Home-Based Prehabilitation In Frail Older Surgical Patients

Key Takeaways

• The primary analyses showed no between-group differences in postoperative disability or in-hospital complications.
• The intervention was a home-based, multimodal, coach-supported program, and adherence was feasible but incomplete, with median overall adherence of 78% and per-protocol adherence of 67%.
• Lower disability scores were observed among participants completing more than 75% of prescribed exercises, while preoperative safety outcomes did not differ and most prespecified secondary outcomes were unchanged in the randomized analyses apart from EQ-VAS.

Among 847 older adults with frailty scheduled for elective inpatient noncardiac surgery, a JAMA Surgery trial report found no advantage for coach-supported home-based multimodal prehabilitation over usual care. Participants assigned to prehabilitation received the program before surgery, while controls received written activity and healthy eating guidance. The coprimary outcomes—postoperative disability and in-hospital complications—were unchanged in their respective primary analysis populations.

Researchers conducted a pragmatic, parallel-arm, multicenter randomized clinical trial with an embedded qualitative assessment at 13 Canadian centers. Recruitment ran from March 2, 2020, to February 8, 2024, and analyses were completed between October 3 and December 5, 2024. Eligible participants were adults aged 60 years or older, living with frailty defined by a Clinical Frailty Scale score of 4 or higher, and scheduled for elective inpatient noncardiac surgery. Of 847 randomized participants, 423 were assigned to prehabilitation and 424 to usual care; 705 underwent planned surgery, split 353 and 352. Mean age was 71.7 years, 53.4% were female, and most had scores of 4.

Prehabilitation began at randomization and continued to surgery, with a median preoperative enrollment of 4 weeks (IQR, 3 to 7 weeks). The home-based program combined personalized nutrition with three weekly 1-hour exercise sessions that included strength, aerobic, and flexibility work, plus protein supplement coupons. Coaches provided at least weekly calls and optional toll-free or email contact, while usual care consisted of publicly available written activity and healthy eating guidance. Clinicians and outcome assessors were blinded.

The coprimary outcomes were WHODAS disability 30 days after surgery and any postoperative complication during the surgical hospitalization. In the primary analyses, WHODAS scores were 23.5 versus 24.7, with an adjusted mean difference of −1.4 (97.5% CI, −4.9 to 2.0; P=.36). Among participants who had surgery, complications occurred in 177 of 353 participants versus 168 of 352 controls, with an adjusted odds ratio of 1.05 (97.5% CI, 0.73 to 1.49; P=.78). Prespecified subgroup analyses showed no effect modification, and the isolated EQ-VAS difference of 3.2 points was paired with the authors’ caution about possible multiple testing. The randomized comparison did not show benefit on either coprimary endpoint in the primary analyses.

Median overall adherence while enrolled was 78%, and median per-protocol adherence in the final 3 preoperative weeks was 67%. Among surgical participants, 152 people, or 43.1%, completed more than 75% of prescribed exercises and comprised the per-protocol subgroup. Competing priorities and motivation were the main reported barriers, and preoperative safety outcomes did not differ between groups. In that subgroup, WHODAS scores were lower with prehabilitation, with a mean difference of −4.9 (97.5% CI, −9.8 to −0.01; P=.02). Complications remained similar, with an odds ratio of 1.06 (97.5% CI, 0.67 to 1.67; P=.79); the investigators cautioned that the adherent-participant findings applied to this population and follow-up window.