'Pre-hab' Speeds Discharges Among Elective Surgery Patients

A home-based pre-operative program to improve the physical conditioning of patients will require surgeons to work out "a lot of complex finances and politics between the various parties involved," says a surgeon who champions the idea.

Physicians in the Michigan Surgical Home and Optimizing Program believe that the preoperative training program they've developed for elective surgery patients will someday become a standard of care in hospitals across the country.

So far, however, the adoption process has been slow.

A University of Michigan study shows that elective surgery patients were discharged sooner and were more engaged in their care if they took part in a home-based pre-operative training program to improve their physical condition in the weeks before their surgery.

Michael Englesbe, MD, a Michigan Medicine transplant surgeon who has studied and championed the idea for nearly a decade, spoke with HealthLeaders about his advocacy for "Pre-hab." The following is a lightly edited transcript.

HLM: This program has been in effect for five years, but participation is quite low. Why?

Englesbe: We haven't necessarily proven scientifically that it works. It makes sense. Patients like it, but the primary outcomes we've followed so far have been financial outcomes, which matter to hospitals.

Doctors care more about things such as complications and survival. Most relevantly, it's just hard to change practice.

Strategically we've focused on hospitals but we've learned that the work is done by the surgeons, and surgeons really don't engage with the hospitals where they practice, and vice-versa. There are a lot of complex finances and politics between the various parties involved here that are going to take time to sort themselves out.

HLM: Could anyone in the care continuum take ownership of pre-hab?

Englesbe: Someone has to do the work. Even though it is minimal work, everyone at every hospital and office is already working fulltime so any incremental additional work is a big deal.

It's hard to change physician practices, and that is particularly true among surgeons. I'm a surgeon. I speak their language. So if anyone can convince them it would be someone like me.

It will catch on when the small amount of money it costs to enroll patients and engage them in this program is either mandated, because globally it makes financial sense, or it gets paid for by payers, and we are making progress in that space.

At a macro level, patients training and being optimized for surgery reduces costs profoundly, but that money isn't real to the people who have to do the work. The analogy is you pay your federal taxes but you don't necessarily feel intimately in contact with where that money goes.

That is the way practitioners feel about the cost savings and downstream implications for a lot of these things. That being said, in two years we've gone from one to now 40 practices participating in the program. We are gaining momentum, but it's taking a long time.

HLM: Should the C-suite mandate this?

Englesbe: I think the C-suite has to mandate it, but a lot of physicians don't work for the C suite. Hospitals within the infrastructure they own have to mandate it or at least make it available in the complex flow of care, which takes time.

HLM: Will the shift to population health and value-based care accelerate this process?

Englesbe: Yes. That resonates well with Medicare and other payers.

HLM: Does pre-hab promote patient engagement?

Englesbe: Yes. That's the most powerful message and it resonates with all the groups, the hospitals, payers, and physicians. Patients feel very engaged and empowered to be part of the team with some ownership over their outcomes during a really scary time.

It's a teachable moment for anyone to change lifestyles. It turns a scary time into a time that has more positive energy. That resonates with everyone. It's been the key to our success so far.

HLM: How much of this is pre-hab psychological versus physical?

Englesbe: There is no way to measure it, but I think that most of it is psychological. For the vast majority of patients who have reasonable functional status a lot of it is psychology. It is the remarkable power of positivity and engagement.

You create a care team, the family is on board, patient empowerment, positive energy, positive psychology. For many patients that is probably the secret sauce.

HLM: What about pre-hab for the elective surgery patient who is ill or immobile?

Englesbe:  The program isn't for everyone. We are trying to ramp up and engage as many patients as possible. You have to be able to walk to do the program. We are working on more diverse exercise opportunities for patients.

But we are locked in to what we told Medicare we were going to do, which is walking. In our experience, 99% of patients who have elective surgery walk into clinic and can walk. The people who cannot shouldn't do the program.

Now, that's different with the specialties, especially with orthopedic surgery where there are a lot of functional limitations, people have a bad hip or knee, things like that. Those numbers are very different and intentionally our program has been designed around patients having major elective thoracic and abdominal surgery.

HLM: Could you devise some sort of program for less-mobile patients?

Englesbe: Absolutely. At the patient level we do our best to try to enable every patient to do the program. At the University of Michigan, the program is different from the statewide program because our institution devoted more resources and we have more staff to care for the patients and try to enable them to participate.

But it takes time; not a lot, but even 10 minutes, if you're supposed to see a patient every 15 minutes through your day and you add 10 minutes to five interactions, over the course of a day that ruins the day.

Future iterations of the program will be more flexible and empower more patients.

HLM: Could this not be done by hiring more health coaches or physical therapy assistants?

Englesbe: It sounds easy, but a big hospital will do 75,000 operations a year. Then, it becomes a throughput issue. Now you need 15 physical therapy assistants. Don't get me wrong. It makes good financial sense. It just takes time to build the business case.

That is exactly what our Medicare project is doing; building a business case for payers and for hospitals to invest in these programs. Technology can bridge most of the work with patient tracking. There are lots of options there. But, it does takes some incremental staff.  

HLM: How could a hospital outside of Michigan take up this initiative?

Englesbe: I'm happy to share everything we've done here. It's a federally funded program. I have no intellectual property nor an equity stake in anything we've done. I'm doing it as an academic, so we'll share anything we've done.

In addition, we use patient-tracking technologies, pedometers, things like that, and there is a litany of private vendors out there who can do that piece of it. More and more hospitals within their own electronic health records have portals where patients can do this.  

HLM: How soon before prehab is a universal practice?

Englesbe: Our hope is that if we can prove to Medicare and other payers that this makes sense financially for them, and also it's good for patients, then we have proven the good-for-patients part.

I sincerely think this is going to be standard of care in surgery in about 10 years. It's going to take about a decade for the practice to change to the degree where this is an expectation. Clinical medicine moves very, very slowly. Like… really slowly.