Remote surgical prehabilitation

Based on evidence in a 2018 report, South Tees Hospitals NHS Foundation Trust launched the UK’s first community-based prehabilitation programme called PREPWELL.

The PREPWELL project is part of a wider Local Delivery Pilot in South Tees called You've Got This. The pilot aims to improve equality of access to physical activity and exercise in the community. It's funded by the national grant award from Sport England.

The Trust worked with Public Health South Tees to improve the physical and mental wellbeing of patients before surgery.

Patients who are better prepared for surgery:

• experience fewer postoperative complications
• spend less time in hospital
• have lower readmission rates
• report better quality of life following surgery

In the first 2 years of the PREPWELL prehabilitation programme, patients attended face-to-face group exercise sessions 2 times a week, with support for other risk behaviours where required.

Approximately 150 patients from 5 surgical specialties were supported. There was excellent patient feedback and high levels of patient attendance and engagement (over 75%) with the programme.

Patients who took part in the programme showed substantial improvements in:

• fitness where the mean improvement was 4 to 5 fold
• quality of life where the mean improvement 10%
• mental health where there was a reduction in anxiety and depression scores

The benefits were maintained up to 3 months post-surgery. The cost of delivery was £52 per patient per week.

Situation

COVID-19 forced the closure of the public health wellbeing hub where sessions were delivered. This put the PREPWELL prehabilitation programme in jeopardy and could leave patients feeling unsupported.

It was clear that remote patient support was needed to continue the excellent foundations established by the PREPWELL team.

Aspiration

• The Trust wanted to transform the perioperative care model by implementing a remote prehabilitation programme. This would improve patient self-management and positively influences lifestyle behaviours linked to surgical risk.
• The Trust wanted to actively support the physical and mental health needs of patients before and after surgery. This would ensure they have the best experience and fastest recovery possible from their surgery.

Solution

The PREPWELL team collaborated with a digital health technology provider, Surgery Hero, to deliver a remote prehabilitation programme.

Surgery Hero launched a multi-behavioural intervention app that works on a mobile phone. It’s tailored for patients approaching and recovering from elective surgery.

The Surgery Hero app provides personalised structured educational material. Digital guidance on preoperative lifestyle changes is combined with one-to-one health coaching to deliver remote prehabilitation support entirely via patients’ smartphones.

It’s a progressive and adaptive solution designed to support patients for up to 8 weeks before surgery and during their initial rehabilitation.

To evaluate the impact of the app and digital health coaching, the Surgery Hero and PREPWELL teams launched a pilot programme for patients waiting for hip and knee surgery.

The PREPWELL team identified a group of patients on a waiting list for orthopaedic surgery and contacted them to participate. Following initial contact, patients were asked for consent and were risk assessed to ensure remote health coaching was a safe and suitable option. Their details were forwarded to the Surgery Hero team to commence their digital health coaching programme.

Impact

Findings from the service evaluation on the pilot programme include:

• a Net Promoter Score of 86 (excellent rating) which indicates overall patient satisfaction
• a 12 point increase in average patient health activation, as captured by Patient Activation Measure (PAM) score

There was a significant shift from low to high levels of patient activation, following programme completion.

The patient activation level before Surgery Hero was introduced was:

• 13% of patients at level 1, which went down to 0% after completing the programme
• 26% of patients at level 2, which went down to 13% after completing the programme
• 39% of patients at level 3, which went up to 48% after completing the programme
• 22% of patients at level 4, which went up to 39% after completing the programme

This change is indicative of an improvement in patient self-management skills.

Higher PAM is also associated with reduced healthcare costs, health service utilisation and fewer postoperative complications. There was also an improvement in all patient self-reported modifiable risk factors. The evaluation showed an average increase of:

• 20% for physical activity
• 10% for nutrition
• 10% for mental wellbeing
• 20% for sleep quality
• 10% in sleep duration

The pilot programme is still being evaluated and perioperative outcome data will be available in the near future. An independent health economic analysis is being performed by York Health Economics Consortium.

Functionality

Surgery Hero is a remote prehabilitation programme that supports patients on waiting lists to address their modifiable risk factors for surgery.

Key features include:

• one-to-one expert health coaching
• health metrics like step count and weight are tracked

It also has a structured education programme covering all key areas of surgical preparation and recovery. It has on-demand access to the Surgery Hero content library with surgery-specific content covering:

• exercise and physical activity
• diet and nutrition
• stress-management
• sleep

The content is available in written, video and audio formats.

Capabilities

• The programme can be accessed remotely using the patient's own mobile phone. This means it supports the physical and mental health needs of patients before and after surgery.
• The programme supports patients to develop their knowledge, confidence and skills to effectively self-manage their needs before and after surgery. This is critical at a time when the NHS is facing unprecedented pressures, including recruitment and retention challenges.

Scope

The programme can be easily accessed by people waiting for and recovering from surgery at home.

The programme can be expanded to support thousands of patients simultaneously. This includes those in remote locations who might otherwise struggle to access support.

It also has significant potential to be adapted for other patient populations or staff who may require wellbeing support.

Key learning points

• Remote digital health coaching is innovative and effective. It's an accepted way to support patients to improve their physical and mental health before surgery.
• Collaboration between NHS and industry partners is an effective way to support patients. It also allows expertise, manpower and resources to be shared.
• Digital health coaching solutions have the potential to reduce costs and can be scaled up quicker than face-to-face interventions.
• Digital health coaching offer more flexibility for many patients over face-to-face alternatives.
• Both face-to-face and digital options are likely to be required in future to maximise patient engagement and access.

Key quotes

“I would never at the age of 75 have envisaged going on a better health journey. However, with the help and encouragement of my coach, in the last 8 weeks I’ve lost over 24lbs, feel healthier, sleep better, and my knees have not felt this pain-free for as long as my ageing memory can recall.”

Joe, a Surgery Hero Member Waiting for a total knee replacement operation

“Our work with Surgery Hero has shown their digital health coaching solution to be well received by our patients and effective in supporting patient optimisation in the lead up to surgery. The surgical waiting list crisis that exists as a result of COVID-19 requires health solutions to work collaboratively in partnership with the health sector to minimise unplanned cancellations, complications and efficiently tackle the backlog.”

Professor Gerard Danjoux, Consultant Anaesthetist, South Tees Hospitals and PREPWELL Programme Lead

“The Surgery Hero solution has been a great resource for our patients to access. It’s easy to facilitate and the streamlined onboarding process means that patients are finding it easy to access and to use. The Surgery Hero team has worked with us to ensure that the burden on the clinical team is minimal. Initial feedback from patients is that they enjoyed using Surgery Hero and found the support invaluable.”

Esther Carr, Senior Physiotherapist at South Tees Hospitals and PREPWELL Programme Manager

Key contact

Luke Eastwood, Chief Operating Officer, Surgery Hero

luke@surgeryhero.com

Professor Gerard Danjoux, Consultant Anaesthetist and PREPWELL Clinical Lead, South Tees Hospitals NHS Foundation Trust

gerard.danjoux@nhs.net