# Effects of multimodal prehabilitation on surgery outcomes: prospective stepped-wedge, hospital-wide implementation study

## TL;DR

A hospital-wide study found that multimodal prehabilitation did not significantly reduce postoperative complications or hospital stay, but suggested it might help high-risk patients.

## Contribution

This study evaluates real-world effectiveness of multimodal prehabilitation in a diverse surgical population through a hospital-wide stepped-wedge design.

## Key findings

- Multimodal prehabilitation did not significantly reduce postoperative complications or hospital stay in a heterogeneous surgical population.
- Exploratory analyses suggested a trend towards fewer complications in patients undergoing gastrointestinal oncological surgery.
- Partial adherence to prehabilitation was observed, with 24.9% attending at least nine exercise sessions.

## Abstract

Multimodal prehabilitation may improve surgical outcomes in selected populations, but its real-world effectiveness remains unclear. The aim of this study was to evaluate the effect of hospital-wide implementation of multimodal prehabilitation on postoperative complications and length of hospital stay in a diverse surgical population.

This single-centre, non-randomized stepped-wedge study (F4S PREHAB) was conducted at Radboudumc, Nijmegen, The Netherlands from March 2019 to April 2024. Patients who underwent elective surgery across 20 clinical pathways received either standard preoperative care or multimodal prehabilitation comprising supervised exercise, nutritional support, psychological counselling, and smoking and alcohol cessation support. The primary outcome was the incidence and severity of postoperative complications within 30 days, with assessment of Clavien–Dindo (CD) grade ≥II complications and the dichotomized Comprehensive Complication Index (CCI). The secondary outcome was the length of hospital stay. Analyses used generalized linear models adjusted for time of inclusion and clinical pathway, as well as other confounders in some models. Subgroup analyses focused on patients who underwent high-risk gastrointestinal (GI) oncological surgery.

During the study interval, 4131 patients received usual care (2660 patients) or prehabilitation (1471 patients). A total of 367 patients (24.9%) attended at least nine exercise sessions, indicating partial adherence. No significant differences between groups were found with regard to postoperative CD grade ≥II complications (adjusted risk ratio 1.02 (95% c.i. 0.90 to 1.16)) and CCI >22.6 (adjusted risk ratio 1.03 (95% c.i. 0.86 to 1.23)) or length of hospital stay (adjusted incidence rate ratio 1.04 (95% c.i. 0.92 to 1.18)). In the high-risk GI oncological surgery subgroup (1230 patients), the relative reduction in CD grade ≥II complication risk was 9%, but this was not statistically significant (adjusted risk ratio 0.91 (95% c.i. 0.75 to 1.10)).

Hospital-wide implementation of multimodal prehabilitation did not reduce postoperative complications or length of hospital stay. A greater effect in high-risk patients suggests a targeted approach may be more effective. Future research should identify such patients and evaluate effectiveness of prehabilitation in this population.

In this hospital-wide stepped implementation study, multimodal prehabilitation showed partial adherence and did not reduce postoperative Clavien–Dindo grade ≥II complications or length of hospital stay in a heterogeneous surgical population. Although no statistically significant effects were observed, the confidence intervals included potentially clinically meaningful differences, meaning a relevant effect cannot be excluded. Exploratory analyses suggested a trend towards fewer complications in patients undergoing gastrointestinal oncological surgery, supporting further evaluation of targeted prehabilitation in high-risk populations.