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Editorial
Prehabilitation and preparation for surgery: has the digital
revolution arrived?
J. W. Durrand,
1,2
J. Moore
3,4
and G. Danjoux
5,6
1 Specialty Trainee, Northern School of Anaesthesia and Intensive care Medicine, Health Education England-North East,
Newcastle-upon-Tyne, UK
2 PhD Student, Department of Sport, Exercise and Rehabilitation, Northumbria University, Newcastle-upon-Tyne, UK
3 Consultant, Department of Anaesthesia and Intensive Care Medicine, Manchester University NHS Foundation Trust,
Manchester, UK,
4 Greater Manchester Cancer Clinical Director for Prehab and Recovery, Manchester, UK
5 Consultant, Department of Peri-operative Medicine, South Tees Hospitals NHS Foundation Trust, Middlesbrough, UK
6 Honorary Professor, Hull York Medical School, York, UK
.................................................................................................................................................................
Correspondence to: G. Danjoux
Email: gerard.danjoux@nhs.net
Accepted: 22 October 2021
Keywords: peri-operative medicine; prehabilitation; preparing for surgery
Twitter: @durrand_james; @mysurgeryandme; @GerryDanjoux
The COVID-19 pandemic has profoundly disrupted global
elective surgical care [1]. There are presently 5 million
people in the UK on an elective surgical waiting list, a
number expected to grow in the coming months [2]. The
capacity of peri-operative services is finite. Increasing this to
address the backlog is a substantial challenge and expected
to be the rate-limiting step [3]. Restoration of elective
surgical pathways will be complicated by the need to
mitigate the risk of peri-operative COVID-19 infection and
its significant implications for patients and staff [4]. This
situation has effectively created a generation of patients
waiting longer for treatment, with reduced pre-operative
support driving increased levels of patient anxiety and
reduced ‘preparedness’for surgery. Given the major
continued burden on front-line NHS staff [5], a co-ordinated
national response comprising innovative solutions is
required to address this problem.
Waiting better
The series of national lockdowns in the UK over the last
18 months may have significantly undermined the nation’s
health, increasing the rates of health risk behaviours that
elevate peri-operative risk. The rates of physical inactivity,
alcohol consumption and smoking may have increased,
with further negative effects on diet and mental health [6, 7].
A recent concern highlighted is the association between
pre-operative patient isolation and adverse postoperative
outcomes [8]. Crucially, existing health inequalities mean
these effects may not be evenly distributed across the
population [9]. The association between high levels of social
deprivation, increased prevalence of health risk behaviours
and associated chronic ill-health leading to adverse peri-
operative outcomes was already well established.
Unfortunately, the pandemic appears to have
disproportionately affected the health of this patient group
[10], acutely exacerbating the problem. Supporting patients
to tackle these health risk behaviours and improve their
physical and mental readiness for surgery is increasingly
recognised by national bodies as an important step forward
in addressing this situation and has been the focus of
several prehabilitation services in the UK [11, 12]. Capturing
the shared learning and experience gathered over the last
3–4 years will now be crucial in seizing the opportunity
which the current national situation presents.
In a national briefing from the UK Centre for Peri-
operative Care [13], the need to redesign peri-operative
©2021 Association of Anaesthetists 1
Anaesthesia 2021 doi:10.1111/anae.15622
pathways for the COVID-19 era was emphasised. A ‘smart
reset’of elective surgery is intended to not only mitigate the
immediate issues of the pandemic but re-engineer peri-
operative pathways for the long term. Two of the key
messages relate directly to the reframing of waiting lists as
preparation lists: 1. The need to develop peri-operative
care as a model to promote healthy living and prevention of
future ill health; and 2. The need to develop effective, virtual
patient solutions. This drive has been reflected in the
establishment of cross-sector ‘waiting well’initiatives within
regional integrated care systems seeking to understand the
needs of, and support required for, patients to improve their
readiness for surgery.
The unplanned shift to digital
prehabilitation
Before the COVID-19 pandemic, the majority of
prehabilitation services were operating as face-to-face
multi-behavioural health promotion programmes. In April
2020, all NHS services were required to rapidly reconfigure
their delivery because face-to-face patient contact was
minimised. This had a major impact on prehabilitation
support due to the lack of evidence-based remotely
supervised (‘home-based’) prehabilitation options to match
and complement face-to-face offers. Pre-pandemic work by
the authors had already highlighted this unmet patient
need. In one service based in the north of England and
serving a tertiary geographical population, approximately
50% of patients approached for face-to-face prehabilitation
participation before surgery declined [12]. Reasons cited by
patients included: travel distance and cost; lack of transport;
inflexibility of timing related to working and other life
commitments; cost; discomfort in group environments; and
preference for home-based support. The need for a wider
menu of options to maximise patient engagement and
reduce inequality of access was therefore already evident
and brought acutely into focus by the changes in healthcare
delivery enforced by the pandemic.
