Association of an Online Home-Based Prehabilitation Program With Outcomes After Colorectal Surgery.

This quality improvement study evaluates the association of an online home-based patient prehabilitation program with colorectal surgery outcomes. Prehabilitation programs in colorectal surgery have been studied in multiple centers and have shown promising results.1 However, most studies have tested in-person, resource-intensive programs, which have limited scalability and generalizability for most medical centers and surgeons’ practices. We evaluated the association of an online home-based prehabilitation program with surgical outcomes of patients undergoing colorectal surgery.

In this quality improvement study, patients scheduled to undergo abdominal colorectal surgery within 3 weeks or more between May 2018 and April 2019 were invited to participate in a home-based prehabilitation program delivered through a mobile application (SeamlessMD). Through the application, participants received information about the Mediterranean diet and set goals for strength exercises and step counts. They received pedometers and completed daily activity surveys. Adherence was measured by the mean percentage of self-reported days of walking 5000 steps, completing all strength exercises, and following the diet (eg, if a patient completed 1 of the 3 goals in 100% of the days, their adherence was 33%). Higher users of prehabilitation were those who achieved their goals on at least 50% of days. Stanford University’s institutional review board approved this study, and participants provided written informed consent. The study followed the SQUIRE reporting guideline. All participants followed the Enhanced Recovery After Surgery (ERAS) pathway. The primary outcome of 30-day postoperative complications was classified according to the Comprehensive Complication Index (CCI).2 Secondary outcomes were length of stay and readmissions. High users of prehabilitation were compared with participants from a previous cohort who also underwent colorectal surgery and had used another version of the same application that only delivered information about ERAS (n = 127). Between June 20 and July 6, 2022, we estimated propensity scores for being a high user of prehabilitation, considering sex, age, body mass index, American Society of Anesthesiologists classification, diagnosis, surgical approach, concurrent procedures, and type of anastomosis. Surgery-related variables were included as a proxy for more extensive or debilitating preoperative disease. Multivariable regression adjusting for the propensity score was used to compare outcomes between groups. Stata, version 17 software (StataCorp LLC) was used for the analysis. A 2-sided P < .05 was considered significant.

The prehabilitation cohort included 212 patients, of whom 96 (45%) used the program (39 men [41%], 57 women [59%], mean [SD] age, 56.3 [13.7] years); 60 (28%) were high users (Table 1). Because race and ethnicity are likely associated with disparities in health care literacy and access, these data were not collected as beyond the scope of this study. Table 1. Demographic and Operative Characteristics. | Characteristic | No. (%) | ||| |---|---|---|---|---| | Prehabilitation program | ERAS only (n = 127) | ||| | Nonusers (n = 116) | Low users (n = 36)a | High users (n = 60)a | || | Sex | |||| | Female | 56 (48) | 23 (64) | 34 (57) | 67 (52) | | Male | 60 (51) | 13 (36) | 26 (43) | 60 (47) | | Age, mean (SD), y | 55.8 (17.2) | 55.7 (15.5) | 56.6 (12.6) | 58.0 (15.3) | | BMI, mean (SD) | 26.1 (6.2) | 27.1 (6.1) | 26.4 (5.5) | 27.2 (6.5) | | ASA classification | |||| | 1 or 2 | 63 (54) | 20 (56) | 44 (73) | 79 (62) | | 3 | 53 (46) | 16 (44) | 16 (27) | 48 (38) | | Diagnosis | |||| | Cancer | 53 (46) | 18 (50) | 26 (43) | 42 (33) | | Diverticulitis | 13 (11) | 2 (6) | 7 (12) | 15 (12) | | Inflammatory bowel disease | 19 (16) | 9 (25) | 8 (13) | 17 (13) | | Ileostomy closure | 10 (9) | 2 (6) | 7 (12) | 13 (10) | | Otherb | 21 (18) | 5 (14) | 12 (20) | 40 (31) | | Minimally invasive | |||| | Yes | 69 (59) | 22 (61) | 37 (62) | 68 (54) | | No | 47 (41) | 14 (39) | 23 (38) | 59 (46) | | Concurrent procedures | |||| | Yes | 42 (36) | 14 (39) | 20 (33) | 43 (34) | | No | 74 (64) | 22 (61) | 40 (67) | 84 (66) | | Anastomosis | |||| | Yes | 66 (57) | 20 (56) | 39 (65) | 82 (65) | | With proximal diversion | 19 (16) | 9 (25) | 8 (13) | 11 (9) | | No | 31 (27) | 7 (19) | 13 (22) | 34 (27) | Abbreviations: ASA, American Society of Anesthesiologists; BMI, body mass index (calculated as weight in kilograms divided by height in meters squared); ERAS, Enhanced Recovery After Surgery. Use of prehabilitation was considered high if patients achieved their goals in 50% of the days or more. Other procedures include ventral mesh rectopexy, colostomy takedown, endometriosis, familial polyposis, and colonic inertia. There were no significant differences between high users of prehabilitation and the ERAS-only group in terms of complication rate, CCI score, or readmission rate (Table 2). However, high users had a significantly shorter length of stay (adjusted estimate, −1.15; 95% CI, −2.19 to −0.11; P = .03). Table 2. Postoperative Outcomes of High Users of Prehabilitation Compared With Patients From the Enhanced Recovery After Surgery (ERAS)–Only Cohort (Propensity Score–Adjusted Analysis). | Outcome | No. (%) | Adjusted estimate (95% CI) | P value | | |---|---|---|---|---| | High users (n = 60) | ERAS only (n = 127) | ||| | Complication | 10 (17) | 36 (28) | 0.55 (0.25 to 1.21) | .14 | | CCI score, mean (SD) | 3.2 (7.9) | 6.9 (12.2) | −3.11 (−6.58 to 0.36) | .08 | | Length of stay, mean (SD) | 3.6 (2.4) | 4.8 (3.6) | −1.15 (−2.19 to −0.11) | .03 | | Readmission | 4 (7) | 16 (13) | 0.48 (0.15 to 1.56) | .22 | Abbreviation: CCI, Comprehensive Complication Index.

