When Prehabilitation Meets Healthcare Analytics

When the Promise of Prehabilitation Meets
the Power of Healthcare Analytics

© 2019 Health Catalyst
Proprietary. Feel free to share but we would appreciate a Health Catalyst citation.
The Promise of Prehabilitation
As the saying goes, “An ounce of
prevention is worth a pound of cure.”
The healthcare industry continues to
place more emphasis on preventive
care, which can help reduce healthcare
costs and improve patients’ quality of life.
Another preventive concept, known as
prehabilitation, is also gaining traction to
help patients who undergo surgical
procedures recover faster.

What is Prehabilitation?
Prehabilitation is defined as any physical
or lifestyle preparation that happens
before surgery and is designed to help
patients regain function in less time.
Patients who undergo surgery frequently
follow a rehabilitation program after
surgery to promote recovery but starting
this program before the procedure may
help further accelerate recovery time.
Prehabilitation prepares the body to
endure a major stressor (such as
surgery) despite lengthy downtime
during the initial recovery process.

A 2017 study published in the Journal of
Bone & Joint Surgery looked at the
associations between preoperative physical
therapy and post-acute care utilization in
total joint replacements found that:
…the use of perioperative physical
therapy was associated with a 29
percent decrease in the use of any
post-acute care services.”

Findings also indicated a significant cost
reduction, resulting largely from reduced
payments to skilled nursing facilities and
home healthcare.
Other studies such as this 2017 review
of prehabilitation programs in abdominal
cancer surgery, have shown promising
results and generated media attention.

Patient behavior is one of the primary determinants
of health and well-being—an association that holds
true when it comes to post-surgical recovery times
and adhering to practices and behaviors that
promote healing.
Prehabilitation includes the following four main
components:
Medical optimization of pre-existing conditions
Physical fitness
Nutritional status
Psychological support
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Medical optimization of pre-existing conditions
This includes intervening on specific conditions
with modifiable factors that are associated
suboptimal patient outcomes; if optimized, the
factors can reduce risks to the patient and the
impacts on the health system.
Conditions frequently addressed include
substance use (e.g. tobacco), anemia, and
chronic medical conditions such as diabetes
and obesity.
In fact, uncontrolled diabetes is one of the most
significant contributors to surgical site infections.

Physical fitness
The patient’s fitness at the time of their
surgery is a significant factor in how well
they recover.

Nutritional status
Patients who eat healthy, balanced
diets and are well-nourished have been
shown to recover faster.
Malnourished patients have significant
risk, and poor nutritional status is
associated with “poor postoperative
outcomes,” including adversely affected
rates for length of stay (LOS), infection,
readmission rates, and mortality.

Psychological support
This factor comprises patients’ cognitive and
mental health prior to surgery. It includes
questions such as:
• Does the patient have early onset dementia?
• How well are they managing stress and anxiety
associated with the event?
• Do they have a support structure in place?
Such factors could influence that patient’s
motivation to comply with the course of
treatment and adhere to healthy behaviors
post-surgery.

Prehabilitation is about treating patients in
their entirety and not just one piece of the
puzzle.
It is also just one component of the patient
journey from pre-surgery to perioperative
and post-surgical recovery.
However, beginning the surgical journey
in the best physical, nutritional, and
psychological condition possible can help
lead to better surgical outcomes and
faster recovery times for patients.

Preparing for surgery through
prehabilitation can also help foster
relationships between the care team
and the patients and their families
prior to surgery.
This can help build trust, lead to
better care management, and, in the
long-term, better outcomes for the
patient and the healthcare system.

Pre-Op Assessments
Once the need for surgery is identified,
patients should have a pre-op assessment.
This type of holistic patient visit considers
the four pre-op factors identified above and
can be a powerful indicator of outcomes.
A frailty assessment is a powerful tool to
identify a patient’s increased risk for
complications and other adverse events.
Patients identified as being frail have
increased LOS, morbidity, mortality, surgical
site infections, costs, and admissions to
skilled nursing and other acute-care facilities.

Why Is Prehabilitation Important?
The reasoning for prehabilitation stems
from the idea that surgery is a major
stress event requiring both physical and
mental preparation.
While there is little consensus on when
the point of care for a patient begins, the
prehabilitation phase can serve as a
starting as soon as the care team
identifies the need for surgery, up until
the surgery takes place.

A robust prehabilitation program ideally
starts four to six weeks prior to surgery,
depending on many factors, such as:
• Type of surgery
• Patient’s fitness
• How far in advance surgery is identified
However, studies have shown that even
one encounter prior to surgery can have
a positive effect on outcomes.

While prehabilitation has shown
promising results in a variety of patients
and situations, its effectiveness is closely
tied to successful care management over
the pre-, peri-, and postoperative phases
of the patient’s journey and has both
short- and long-term ramifications.

Providing coordinated care throughout the
prehab period is particularly important.
Health systems can glean important
insights about care best practices if they
are able to effectively follow the patient
journey and capture relevant data
throughout.
To do so, some health systems have a
nurse or patient guide that helps patients
navigate the journey four to six weeks out
from the surgical encounter through to the
recovery phase.

Regular interaction with a patient leverages
some of the principles of adaptive leadership
in optimizing care management.
Any healthcare encounter is an opportunity
to close gaps in care and optimize the
patient’s health in order to improve
outcomes, and the pre-operative encounter
can be an especially important opportunity.

The biggest factor impacting surgical
outcomes is complications, often related to
poor chronic disease management, most
commonly diabetes.
Helping patients meet their short-term and
intermediate goals can also influence their
longer-term outcomes.

