Training patients for surgery shortens hospital stays

25/04/2017

Just as an athlete might work to build up stamina before a race, a person entering the hospital also can benefit from prepping the mind and body. Even minor adjustments to diet and mental health could help some individuals go home sooner - and, in turn, save hospitals and insurance companies money.

Image: Symbols for swimming, an apple, smoking prohibited and a checklist in a row next to each other; Copyright: Manifest/Michigan Medicine

Athletes prepare for competition well in advance. Surgical patients, a University of Michigan surgical team asserts, ought to do the same; ©Manifest/ Michigan Medicine

But for many health care providers, that concept is not always put into practice. "We do a lot in medicine to get people ready for surgery, but they are primarily administrative tasks - checking off boxes that do not necessarily make a patient better," says Michael Englesbe, M.D., a University of Michigan transplant surgeon who has studied and championed the idea for nearly a decade. "The more you can do to manage your status preoperatively, the quicker you'll be able to bounce back."

In February, Englesbe, colleague Stewart Wang, M.D., Ph.D., FACS, and several other authors confirmed their longtime hunch: A study published in Surgery found that basic fitness and wellness coaching, administered in advance, could reduce a surgical patient's average hospital stay two days, from seven down to five, when compared to a control group. And, in a benefit to patients and providers alike, the regimen cut medical costs 30 percent.

Moreover, the participation rate among the study's 641 subjects was high - about 80 percent, far better adherence than what might follow a typical medical appointment. "As a physician, you always tell people to quit smoking and exercise," says Englesbe, "but the compliance rates are notoriously abysmal." The prospect of serious surgery, he notes, can be a change agent in itself: "Big health crises can scare people straight, so to speak, and change their lifestyle."

Still, the researchers say, promoting healthful habits in advance of an operation is a measure that should be just as crucial as any other step in the admittance process. Adds Wang: "The condition of the body is so important. It is so much common sense that people often fail to recognize it."

The recent study marks the third time Englesbe and Wang have examined the idea of athletic training applied to surgical preparation, which they call "prehab." Hospitalization times and cost savings were consistent among the analyses.

Each review followed the Michigan Surgical and Health Optimization Program (MSHOP), an initiative aimed at helping patients target and strengthen weaknesses before surgery. A web-based risk assessment tool using a person's existing data enables shared decision-making between patient and physician and helps identify patients who will best benefit from MSHOP. Elements of the program include improving one's diet, reducing stress, breathing exercises and smoking cessation, and, most crucial, an emphasis on light physical activity - with the latter reinforced via daily notifications.

Most MSHOP patients are advised to log 12 miles of walking per week, or about an hour a day. Each participant is given a pedometer to track progress. It sounds simple, but it can pay off: Walking aids blood flow and speeds healing. "The vast majority of the program benefits come from the walking," says Wang, endowed professor of burn surgery and director of the Morphomic Analysis Group at Michigan Medicine.

Early MSHOP efforts encouraging patients to boost their steps involved personal phone calls, a method ultimately revised due to staffing requirements and, given the demands of patients' work and personal lives, subpar reach. The system now relies on automated daily text messages or automated phone calls to deliver a reminder. Program facilitators worked to craft notes with positive, natural-sounding language to make the exchanges personal and more effective. That way, "the patient feels like someone is actually paying attention to them," says June Sullivan, the technology director for MSHOP, noting that any replies are monitored and logged.

And MSHOP components can not only boost physical healing, but also provide emotional benefits in the days before the procedure - and, ideally, beyond. "Patients do not care about costs or how long they are going to be in the hospital; they just want to get through the experience," Englesbe says. "This is an empowering tool that helps them do something positive in the face of a very negative event."

Since its establishment five years ago, the MSHOP curriculum is now offered in more than 20 hospitals and 30 practices across Michigan. Despite plenty of positive feedback and proof of prehab's benefits, the practice encompasses just a sliver - about 1,250 patients - of the 65,000 surgeries performed annually at Michigan Medicine. Debate about logistics and wider implementation also remain among medical professionals.

"First, we hear that everyone thinks it makes sense for their patients," says Englesbe. "Second, it is really hard to change clinical practice, especially among busy surgeons. It's essentially adding work to the busiest people." Although the cost benefits are notable, that factor does not necessarily register with clinicians, the researchers note. And, says Sullivan, the technology director, surgeons must be the ones to start the dialogue: "They have to deliver the message; that's who the patient believes." Still, the MSHOP movement has caught the attention of insurance payers that might be able to help facilitate a wider reach.

"Once it is a billable service, it will really take off," Englesbe says. Because current prehab guidelines are somewhat general, there also is room to grow. They could one day be tailored to address more specific scenarios, such as prescribing certain exercises prior to a joint replacement surgery. "The technology is scalable," Wang says. "Expected complications or recovery difficulties could be addressed in advance with targeted training. This is just the beginning."

MEDICA-tradefair.com; Source: Michigan Medicine - University of Michigan

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