Since 2019, physician-led teams at 27 BC hospitals have been working together through SSC’s Surgical Patient Optimization Collaborative (SPOC) to help patients better prepare for major elective surgery, to reduce their risk of complications, shorten hospital stays, accelerate recovery, and improve their health outcomes.
Through prehabilitation, multidisciplinary teams support patients to optimize their physical and mental health before surgery. At its core, there are 13 prehabilitation components that can be tailored to a patient: physical activity, nutrition, social supports, substance abuse, smoking cessation, anxiety, anemia, cardiac, frailty, glycemic control, pain management, sleep apnea, and obesity.
Introduction of SSC SPOC
Following the implementation of the Enhanced Recovery After Surgery program across BC in 2014, several BC physicians began to explore ways to optimize their patients’ health before surgery.
Intuitively, they were aware of the importance of patients being in the best physical and mental health condition possible prior to surgery. But supportive evidence, and standardized prehabilitation processes and tools were not widely available in BC hospitals.
SPOC’s current co-chair, Dr Kelly Mayson, an anesthesiologist at Vancouver General and UBC Hospitals, was among a group of early adopters who started using components of prehabilitation in practice. That work planted the seed for the creation of SPOC by SSC in 2018 and its first cohort of 14 teams representing all health authorities.
Connecting with evidence
To support service delivery, SPOC developed a BC Surgical Prehabilitation Toolkit – some of which was informed by research and evidence on exercise, nutrition, and psychological support produced by UK surgeon Dr Malcolm West with Canadian and European collaborators.
Dr West and his team were one of the first clinical teams worldwide to use the word ‘prehabilitation’ in 2011, and have worked for the past 13 years to produce evidence of its benefits as a safe, feasible, and tolerable intervention – one that can improve quality of care, patient outcomes, and save health system resources. Their research is highlighted in more than 59 academic publications.
Dr West is an Associate Professor of Colorectal Surgery and Prehabilitation Medicine at the University of Southampton. He is driven to improve surgical cancer patient perioperative and long-term outcomes through prehabilitation interventions, and is working with several UK-based health care organizations to introduce it into practice there.
The SSC’s SPOC organizers first connected with Dr West at an international prehabilitation conference in the UK in 2022. Realizing they were doing very similar things in similar public health care structures, they agreed to share learnings and support each other clinically and academically for greater impact.
The exercise prescription
Dr West and his team were the first to launch a randomized control trial in exercise prehabilitation in rectal cancer patients receiving chemotherapy and radiotherapy. Immediately after radiotherapy treatment and prior to surgery, patients participated in tailored, high-intensity interval training on a bike over a six-week period (although three weeks was found to be sufficient).
The trial demonstrated that fitness, in conjunction with chemotherapy and radiotherapy, reduced length of [rehabilitation] time. Patients who were fitter to begin with, had better outcomes and quality of life after rectal surgery. This, and subsequent research showed a very good link between a change in fitness through an exercise prescription, and reduction of outcome complications in a variety of situations.
Dr West and his team research additional prehabilitation components to optimize an elective surgical patient's mental and physical health to directly improve surgical and cancer outcomes.
Implementation in BC
With evidence and tools available, implementation in BC hospital settings was the next big step. The first 14 SPOC teams assembled in 2019 were from both large and small hospitals, and primary led by anesthesiologists and some surgeons, working with nurses, allied health, data collectors, and administrators.
Teams were encouraged to select the specialty and components they wanted to start with. Through the course of the collaborative, they spread to other specialties and added more prehabilitation components. They also worked towards embedding prehabilitation into existing and new workflows to minimize the need for additional FTE resources.
In spring 2023, Dr West travelled to Canada to meet with BC SPOC teams and learn about their processes and tools. He observed that the unique collaborative structure of the SSC provides an advantage for implementation that the UK does not have. He also took the time to share his knowledge with the teams.
“Having Dr West come out and show us some of the research that they have done, particularly with regard to exercise and how it can have such a profound effect on people's cancer treatments and health, was really worthwhile,” said Dr Mayson.
Assessments of BC’s SPOC program over the course of two cohorts (launched in June 2019 and May 2022) validate length of stay improvements, less critical care usage, less readmissions to hospital, and improvements in severe complications and in benchmarks like surgical site infection rates.
Combined data from two cohorts (June 2019 to April 2023) shows that of a total of 5158 patients who received prehabilitation prior to surgery:
91.6% (1976 out of 2158 patients) agreed that their surgical experience improved as a result of the information and care provided; and
75.2% (1625 out of 2162 patients) agreed that their health improved.
An independent analysis of the first cohort also pointed to potential annual savings for BC hospitals ranging from $7.1M to $28.3M per year.
Dr West sees similar savings for UK health systems, noting that with the economic analysis, outcomes data, and parallelism, it makes sense to work and publish collaboratively with SSC SPOC. He points out that a strong case for adoption in health systems in both the UK and Canada can also be made through the patients’ lens.
“Patients come back after having big cancer surgery telling us that if it wasn't for prehab, they wouldn't be here, or they just would not have had the opportunity to enjoy the full benefits of their surgery,” he says. “With powerful patient advocates and stories to take back to the government, I think the future for prehabilitation is bright.”
Dr Mayson is also optimistic about future potential. “I am encouraged by the fact that we have developed and installed resources in over half of BC hospitals providing surgical care, resulting in those patients are receiving some degree of optimization,” she says.
“Prehabilitation should be the model for every patient who goes through surgery throughout BC. The basic principles should be spread to all patients, to become the standard of care.”
SPOC continues to expand to more sites across the province through a cohort starting in 2023. Read more here.