Older adults are increasingly undergoing surgery and are at risk of poor postoperative outcomes.1 Prehabilitation, defined as the enhancement of the preoperative condition of a patient,2 has recently emerged as a potential mechanism by which to improve surgical outcomes for older adults. There is evidence that physical prehabilitation programs may improve both preoperative physical function (i.e., increased respiratory muscle endurance, improved walking distance, and increased oxygen uptake during exercise) and postoperative clinical outcomes (i.e., lower postoperative pain scores, decreased likelihood of postoperative complications, and reduced length of stay [LOS]).3-6 A recent randomized clinical trial in adults undergoing elective esophagogastric resection showed that patients receiving prehabilitation had improved functional capacity both before and after surgery.7
Recently, the surgical community has embraced enhanced recovery protocols as a way to improve surgical outcomes.8 These evidence-based perioperative protocols have been shown to improve clinical outcomes after procedures spanning numerous subspecialties including colorectal surgery, thoracic surgery, orthopedic surgery, gynecologic surgery, and urology.9 As a result, the Clinical Practice Guidelines for Enhanced Recovery After Colon and Rectal Surgery has recommended considering prehabilitation before elective surgery in patients with multiple comorbidities or significant deconditioning.10
Despite promising results from early studies and inclusion of prehabilitation in select surgical clinical practice guidelines, research efforts in the field are ongoing, as many studies investigating prehabilitation programs have been limited by small sample size, moderate methodological quality, and variable compliance with protocols.5 Furthermore, few studies have specifically focused on vulnerable populations that may benefit the most from prehabilitation, such as frail older Veterans.11
Our group aims to develop, evaluate, and implement a prehabilitation program for frail older Veterans at Veterans Affairs (VA) healthcare systems across the nation. We build upon the infrastructure of the long-standing Gerofit program, which is an exercise and health promotion program for all older Veterans (i.e., not necessarily just surgical patients).12 Our program uses a multidisciplinary approach, similar to that successfully implemented by other programs designed to improve clinical outcomes for at-risk older adults, including the Hospital Elder Life Program (HELP).13 In this study, we present data from a local pilot project at our institution and describe plans to develop a national quality improvement effort within the VA specifically to prepare frail older Veterans for elective surgery through a novel prehabilitation program.
Background on Gerofit Program in VA Hospitals
The Gerofit program was originally established in 1986 as an exercise and health-promotion program targeting older Veterans (65 years or older) at risk of functional decline because of deconditioning, chronic disease, or limited mobility.14 Primary care providers refer patients to Gerofit to complete a structured personalized exercise program, and functional capacity is assessed at baseline and at 3, 6, and 12 months after initiation. Gerofit recently secured funding for dissemination to other VA hospitals as a model of care to prevent functional decline,14 and our institution was one of the first dissemination sites. A recent study of 1-year outcomes at these sites revealed statistically significant improvement in each of the functional tasks compared with baseline (gait speed, 8-foot up and go, 30-second chair stands, and 6-minute walk distance; paired t-test significant at p < .05) and high patient satisfaction ratings (88–94%).14 The infrastructure from the Gerofit program at our institution was used to create the pilot project for prehabilitation to optimize frail surgical patients.
Pilot Project Using Gerofit to Prepare Frail Veterans for Major Surgery
The prehabilitation pilot project was developed as a collaboration between geriatrics, anesthesia/critical care, and surgery with the goal of providing a person-centered approach to support quality in geriatric surgery. Patients were referred through a Gerofit prehabilitation consult through the Computerized Patient Record System (CPRS) if they had any of the following trigger factors: assistance with activities of daily living or instrumental activities of daily living, multiple medical comorbidities, polypharmacy, cognitive decline, vision or hearing impairment, or risk factors unique to the Veteran population including chronic opioid use and posttraumatic stress disorder.
Referred patients were contacted by phone and asked if any of the following exclusion criteria were present: (1) unable to perform any activities of daily living; (2) unstable angina; (3) proliferative diabetic retinopathy; (4) oxygen dependence; (5) incontinence; (6) open wounds; (7) no permanent residence; (8) requires VA transportation/travel; (9) cognitive impairment that impairs ability to follow instruction; and (10) history of disruptive behavior or not conducive to group activity. Patients were asked about their use of a mobility aid, current exercise, and barriers to exercise. If deemed a good candidate for the Gerofit prehabilitation pilot based on the telephone interview and if interested in participating, the patient was scheduled for a baseline assessment at the Gerofit gym.
