“In both cases, there’s a kind of shared physiology behind the training,” says Michael Englesbe, a transplant surgeon at the University of Michigan Health System. “Functional disability underlies a lot of bad outcomes.”
Yet, conventional health care is skewed more towards post-surgery care rather than pre-operation preparation.
“We do a lot in medicine to get people ready for surgery, but they’re primarily administrative tasks — checking off boxes that don’t necessarily make a patient better,” says Englesbe.
Reduces readmission rates and lowers medical costs
In the study evaluating 641 patients who participated in the Michigan Surgical Home and Optimisation Programme (MSHOP), Englesbe, trauma surgeon Stewart Wang and several other authors confirmed that basic fitness and wellness coaching administered prior to surgery could reduce hospital stay by two days.
Preventable frailty because of poor diet or inactivity before a procedure was found to be a key predictor of post-operative complication, and “it became obvious a lot of patients struggle with [prior] functional issues”, says Englesbe.
“We came up with the idea that people should start training to combat that … to augment the recovery,” he says.
“As a physician, you always tell people to quit smoking and exercise,” Englesbe adds, “but the compliance rates are notoriously abysmal.”
The study that was carried out between June 2014 and December 2015 showed that preparing patients for surgery also reduced the likelihood of readmission and lowered medical costs by 30%.
According to Wang, “The condition of the body is so important. It’s so much common sense that people often fail to recognise it.”
Empowering patients to control their outcome
Championing the idea for almost a decade, Englesbe and Wang initiated the MSHOP project in 2010, a structured home-based and preoperative training programme aimed at providing physical, nutritional and psychological guidance before surgery.
The programme uses a web-based risk assessment tool where doctors can plan nutrition, exercise and emotional goals for patients according to the input keyed in, such as their age, weight, existing health issues and intended surgery. Goals include improving diet, reducing stress, having breathing exercises, ceasing smoking, and emphasising on light physical activity.
Most patients are advised to log about 19km of walking per week or about an hour a day, as Wang attests that the vast majority of the programme benefits come from the walking. Each patient is given a pedometer to track the progress and given reminders via text messages.
The bottom line is that being proactive helps to boost confidence and calm anxieties in times of uncertainty. “Patients often feel very powerless when they’re having big operations,” Englesbe says.
“Anything we can do to empower them to have some control of their outcome in what is inherently a situation they can’t control very well is a good thing,” he explains.
Surgeons must start the dialogue
The MSHOP initiative, which won a USD $6.4 million Health Care Innovation Award by the Centres for Medicare & Medicaid Services in 2013, has now expanded to 22 medical practices and hospitals across Michigan.
However, healthcare professionals are concerned about issues concerning logistics and wider implementation, but technology director June Sullivan believes that surgeons must be the ones to start the dialogue.
“They have to deliver the message; that’s who the patient believes,” says Sullivan.
“First, we hear that everyone thinks it makes sense for their patients,” says Englesbe. “Second, it’s really hard to change clinical practice, especially among busy surgeons. It’s essentially adding work to the busiest people.”
There needs to be a “cultural change”, according to Englesbe, and it should start with the surgeon at the time of decision to proceed with surgery. The prospect of serious surgery can also be a change agent in itself, influencing patients to change their lifestyles.
As much as champions are not made overnight, change is not impossible. MIMS
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