Commentary

Prehabilitation-Improving Outcomes Proactively

One area where outcomes-based care is having a huge impact is orthopedic surgery. According to a 2014 study published in the Journal of Strength Conditioning Research, the projected number of total knee replacement surgeries for 2016 is 1,046,000—in 15 years, this number is projected to increase by 600%. While rehabilitation is important for improving outcomes in this type of procedure, the groundwork laid before the surgery—with prehabilitation—can make all the difference for patients’ recovery.

Prehabilitation in an orthopedic setting involves special exercises and physical therapy to increase strength and fitness in the weeks prior to having surgery. The study mentioned above found that patients who engaged in prehabilitation before knee replacement surgery reported higher levels of self-efficacy and higher outcomes expectations for exercise afterward.

In an article published in the Journal of Bone and Joint Surgery, researchers reviewed 4,733 hip and knee replacement cases and looked at the association between prehabilitation and the use of postoperative care services in the 90 days following hospital discharge.

They found that 79.7% of patients who did not do prehabilitation needed to use acute care services after surgery, compared with 54.2% of patients who engaged in prehabilitation. The researchers concluded that prehabilitation was linked to a 29% reduction in acute care use post-surgery. This, in turn, resulted in an estimated savings that averaged $1,215 per patient. These savings were a result of reductions in the use of skilled nursing facilities, home healthcare, and inpatient rehabilitation.

With these kinds of reductions in costs and disability, prehabilitation deserves a closer look. 

While most patients expect to need rehabilitation following orthopedic surgery, prehabilitation is usually a new concept for them. According to Blaine Warkentine, MD, MPH, CMO of Pumpone.com and a critical consultant for Orthopedic Surgery for Tenet, “Prehab has only been around since maybe 2000, and not everyone has absorbed it. People remember that their friends and family didn’t have to do it in the past. But it is rapidly becoming a central part of the equation.”

To get patients motivated, Dr. Warkentine recommended telling patients how prehab not only improves ability before surgery, it also improves outcomes afterward. Here are a few things to keep in mind when engaging patients in a prehabilitation regimen:

Give fair warning: Patients are often asked to start a prehabilitation regimen up to six weeks before their surgery. Letting them know what to expect well in advance can help them stick with a program.

Stay in touch: To make sure patients get the most from their prehabilitation, use regular communications that have a practical component—like exercise videos patients can follow on a youtube channel, or an online journal they can use to track their progress.

Keep patients learning: Prehabilitation improves outcomes for everyone concerned—make sure patients know exactly how this practice will help them recover after surgery. Educating them about the benefits will help patients make a commitment to a prehabilitation routine—including caregivers in the process adds another level of support.

High co-pays for physical therapy, and time constraints on the patient’s part are two potential obstacles to compliance. Dr. Warkentine pointed out, “There is a need for patients to be able to do their regimen remotely—at home or at the gym. PTs can create programming and give it to their patients to do outside of the therapy center. This also improves compliance, since patients don’t have to leave work to go to an appointment in the middle of the day.”

Because it is a relatively new development, patients may be reluctant to start a prehabilitation regimen. This is where they need encouragement. “The more work you do ahead of time, the less work you have to do after, the more successful your recovery will be, and the faster you will feel better,” Dr. Warkentine said. “Prehab sets the tone for what is possible.”

Prehabilitation before orthopedic surgery, coupled with focused and tailored education, engages patients in taking the initiative in their recovery—and this in turn can reduce post-surgical costs and give patients the best chance of a good outcome.

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