Existing prehabilitation services around the UK
responded rapidly to this challenge through a period of
innovation, development and delivery of virtual alternatives
to enable continued support of patients awaiting urgent
surgery or other treatments. Examples included:
Conversion of patient information materials to multimedia
online formats; introduction of live virtual classes using
teleconferencing programmes; structured web and app-
based health promotion programmes; and digital health
coaching. A range of road-tested virtual options now
support the initial development of ‘hybrid prehabilitation’
with a combination of digital and face-to-face offers.
Further successful peri-operative digital interventions
have taken place, including ‘digital joint school’. Although
as yet unpublished, compelling results from this digital
innovation have driven a major change in the peri-operative
orthopaedic pathway at South Tees Hospitals. Between
2017 and 2020, digital joint school showed excellent patient
engagement and significant improvements in quality of life,
with associated improvement in Oxford hip and knee scores
and reductions in hospital duration of stay [14].
Manchester’s surgery school has also produced a virtual
version to support group education in major surgical
pathways [15]. As peri-operative care pathways seek to
make digitally facilitated prehabilitation and preparation
options available, valuable groundwork has been laid.
The case for digital?
Digitally facilitated interventions to support health
behaviour change are established in several clinical
settings. Perhaps the nearest aligned healthcare setting is in
cardiac rehabilitation where multi-behavioural digital
platforms have demonstrated comparable efficacy in
behaviour change to face-to-face programmes, with
excellent rates of patient engagement and adherence [16].
Other successful interventions have demonstrated improved
glycaemic control in patients with type-2 diabetes through
increased physical activity and dietary change [17], and
reduced alcohol consumption [18].
These interventions align with NHS priorities to adopt
technology in healthcare delivery closer to home. They
confer several potential advantages over face-to-face and
paper-based remote models, including flexibility for patients
and staff. Potential cost effectiveness is supported by the
capacity for comparatively fewer team members to monitor
and support multiple patients simultaneously, alongside
reduced space and equipment requirements. Developments
in audiovisual and communication technology increasingly
allow some of the unique benefits of a face-to-face
interaction with a healthcare professional to be obtained
remotely. Wearable devices capable of increasingly
sophisticated continuous and detailed biometric monitoring
can be integrated to enhance intervention fidelity, providing
continuous feedback to patients and insight into the
physiological effects of their peri-operative journey.
Digital solutions also have the capability to be scaled
rapidly geographically to support large numbers of patients
at minimal additional expense creating a potentially
attractive return on investment solution. Platforms can also
be designed to integrate with existing electronic record
systems with the potential to streamline and digitalise
complete peri-operative care pathways.
2©2021 Association of Anaesthetists
Anaesthesia 2021 Editorial
A digital prehabilitation framework
Figure 1 presents a potential framework for discussing the
range of digital prehabilitation options now available. The
‘tiered offer’for prehabilitation support more broadly
introduced in national guidance for prehabilitation of
people with cancer [19] was used as a basis for this, with the
framework aiming to help rationalise which resources are
offered. The wide range in patient need across the surgical
population must be balanced against the intensity of
support and resources required. Universal offers are
applicable to most patients preparing for surgery providing
generic support with minimal healthcare staff input.
‘Targeted’offers provide more structured support, tailored
to patient needs and introduction of remote supervision by
a healthcare professional. Finally, ‘specialist’offers are
intended to support patients requiring the most intensive
support for complex needs, providing the elements of
targeted interventions with more intensive staff supervision
and support.
Challenges and potential pitfalls
The range of digital options now becoming available could
revolutionise prehabilitation and peri-operative support in the
UK, with the potential for rapid dissemination and uptake.
However, it is critical not to lose sight of the fact that despite
use of cutting-edge technology, these solutions are
fundamentally health behaviour change interventions. It is also
important to acknowledge that although many of the available
digital solutions have undergone ‘live’preliminary road testing
with encouraging results, rigorous evaluations are not yet
available. This situation reflects the tension between choosing
rapid resource creation withacontemporaneouslive
evaluation process or a slower, systematic design and
development process leading to formal testing.