Five short physical performance tests were conducted: (1) gait velocity as measured by a 10-meter walk; (2) leg strength as measured by number of chair stands in 30 seconds; (3) endurance as measured by yards walked in 6 minutes; (4) balance and mobility as measured by an eight-foot up and go; and (5) arm strength as measured by number of arm curls in 30 seconds.15 Percentile rank was provided for each performance test based on patient's gender and age. A physical function survey was performed to assess how the patient's health limits them in everyday activities. Self-report was obtained for comorbid health conditions, recent emergency department or hospital visits, and recent falls.
Gerofit Gym Program
Based on the results of the baseline assessment, a personalized exercise program was designed for the patient and they were asked to come to the gym 1–3 times per week as their schedule permits. The program includes aerobic exercise; resistance training with therabands, free weights, and resistance machines; and group exercise classes on flexibility, mobility, and balance. Patients were reassessed before surgery (usually after 4–6 weeks in the program) using the five performance tests described above, and percentile ranks were compared to the baseline assessment and communicated to the referring surgeon.
The following areas were also addressed by the Gerofit staff during the patient's time at the gym: care coordination for medical optimization before surgery, mental preparation (e.g., reviewing what to expect in the hospital, risks of surgery based on the American College of Surgeons National Surgical Quality Improvement Program [ACS NSQIP] Surgical Risk Calculator), goals of care including peer counseling from previous Gerofit participants, inspiratory muscle training through teaching how to use an incentive spirometer, obtaining patient-centered data about “Who I Am” (e.g., what patient prefers to be called, who they live with, and military history) and “Patient Preferences” (e.g., hobbies, foods, and sleep/wake times).
Transition into the Hospital
Gerofit staff helped reinforce perioperative instructions with the patient before surgery (e.g., medications to start or stop, bowel preparation). The patient-centered “Who I Am” and “Patient Preferences” were included in CPRS as a Gerofit progress note so that staff caring for the patient after surgery could review the information. Patients were also followed by the Gerofit team daily while in the hospital to promote early mobilization with the assistance of undergraduate premedical student volunteers.
Preliminary data from the first nine participants in the pilot project are presented including patient demographics (e.g., age and gender), number of trigger factors, number of prehabilitation sessions completed, percentile ranks for baseline and presurgery performance tests, and outcomes after surgery (e.g., LOS, complications, and readmission). The pilot project was considered quality improvement and did not require institutional review board (IRB) approval from our institution. Future research plans for alpha testing and beta testing described in this study will require IRB approval, which is currently pending.
Prehabilitation to Optimize Functional Status Before Surgery Is Feasible
To date, nine participants have completed the Gerofit prehabilitation pilot before an elective surgical procedure. Participants had a mean age of 73 years, an average of 2.2 trigger factors, and completed an average of 17.7 prehab sessions (Table 1). Three patients underwent colorectal surgery (open right hemicolectomy, ileostomy reversal, and sigmoid colectomy), three patients underwent cardiac surgery (1-vessel coronary artery bypass graft, mitral valve replacement with 2-vessel coronary artery bypass graft, and aortic valve replacement), two patients underwent orthopedic surgery (total knee arthroplasty), and one patient underwent urologic surgery (transurethral incision of bladder neck).
Patients demonstrated improvement in the following fitness outcomes: gait velocity (one of eight improved), chair stands (five of eight improved), 6-minute walk (two of eight improved), 8-foot up and go (two of eight improved), and arm curls (five of seven improved) (Table 1). Five patients improved in two or more of the fitness assessments completed.
According to the ACS NSQIP Surgical Risk Calculator, patients had a mean predicted 15% chance of serious complication and 17.9% chance of any complication (Table 2). Only one patient (11%) had a postoperative complication, which was cellulitis. Patients had a mean 1.3% chance of death within 30 days according to the NSQIP Surgical Risk Calculator, and there were no 30-day deaths. As of June 2018, only 1 patient died and this occurred 8 months postoperatively and was due to causes unrelated to the operation. Seven of nine patients (77.8%) had an LOS that was equal to or less than that predicted by the NSQIP Surgical Risk Calculator. NSQIP predictions for discharge to skilled nursing facility (SNF) ranged from 1.9 to 47.4%. Four of nine patients (44%) were discharged to a nonhome location, including both SNF and acute rehab. The mean predicted rate of readmission was 9.7% according to the NSQIP Surgical Risk Calculator, and zero patients were readmitted within 30 days of discharge.
