On the cusp of an exciting new era in digital prehab

Professor Tara Rampal, founder of telehealth firm QuestPrehab, on the significance of its new landmark NHS liver transplant trial.

Increasingly the number of patients with frailty, sarcopenia (loss of muscle mass and strength), complex comorbidities and advanced age are being offered major surgical interventions.

This leaves them vulnerable to complications, which often means unplanned hospital readmissions and increased healthcare costs.

Sadly, this is particularly the case for many patients with advanced liver disease who are waiting for a transplant. Liver failure accelerates frailty in an already high-risk population – and this combined with sarcopenia are important predictors of post-transplant mortality.

In addition, low exercise capacity, reflection of an inability to increase the delivery of oxygen when the demand increases, is often associated with worse outcomes following transplant.

At QuestPrehab, we know these are potentially modifiable factors. Our extensive experience of providing bespoke, digital prehabilitation (prehab) services to over 1,200 cancer patients has seen us witness the long-term positive impact it has had on our patients’ quality of life and clinical outcomes.

Prehab is a relatively new area of healthcare that focuses on improving the general health of patients before their surgery or treatment as a way of improving their functional outcomes, helping their recovery and lowering the likelihood of complications. It is a complex, multidisciplinary intervention the success of which depends on personalisation.

There’s increasing acceptance in the global clinical community that prehab reduces post operative complications, decreases unplanned readmissions and improves patients’ health related quality of life.

For example, the Royal College of Anaesthetists believes “fitter patients who are able to improve their health and activity levels recover from surgery more quickly and with fewer complications. What you do in the time leading up to surgery can have a really big impact on your recovery and long-term health.”

According to the Centre for Perioperative Care, a multidisciplinary initiative working to optimise patient outcomes, a quarter of a million people in the UK are at a higher risk from surgery – a number that’s set to rise.

Its research highlighted that while 12% of operations result in a complication, being inactive raises this risk four-fold. However, preparing in advance of an operation – and in particular by taking exercise and following nutritional guidance to help build strength and fitness – halves the chances of suffering a complication.

We’ve always been keen to expand our digital services beyond oncology to other medical specialties, so embraced the opportunity to work with the South West Liver Unit at University Hospitals Plymouth NHS Trust to deliver digital prehab services to their liver patients across Devon, Cornwall and Somerset.

On July 5^th, after completing all the required governance and due diligence processes, we commenced a year-long trial to work with 50 patients undergoing assessment and listing for liver transplant. If successful, we aim to expand the service to other patients living with liver disease who currently are not on the list.

The waiting time for patients listed for liver transplantation is on average between four and six months. It’s a long and challenging time – they face the uncertainty of when they will be called up for the transplant whilst also dealing with the consequences of advanced liver disease and the worry that their condition may deteriorate during this time.

However, the delay also provides a unique opportunity to provide an intervention such as prehab. Without doing so, there’s a risk of further loss of physical activity, worsening frailty and muscle mass loss over the waiting period.

We’ve deliberately built the programme on a digital platform as it addresses the challenges normally associated with delivering prehab services to the public. It eliminates geographical barriers and addresses health inequalities so patients in the trial who don’t live close to a hospital can access and benefit from their programme, thus removing the post code lottery. Additionally, digital prehabilitation helps patients’ decrease opportunity costs (travel etc)  in addition to offering the ability to participate from the comfort and psychological safety of their home.

Doing so extends the programme’s impact beyond reduction in complications and readmissions and presents a real opportunity to positively impact the health of the wider population.

Each patient will have their own prehab instructor and will be able to access their individualised programmes via an app. Exercise classes (based on clinical needs), nutritional guidance, psychological support and lifestyle modifications sessions (such as smoking cessation) will be delivered by a combination of phone, Zoom or Skype calls.

Those who do not have access to suitable technology will be able to loan equipment from the South West Liver Unit during the trial at no cost to themselves.

When delivered digitally, prehab routinely delivers a service at a significantly lower cost compared to face to face services as well as being just as valid in terms of patient experience. There are additional savings, as improved health related quality of life leads to earlier returns to work and less demand on social and primary care. It also offers the advantage of lowering the pressure on clinicians and the hospital workforce.

The next 12 months will be busy and exciting for us.

It’s a privilege to be working with the South West Liver Unit at University Hospitals Plymouth NHS Trust and we’re determined and confident that our unique prehab service will achieve long-term, positive effects on patients’ quality of life.

Professor Rampal is a consultant anaesthetist with an interest in peri-operative care and population health. Over the past four years QuestPrehab has worked with over 1,200 cancer patients, delivering digital programmes covering physical fitness, nutrition, mindfulness and lifestyle support.