Use and adherence to the online home-based prehabilitation program was modest, but greater adherence was associated with better outcomes. Previous prehabilitation studies found a decreased risk of complications among colorectal surgery patients undergoing prehabilitation3,4,5 but not among frail patients with colorectal cancer.6 Frailty, along with other patient-related factors (eg, socioeconomic stressors, more debilitating disease), can increase the risk of postoperative complications and may have prevented optimal use and adherence to prehabilitation in our study. High users of prehabilitation may have had more positive health attitudes and better physical fitness at baseline, leading to improved outcomes regardless of prehabilitation. However, even after adjusting for propensity score, high users still had significantly shorter lengths of stay than the ERAS-only group, suggesting an association between prehabilitation and faster recovery.

of this study include the lack of a formal assessment of frailty and of multiple language options for the mobile application, which may make this study less generalizable. Strategies to improve engagement and adherence are critical to optimize online and home-based prehabilitation programs. Research is needed to confirm whether this modality of prehabilitation is clinically meaningful for surgical outcomes in diverse populations.

- 1.Gustafsson UO, Scott MJ, Hubner M, et al. Guidelines for perioperative care in elective colorectal surgery: Enhanced Recovery After Surgery (ERAS®) Society Recommendations: 2018. World J Surg. 2019;43(3):659-695. doi: 10.1007/s00268-018-4844-y [DOI] [PubMed] [Google Scholar] - 2.Slankamenac K, Graf R, Barkun J, Puhan MA, Clavien PA. The Comprehensive Complication Index: a novel continuous scale to measure surgical morbidity. Ann Surg. 2013;258(1):1-7. doi: 10.1097/SLA.0b013e318296c732 [DOI] [PubMed] [Google Scholar] - 3.Gillis C, Buhler K, Bresee L, et al. Effects of nutritional prehabilitation, with and without exercise, on outcomes of patients who undergo colorectal surgery: a systematic review and meta-analysis. Gastroenterology. 2018;155(2):391-410.e4. doi: 10.1053/j.gastro.2018.05.012 [DOI] [PubMed] [Google Scholar] - 4.de Klerk M, van Dalen DH, Nahar-van Venrooij LMW, Meijerink WJHJ, Verdaasdonk EGG. A multimodal prehabilitation program in high-risk patients undergoing elective resection for colorectal cancer: a retrospective cohort study. Eur J Surg Oncol. 2021;47(11):2849-2856. doi: 10.1016/j.ejso.2021.05.033 [DOI] [PubMed] [Google Scholar] - 5.Berkel AEM, Bongers BC, Kotte H, et al. Effects of community-based exercise prehabilitation for patients scheduled for colorectal surgery with high risk for postoperative complications: results of a randomized clinical trial. Ann Surg. 2022;275(2):e299-e306. doi: 10.1097/SLA.0000000000004702 [DOI] [PMC free article] [PubMed] [Google Scholar] - 6.Carli F, Bousquet-Dion G, Awasthi R, et al. Effect of multimodal prehabilitation vs postoperative rehabilitation on 30-day postoperative complications for frail patients undergoing resection of colorectal cancer: a randomized clinical trial. JAMA Surg. 2020;155(3):233-242. doi: 10.1001/jamasurg.2019.5474 [DOI] [PMC free article] [PubMed] [Google Scholar]