Capacity Building and Expansion as a Patient Safety Center of Inquiry: Center for Complex Patient Care Transition Safety
The data from this pilot project was used to obtain funding from the National Center for Patient Safety for our institution to become a Patient Safety Center of Inquiry (PSCI). PSCIs, located in VA medical centers around the country, research specific areas of patient safety and develop, disseminate, and implement innovative interventions to improve patient safety at the bedside.16 Our institution is a new PSCI, the Center for Complex Patient Care Transition Safety, that focuses on two specific Veteran populations with complex care needs: (1) Veterans hospitalized on general medical services with complex social needs and (2) elderly Veterans requiring hospitalization for surgery. The Transitions in Geriatric Surgery project addresses the second population of Veterans and aims to identify high-risk frail older Veterans undergoing elective inpatient surgery and address transitions of care across the perioperative period. Prehabilitation to improve mental and physical fitness before elective surgery through an individualized exercise and provision of care coordination before surgery are key components of this project.
The current pilot project will soon be transitioned into alpha testing, which will include 100–125 patients across 6 surgical subspecialties: cardiac, general/colorectal, orthopedic, urologic, vascular, and neurological surgery. Several improvements to the program will be made, including streamlining the clinic assessment to include components of the Denver Frailty score17 and offering non-Gerofit gym prehabilitation options (e.g., home based with telephone coaching) for patients with logistical difficulties getting to our institution's Gerofit gym. Other improvements to the pilot project include better measurements of the effectiveness of the prehabilitation program. For example, in addition to presurgery assessment of fitness outcomes, we will reassess fitness outcomes at 30 and 90 days postoperatively to measure the trajectory of patient recovery. Although we do not plan to include a control group, we will use data from the Veterans Affairs Surgical Quality Improvement Program (VASQIP) to compare clinical outcomes of prehabilitation program participants to that of the general population of older Veterans undergoing similar operations.
If the patient is a candidate for prehabilitation based on the clinic assessment, then patients will be offered one of the following prehabilitation programs: Gerofit gym at our institution, use of local gym if they have access to one, or home-based phone counseling. Patients who choose the home-based program will be provided with two therabands (one for spouse/family member to use with the patient) and a pamphlet that demonstrates the exercises.
Next, the program will be beta tested in three VA hospitals, including one with an existing Gerofit program and two that do not have Gerofit programs. We estimate that 150–300 patients will be recruited, with 50–100 from each of the Gerofit sites and 25–50 from each of the 2 non-Gerofit sites.
We will document implementation activities, resources used, barriers, and successful strategies used to overcome those barriers. We will do so first at our institution in the alpha test phase and then in the other facilities during the beta phase. We will also conduct summative evaluation interviews with beta site key informants to identify strategies to overcome implementation barriers to facilitate successful future implementation. In addition, we will develop and evaluate toolkits including a prehabilitation assessment sheet, an intervention workbook for providers, and an intervention workbook for patients. We will leverage dissemination through the existing Gerofit program, national VA partners such as the Office of Geriatrics and Extended Care, VA stakeholders through the Coalition for Quality in Geriatric Surgery Project, and VA cyberseminars. Ultimately, we plan to disseminate toolkits to facilitate the implementation of prehabilitation programs at VA hospitals nationwide.
There are several limitations to this program. First, many studies have suggested that a multimodal prehabilitation program is most likely to have the most substantial impact on functional outcomes18 and our program is primarily focused on physical prehabilitation. However, we do recommend consultation with a nutritionist in patients who seem to be malnourished (e.g., low albumin) and promote mental preparation for surgery in all participants. Second, our program is specific to older Veterans and the program may not be generalizable to other populations. Despite this, older Veterans are a vulnerable population, consume a disproportionate amount of VA resources,11 and thus are a population in need of improved services. Finally, we present data only from a pilot project and are not able to show significant improvement in clinical outcomes with our small sample size. Nonetheless, as a PSCI with detailed plans for expansion, evaluation, and dissemination, we feel confident that our prehabilitation program will benefit older Veterans undergoing surgery.
The population is aging, and the growing number of frail older patients undergoing surgery poses a major healthcare challenge. Older Veterans are in particularly poor health, with over half reporting limitations in functional capacity.11 Studies have shown that preoperative physical capacity is an important predictor of postoperative course.19-21 Preliminary results from prehabilitation programs suggest that they may improve physical function before surgery and improve outcomes.3-6 The Exercise Prehabilitation in Colorectal Cancer Delphi Study Group concluded that exercise training should be a part of perioperative care and would be supported by surgeons.22 The Veteran community is in need of prehabilitation programs for older adults, to improve the safety and quality of surgical care in this vulnerable population.