Learning from the longer term use of similar
interventions in wider healthcare contexts supports the latter
approach. The importance of applying this learning from
wider healthcare to prehabilitation interventions has been
shown [20]. Employing established, systematic methods for
iterative intervention development, grounded in health
behaviour change theory, facilitates a clear understanding of
intervention function and why specific behaviour change
techniques were chosen and incorporated. Involving patients
at the earliest possible opportunity in this process(co-design)
is crucial to later success. A robust intervention development
process supports subsequent evaluation and the understanding
of why a given intervention does (or does not) perform well
[21]. If an evidence base for digital solutions is to be built,
we must use this to capitalise on the efforts already made
and further develop those interventions now available to
Figure 1 Framework for digitally facilitated prehabilitation support. PROM, patient-reported outcome measure; PREM, patient-
reported experience measure. Adapted with permission from [24].
©2021 Association of Anaesthetists 3
Editorial Anaesthesia 2021
provide the best chance of real-world durable success and
ensure a return on resource investment. A time-efficient
combined approach may be possible; however, close
synergy will be required between industry and NHS
partners in achieving this. The authors are aware of several
examples in the UK where this type of collaboration is
already underway.
One particular concern that is widely discussed is
the concept of ‘digital exclusion’. For many of the patients
who stand to benefit most, the offer of a digital prehabilitation
intervention may be unappealing, anxiety provoking or
completely inaccessible. Digital exclusion is strongly
associated with wider health inequality. It is estimated that
20% of the UK population (11.6 million people) lack basic
digital skills, or do not use digital technology at all. This group
is likely to predominantly comprise people who are older or
from a poorer socio-economic background (and therefore
lacked opportunity), both of which are associated with an
increased risk of chronic ill-health and utilisation of healthcare
services. In a move towards digital, without a plan to
proactively address this, we run the risk of worsening the
situation we aimed to improve. In the Digital Inclusion Guide
for Health and Social Care [22], NHS digital identifies several
key barriers, including:
(i) Confidence and skills - patients may lack the
information technology literacy necessary or fear risks
such as online crime. Interventions must be co-
designed with intended users with this in mind.
(ii) Opportunity and access - 20% of households with an
adult >65 years of age may lack an internet connection
or have variable device access. For example, learning
from Digital Joint School identified that older patients
may be more comfortable using desktop devices over
mobile alternatives [14].
(iii) Motivation, awareness, and staff capability and capacity -
patients may be unaware of resources available or the
potential benefits to them. Staff involvement in the design
process is critical to build confidence in recommending
digital interventions to patients and supporting their
usage.
NHS Digital recommends a holistic series of cross-sector
measures that can be undertaken to address these barriers
based upon local needs and barriers, adopting learning from
the NHS widening digital participation programme [23] that
demonstrated a £6.40 return on investment for every £1
spent on inclusion support (see Box1).
Clearly, active input and collaboration across several
agencies, including healthcare and industry partners, will be
required to meet this challenge.
In conclusion, the marked shift to digital prehabilitation
delivery holds enormous potential to produce rapidly
scalable solutions that can support patients facing extended
waits for surgery. Realising this potential will require
thoughtful intervention development that places patients at
the centre, minimises the risk of increasing inequalities and
supports creation of an evidence base. Finally, despite
efforts to deliver inclusive digital solutions that meet patient
and service needs, demand will continue for equally
robustly developed face-to-face and ‘paper-based’remote
options. If our aim is to engage the fullest range of patients
in prehabilitation activity, a menu of options will be required
as one size cannot fit all.
Acknowledgements
GD provides consultancy advice to Sapien Health Ltd, a
health coaching company. GD and JD have received a
national open grant award from Sport England for research
Box 1
•Community digital skills training: community online
centres can provide support to patients, delivered in
partnership between public, private and voluntary
sector organisations.
•Digital champions: designated patient volunteers
and staff can access training to support others in
enhancing their skills and understand the potential
benefits of getting online. Enhancing the digital skills
of staff to act in this role is a focus of the Health
Education England (HEE) digital capabilities
framework [24].
•Intergenerational mentoring: digitally enabled family
members and friends are a powerful resource to
introduce and support older patients in utilising
available resources.
•Assistive technologies: patients facing physical
barriers to inclusion, for example poor eyesight
preventing keyboard usage can be supported by
dedicated technologies such as voice activated
systems.
•Signposting to free public Wi-Fi: patients can be
signposted and supported to safely access freely
available Wi-Fi including at most NHS GP practices.
•Social prescribing: social prescribing initiatives are
now embedded within NHS primary care and ideally
placed to connect patients to locally available digital
support.
4©2021 Association of Anaesthetists
Anaesthesia 2021 Editorial
to develop a digital prehabilitation platform for patients
before surgery. GD holds an Honorary Chair at Teesside
University (Middlesbrough, UK) and is Clinical Lead for
South Tees prehabilitation strategy and implementation. No
competing interests declared.
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