For example, a patient with well controlled
blood sugar reduces his risk of post-op
infections, thus improving outcomes such as
LOS, and morbidity, and cost-per-case, as
well as hastening recovery times.
Although most studies are in the surgical
population, there is likely benefit in these
prehabilitation concepts in all types of
patients with complex medical conditions.

Prehabilitation and Functional Capacity
Colorectal cancer is the second most prevalent
cancer; surgery is the only remedial option for
the more than 100,000 annual diagnoses
According to a 2019 article in BMC cancer:
…as many as 50 percent of patients experience
postoperative complications, and are associated
with higher morbidity and mortality rates, lower
quality of life, and increased expenditure in
healthcare.”
These complications have been closely tied to
the four components mentioned above:
preoperative functional capacity, nutritional
state, psychological state, and optimization of
medical complications.

While most clinicians have focused on patient
outcomes following surgery, targeting behavior
changes and rehabilitation, a 2017 study at
McGill University targeted improved outcomes
through prehabilitation efforts, looking
specifically at improved walking capacity.
The study concluded that:
…a structured multi-modal prehabilitation
program improved walking capacity before
and after surgery for colorectal cancer.”

A related study at McGill University that
compared prehabilitation results to
rehabilitation in post-surgical colorectal
cancer patients was cited in an article by
Kaiser Health News, showing:
…eight weeks after surgery, 84 percent of
prehab patients’ performance on a six-minute
walking test had recovered to or over their
baseline measurements compared with 62
percent of rehab patients.”

While much of the available research seems
to suggest a positive correlation between
prehabilitation and improved outcomes,
there’s a consensus that a larger body of
research is needed.
However, there are still compelling reasons
to integrate prehabilitation efforts into the
surgical care continuum, while continuing to
stay abreast of the latest ongoing research
recommendations and conclusions.

The Power of Healthcare Analytics
Accurately measuring both short- and
long-term patient outcomes relates to
the ability of health systems to
measure patient adherence to a plan.
An analytics platform can help
clinicians determine the optimal time
for prehabilitation intervention.
An analytics system can also help
synthesize data from a myriad of
sources that can alter the course of
patient recovery.

Data sources might include patient visits
outside the system, patient-reported
outcome measures (PROMS), claims
data, as well as data about diet and
exercise from sources such as wearables
or wellness centers.
A robust analytics platform and solution
makes it possible to provide more holistic
care by ingesting data and making sense
of these disparate pieces that aren’t
otherwise captured.

In addition to the powerful Health Catalyst
Data Operating System (DOS™), Health
Catalyst also offers a suite of advanced
applications, including Community Care,
which can help clinicians identify care
gaps and understand how to close them.
There are also several surgical
applications that consolidate these
different sources of information into a
central and robust platform that provides
organizations with actionable data.

In order to measure the success of
prehabilitation efforts, clinicians can set
long-term outcome goals with process
improvements during the prehab period
that apply to multiple types of patient
cohorts.
With the increasing number of metrics that
clinicians and health systems are trying to
measure, adding more to this list can
seem impossible.

However, additional data provides an
opportunity to leverage the work that
improvement teams have done or improve
process metrics that other teams are
already working on.
For instance, many health systems that
Health Catalyst works with have improved
their management of diabetes.
This improvement can be further
leveraged by a team looking to implement
and measure prehabilitation efforts can
further leverage this improvement.

Treating the Whole Patient
While a number of studies show promising
results of prehabilitation efforts, this is only
one part of providing holistic treatment to
patients that accounts for preventive care,
perioperative best practices and
postoperative rehabilitation.
When patients are prepared for surgery by
optimizing pre-existing medical conditions,
physical fitness, nutritional status, and
psychological support, early studies have
shown a positive correlation with better
outcomes.

Treating the Whole Patient
Although more research is needed,
prehabilitation is part of a coordinated
care effort.
Health systems can also leverage the
improvement work on process metrics in
coordination with prehabilitation efforts.
Prehabilitation is one more component
that can help lead to better care manage-
ment in the short term and, in the long
run, lead to better outcomes for both
the patient and the healthcare system.

For more information:
“This book is a fantastic piece of work”
– Robert Lindeman MD, FAAP, Chief Physician Quality Officer

More about this topic
Link to original article for a more in-depth discussion.
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The Top Six Examples of Quality Improvement in Healthcare
Health Catalyst Editors

Other Clinical Quality Improvement Resources
Click to read additional information at www.healthcatalyst.com
Josh is a nurse practitioner who has over 20 years of nursing experience. Most recently,
Josh joined Health Catalyst as a Clinical Outcomes Improvement Director. In this role, he
helps healthcare organizations achieve their improvement goals. Prior to joining Health
Catalyst, Josh worked at Intermountain Healthcare in a respiratory and medical intensive
care unit as a nurse practitioner. During this time, he also worked closely with multiple
clinical program leads and clinicians to develop and implement systemwide applications, protocols,
and order sets to reduce variation in care. You will also, on occasion, find him lecturing to nurse
practitioner students at the University of Utah.
Josh Ferguson APRN, ACNP, ANP-BC

Other Clinical Quality Improvement Resources
Click to read additional information at www.healthcatalyst.com
Health Catalyst is a mission-driven data warehousing, analytics and outcomes-improvement company
that helps healthcare organizations of all sizes improve clinical, financial, and operational outcomes
needed to improve population health and accountable care. Our proven enterprise data warehouse
(EDW) and analytics platform helps improve quality, add efficiency and lower costs in support of more
than 65 million patients for organizations ranging from the largest US health system to forward-thinking
physician practices.
Health Catalyst was recently named as the leader in the enterprise healthcare BI market in
improvement by KLAS, and has received numerous best-place-to work awards including Modern
Healthcare in 2013, 2014, and 2015, as well as other recognitions such as “Best Place to work for
Millenials, and a “Best Perks for Women.”

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