This pilot project showed that a VA Gerofit-based prehabilitation program is feasible and seemed effective at improving preoperative physical function of older Veterans before surgery. Feasibility was demonstrated by successful screening and enrollment of appropriate patients, completion of the exercise program at the Gerofit gym, improvements in preoperative physical function, and safe completion of the scheduled operations. At least one patient improved in every one of the fitness outcomes measured, and five patients improved in two or more areas. The rate of postoperative complications was low in this high-risk population and there was only one death, which occurred 8 months after surgery and was unrelated to the surgery. Length of stay and readmission were lower than expected in most patients. These preliminary data contributed to our group to obtaining the distinction of a PSCI, which will allow the program to expand to six surgical subspecialties and three VA hospitals.
The significant contributions of this multidisciplinary, multi-institutional prehabilitation program targeted at frail high-risk older Veterans are twofold. First, it will contribute to the growing body of literature on the effectiveness of prehabilitation programs. Despite overall enthusiasm for prehabilitation as a method by which to improve postoperative outcomes, several systematic reviews and meta-analyses conclude that there is not yet sufficient evidence to demonstrate meaningful improvement in clinical outcomes.4,18,23,24 Specific weaknesses identified in the existing literature include small sample size, lack of targeting of programs to high-risk groups of patients, as well as nongeneralizability of results, given the heterogeneity of programs.5,18 Our group's prehabilitation program overcomes these pitfalls by ensuring a sample size with adequate power to detect small changes in outcome scores, using trigger factors and strict inclusion/exclusion criteria to identify the highest-risk older Veterans to enroll, and implementing a program that is designed to be disseminated across all surgical departments at VA hospitals nationwide.
Despite limited evidence to recommend prehabilitation programs to younger adult patients preoperatively, evidence for the benefit of these programs in older adults is stronger and thus it is essential to create targeted programs and to plan for expansion and widespread implementation. The second significant contribution of this work is that it will produce the tools and methods to facilitate the dissemination of prehabilitation programs at VA hospitals nationwide. With the support of the National Center for Patient Safety, our prehabilitation program has the potential to spread to VA hospitals across the country and improve the quality of surgical care provided to the vulnerable frail older Veteran population nationwide.
The results from this Gerofit prehabilitation pilot show feasibility and preliminary data that suggest that the program can be successfully implemented at VA hospitals. With the support of the National Center for Patient Safety, as a PSCI, we plan to proceed with alpha- and beta-testing phases to eventually implement a multidisciplinary, multi-institutional prehabilitation program, targeted at frail older Veterans to improve postoperative clinical outcomes.
Prehabilitation has recently emerged as a mechanism by which to improve postoperative outcomes. The frail older Veteran population is particularly vulnerable to postoperative morbidity and mortality. Thus, our prehabilitation program has the potential to improve the quality of care provided to Veterans undergoing elective surgery nationwide. Future directions include adapting this program to other hospital systems to ensure preoperative optimization for all older adults regardless of treatment location.
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Jill Q. Dworsky, MD, MS, is a resident physician in general surgery at the David Geffen School of Medicine at UCLA in Los Angeles, CA. She is also a postdoctoral fellow at the UCLA Fielding School of Public Health in the Department of Health Policy and Management in Los Angeles, CA.
Steven C. Castle, MD, is a clinical professor of medicine at the David Geffen School of Medicine at UCLA and is the clinical director of geriatrics for the Geriatric Research Education and Clinical Center at the VA Greater Los Angeles Healthcare System.
Cathy C. Lee, MD, MS, is an associate professor in internal medicine/geriatrics at the David Geffen School of Medicine at UCLA in Los Angeles, CA, and is the director of the Gerofit Program at the VA Greater Los Angeles Healthcare System.
Sumit P. Singh, MD, is an associate professor in the Department of Anesthesiology and Perioperative Care at the David Geffen School of Medicine at UCLA in Los Angeles, CA, and is the director of the Surgical ICU at the VA Greater Los Angeles Healthcare System.
Marcia M. Russell, MD, is an associate professor in surgery at the David Geffen School of Medicine at UCLA in Los Angeles, CA, and is a staff surgeon at the VA Greater Los Angeles Healthcare System.