyday clinical practice and to create opportunities for prehabilitation.

[Prehabilitation for Preparing Older People with Frailty for Surgery]. / Prähabilitation als OP-Vorbereitung bei Patienten mit Frailty.

Older people demonstrate a higher risk for the occurrence of peri- and postsurgical complications. A frequent risk factor for this is the prevalence of a status called "frailty". In general, this status can be reversed by adequate therapeutic and medical interventions. More, current evidence suggests that these measures, as part of a so-called prehabilitation, can reduce the risk for experiencing peri- and postsurgical complications and thus assist the rehabilitation process, increase quality of life, and avoid care dependency and a loss of autonomy of these patients. In this article, we describe the concept of prehabilitation, its options to adapt and design this new form of intervention, as well as presenting current evidence. An actual project and a case example on prehabilitation provide an example and outlook.

Prehabilitation of elderly frail or pre-frail patients prior to elective surgery (PRAEP-GO): study protocol for a randomized, controlled, outcome assessor-blinded trial.

BACKGROUND: Frailty is expressed by a reduction in physical capacity, mobility, muscle strength, and endurance. (Pre-)frailty is present in up to 42% of the older surgical population, with an increased risk for peri- and postoperative complications. Consequently, these patients often suffer from a delayed or limited recovery, loss of autonomy and quality of life, and a decrease in functional and cognitive capacities. Since frailty is modifiable, prehabilitation may improve the physiological reserves of patients and reduce the care dependency 12 months after surgery. METHODS: Patients ≥ 70 years old scheduled for elective surgery or intervention will be recruited in this multicenter, randomized controlled study, with a target of 1400 participants with an allocation ratio of 1:1. The intervention consists of (1) a shared decision-making process with the patient, relatives, and an interdisciplinary and interprofessional team and (2) a 3-week multimodal, individualized prehabilitation program including exercise therapy, nutritional intervention, mobility or balance training, and psychosocial interventions and medical assessment. The frequency of the supervised prehabilitation is 5 times/week for 3 weeks. The primary endpoint is defined as the level of care dependency 12 months after surgery or intervention. DISCUSSION: Prehabilitation has been proven to be effective for different populations, including colorectal, transplant, and cardiac surgery patients. In contrast, evidence for prehabilitation in older, frail patients has not been clearly established. To the best of our knowledge, this is currently the largest prehabilitation study on older people with frailty undergoing general elective surgery. TRIAL REGISTRATION: ClinicalTrials.gov NCT04418271 . Registered on 5 June 2020. Universal Trial Number (UTN): U1111-1253-4820.

[Interventions for Assisting Geriatric Patients with Frailty Before Surgery]. / Interventionen zur präoperativen Unterstützung geriatrischer Patienten mit Frailty.

Frailty is a complex syndrome leading to a higher vulnerability in elderly patients, especially during and after surgery. It is characterized by the simultaneous presence of at least three of five phenotypical symptoms: unintentional weight loss, exhaustion, muscle weakness, slow walking speed, and low activity levels. The presence of two of these symptoms is often labelled as pre-frailty.By identifying these symptoms of frailty, medical teams can plan and perform suitable interventions prior to a planned surgery in order to lower these risk factors and to avoid complications, such as delir, hospital re-admission, loss of independence, and increased mortality. Examples for these interventions are pre-surgery rehabilitation and Delirium Management Units (DMU).This article describes the frailty syndrome and its associated consequences for complications during and after surgery. Additionally, clinical assessments for identifying frailty symptoms as well as pre- and post-surgical interventions to reduce these risk factors are presented.