Dr Melmed reviews the prehabilitation protocol trialed at Cedars-Sinai among patients with IBD who were preparing for surgery, which showed a significant reduction in complications as well as cost reductions among the cohort that received multidisciplinary care. 

Gil Y Melmed, MD, is director of Inflammatory Bowel Disease Clinical Research and codirector of the Clinical Inflammatory Bowel Disease program at Cedars-Sinai Medical Center in Los Angeles, California.

Multidisciplinary Prehabilitation Before Surgery Reduced Complications in IBD Patients

• Inflammatory bowel disease (n=192; prehabilitation vs standard surgical preparation: A 10-week multidisciplinary prehabilitation program beginning 4 weeks before surgery included weekly visits with a dietician, nurse practitioner, social worker, and physical therapist, plus surgery-specific exercise, carbohydrate loading (100 g the night before surgery and 50 g the morning of surgery), and immunonutrition twice daily for 5 days before and 5 days after surgery. Patients receiving prehabilitation experienced a nearly 50% reduction in surgical complications as measured by the Comprehensive Complications Index, with better outcomes across all complication grades compared with standard care.
• 30-day postoperative outcomes: Prehabilitation was associated with significant reductions in hospital readmissions within 30 days (15% vs 25% with standard care) and reoperations within 30 days (3% vs 8% with standard care); reoperations most commonly related to anastomotic leak.
• Adherence and economic impact: Greater adherence to the prehabilitation program was associated with better surgical outcomes, lower postoperative morphine requirements, and improved outcomes related to pain control, complications, and length of stay. Patients undergoing prehabilitation had significantly lower costs during the 30 days after surgery, including approximately $7,000 lower cost per patient among the highest-cost quartile of patients with complications such as readmissions or reoperations.

Hello, I'm Gil Melmed from Cedars-Sinai in Los Angeles, and it was our privilege to present our latest data on prehabilitation and the effects of prehabilitation before surgery on outcomes after surgery in patients with inflammatory bowel disease.

People ask, what is prehabilitation? The idea is, just like one would prepare before a major stress to the body, like running a marathon, for example, nutritionally, physically, mentally, so too we've learned across the surgical literature that it's important to prepare patients for surgery with those same aspects of care. And by doing so, we can realize and achieve significant improvements in various surgical outcomes, including important surgical complications.

So we set out to develop a prehabilitation program specifically designed for patients with inflammatory bowel disease—Crohn's and ulcerative colitis, which is a 10-week program beginning 4 weeks prior to surgery. Patients would receive care from a multidisciplinary team that includes a dietician, a nurse practitioner, social worker, and a physical therapist with specialized and personalized components of care in those weeks prior to surgery—one visit per week for a total of 4 visits prior to surgery with this multidisciplinary care team, as well as the introduction of specific interventions, including exercises tailored to the specific surgery that the individual is expected to undergo, as well as nutritional interventions with carbohydrate loading of 100 grams the night before surgery and 50 grams the morning of surgery of carbohydrate-rich drinks, as well as immunonutrition, which were oral nutritional supplements given twice a day for 5 days prior to surgery and 5 days following surgery.

Our outcomes were looked at in 192 patients, and this represents the largest cohort we are aware of for this intervention in inflammatory bowel disease. Half the patients received prehabilitation and half the patients received standard of care surgical preparation instructions. In the group that underwent prehabilitation, we noticed a significant reduction in surgical complications as defined by the validated CCI, or Comprehensive Complications Index, by nearly half. When we looked at each individual grade of surgical complications, going from grade 0, which is no complications; grade 1, which are generally classified as mild and probably less consequential; grade 2, grade 3, and grade 4, which includes complications severe enough to require ICU hospitalization, as well as reoperations, that at every single grade of surgical complications, those in the prehab group did better than those in the standard of care group.

In addition, for the very important complications of hospital readmissions within 30 days of surgery, as well as reoperations within 30 days of surgery, we saw significant reductions in patients who were exposed to prehabilitation as opposed to those that weren't. Readmissions were 25% in the standard of care arm, whereas in the prehabilitation group, only 15%. Reoperation within 30 days, most commonly due to an anastomotic leak, was seen in about 8% of patients in the standard of care arm and in only 3% of patients in the prehabilitation arm. This suggests a significant benefit to patients undergoing this relatively low-cost intervention.

We took this one step further. We then asked the question, does the degree of adherence to the prehabilitation protocol affect the outcome? And the answer is, it most certainly does. We found that the more visits a patient attended, the better their outcomes. In addition to better outcomes, we also noticed that the more visits a patient attended, the lower their morphine requirements after surgery in dealing with the post-operative pain.

We asked the question, well, what about the nutritional interventions? Is there a noticeable impact on some of these specific components that we introduced in this multidisciplinary care bundle, if you will? And we noticed that indeed, the more oral nutrition shakes a patient drank in those days prior to surgery, the better their outcomes were. And that included better outcomes in terms of pain control, better outcomes in terms of complications, and interestingly, better outcomes in terms of their length of stay after their index surgery.

We then asked one final question, which is a question that we often get when we present our data in a public forum, which is the cost. What does this mean in practical relevance for the average site or hospital system that may not have access to the specialty care that we were able to offer to our patients because it's expensive. PT, physical therapy, nutrition care is not ubiquitously available, and we recognize that. And so we set out to demonstrate a cost case to be made for the benefits of rehabilitation. And when thinking about and factoring in all the costs that go into what happens after surgery, we found that patients who underwent prehabilitation on average experienced significant reduction in costs for those 30 days after surgery.

In particular, if we took the highest quartile of the most expensive patients, those that were readmitted, those that had reoperations, we found that even in those patients who had those particular kinds of complications, those complications still cost our hospital system less money in the patients who had been exposed to prehabilitation compared to those that hadn't on the order of about $7,000 per patient.

And so our conclusion is that prehabilitation improves various and multiple surgical outcomes for patients with inflammatory bowel disease in a dose-dependent manner. We get better outcomes when we do more of it. In addition, we found that it is a significant cost savings to a health system, given the significant reduction in complications and readmissions that occur after surgery from this exposure.

And so our conclusion is, it's a no-brainer. If we expose patients to this low-cost intervention, we can both achieve better outcomes and save money. And therefore, we suggest that this be adopted as a universal standard of care for all patients with inflammatory bowel disease.