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Zarate Rodriguez JG, Cos H, Koenen M, Cook J, Kasting C, Raper L, Guthrie T, Strasberg SM, Hawkins WG, Hammill CW, Fields RC, Chapman WC, Eberlein TJ, Kozower BD, Sanford DE. Impact of Prehabilitation on Postoperative Mortality and the Need for Non-Home Discharge in High-Risk Surgical Patients. J Am Coll Surg 2023; 237:558-567. [PMID: 37204138 DOI: 10.1097/xcs.0000000000000763] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/20/2023]
Abstract
BACKGROUND The preoperative period is an important target for interventions (eg Surgical Prehabilitation and Readiness [SPAR]) that can improve postoperative outcomes for older patients with comorbidities. STUDY DESIGN To determine whether a preoperative multidisciplinary prehabilitation program (SPAR) reduces postoperative 30-day mortality and the need for non-home discharge in high-risk surgical patients, surgical patients enrolled in a prehabilitation program targeting physical activity, pulmonary function, nutrition, and mindfulness were compared with historical control patients from 1 institution's American College of Surgeons (ACS) NSQIP database. SPAR patients were propensity score-matched 1:3 to pre-SPAR NSQIP patients, and their outcomes were compared. The ACS NSQIP Surgical Risk Calculator was used to compare observed-to-expected ratios for postoperative outcomes. RESULTS A total of 246 patients were enrolled in SPAR. A 6-month compliance audit revealed that overall patient adherence to the SPAR program was 89%. At the time of analysis, 118 SPAR patients underwent surgery with 30 days of follow-up. Compared with pre-SPAR NSQIP patients (n = 4,028), SPAR patients were significantly older with worse functional status and more comorbidities. Compared with propensity score-matched pre-SPAR NSQIP patients, SPAR patients had significantly decreased 30-day mortality (0% vs 4.1%, p = 0.036) and decreased need for discharge to postacute care facilities (6.5% vs 15.9%, p = 0.014). Similarly, SPAR patients exhibited decreased observed 30-day mortality (observed-to-expected ratio 0.41) and need for discharge to a facility (observed-to-expected ratio 0.56) compared with their expected outcomes using the ACS NSQIP Surgical Risk Calculator. CONCLUSIONS The SPAR program is safe and feasible and may reduce postoperative mortality and the need for discharge to postacute care facilities in high-risk surgical patients.
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Affiliation(s)
- Jorge G Zarate Rodriguez
- From the Department of Surgery, Barnes-Jewish Hospital and Washington University School of Medicine, St Louis, MO (Zarate Rodriguez, Cos, Koenen, Cook, Kasting, Raper, Guthrie, Strasberg, Hawkins, Hammill, Fields, Chapman, Eberlein, Kozower, Sanford)
| | - Heidy Cos
- From the Department of Surgery, Barnes-Jewish Hospital and Washington University School of Medicine, St Louis, MO (Zarate Rodriguez, Cos, Koenen, Cook, Kasting, Raper, Guthrie, Strasberg, Hawkins, Hammill, Fields, Chapman, Eberlein, Kozower, Sanford)
| | - Melanie Koenen
- From the Department of Surgery, Barnes-Jewish Hospital and Washington University School of Medicine, St Louis, MO (Zarate Rodriguez, Cos, Koenen, Cook, Kasting, Raper, Guthrie, Strasberg, Hawkins, Hammill, Fields, Chapman, Eberlein, Kozower, Sanford)
| | - Jennifer Cook
- From the Department of Surgery, Barnes-Jewish Hospital and Washington University School of Medicine, St Louis, MO (Zarate Rodriguez, Cos, Koenen, Cook, Kasting, Raper, Guthrie, Strasberg, Hawkins, Hammill, Fields, Chapman, Eberlein, Kozower, Sanford)
| | - Christina Kasting
- From the Department of Surgery, Barnes-Jewish Hospital and Washington University School of Medicine, St Louis, MO (Zarate Rodriguez, Cos, Koenen, Cook, Kasting, Raper, Guthrie, Strasberg, Hawkins, Hammill, Fields, Chapman, Eberlein, Kozower, Sanford)
| | - Lacey Raper
- From the Department of Surgery, Barnes-Jewish Hospital and Washington University School of Medicine, St Louis, MO (Zarate Rodriguez, Cos, Koenen, Cook, Kasting, Raper, Guthrie, Strasberg, Hawkins, Hammill, Fields, Chapman, Eberlein, Kozower, Sanford)
| | - Tracey Guthrie
- From the Department of Surgery, Barnes-Jewish Hospital and Washington University School of Medicine, St Louis, MO (Zarate Rodriguez, Cos, Koenen, Cook, Kasting, Raper, Guthrie, Strasberg, Hawkins, Hammill, Fields, Chapman, Eberlein, Kozower, Sanford)
| | - Steven M Strasberg
- From the Department of Surgery, Barnes-Jewish Hospital and Washington University School of Medicine, St Louis, MO (Zarate Rodriguez, Cos, Koenen, Cook, Kasting, Raper, Guthrie, Strasberg, Hawkins, Hammill, Fields, Chapman, Eberlein, Kozower, Sanford)
- the Alvin J Siteman Cancer Center, Washington University School of Medicine, St Louis, MO (Strasberg, Hawkins, Hammill, Fields, Chapman, Eberlein, Kozower, Sanford)
| | - William G Hawkins
- From the Department of Surgery, Barnes-Jewish Hospital and Washington University School of Medicine, St Louis, MO (Zarate Rodriguez, Cos, Koenen, Cook, Kasting, Raper, Guthrie, Strasberg, Hawkins, Hammill, Fields, Chapman, Eberlein, Kozower, Sanford)
- the Alvin J Siteman Cancer Center, Washington University School of Medicine, St Louis, MO (Strasberg, Hawkins, Hammill, Fields, Chapman, Eberlein, Kozower, Sanford)
| | - Chet W Hammill
- From the Department of Surgery, Barnes-Jewish Hospital and Washington University School of Medicine, St Louis, MO (Zarate Rodriguez, Cos, Koenen, Cook, Kasting, Raper, Guthrie, Strasberg, Hawkins, Hammill, Fields, Chapman, Eberlein, Kozower, Sanford)
- the Alvin J Siteman Cancer Center, Washington University School of Medicine, St Louis, MO (Strasberg, Hawkins, Hammill, Fields, Chapman, Eberlein, Kozower, Sanford)
| | - Ryan C Fields
- From the Department of Surgery, Barnes-Jewish Hospital and Washington University School of Medicine, St Louis, MO (Zarate Rodriguez, Cos, Koenen, Cook, Kasting, Raper, Guthrie, Strasberg, Hawkins, Hammill, Fields, Chapman, Eberlein, Kozower, Sanford)
- the Alvin J Siteman Cancer Center, Washington University School of Medicine, St Louis, MO (Strasberg, Hawkins, Hammill, Fields, Chapman, Eberlein, Kozower, Sanford)
| | - William C Chapman
- From the Department of Surgery, Barnes-Jewish Hospital and Washington University School of Medicine, St Louis, MO (Zarate Rodriguez, Cos, Koenen, Cook, Kasting, Raper, Guthrie, Strasberg, Hawkins, Hammill, Fields, Chapman, Eberlein, Kozower, Sanford)
- the Alvin J Siteman Cancer Center, Washington University School of Medicine, St Louis, MO (Strasberg, Hawkins, Hammill, Fields, Chapman, Eberlein, Kozower, Sanford)
| | - Timothy J Eberlein
- From the Department of Surgery, Barnes-Jewish Hospital and Washington University School of Medicine, St Louis, MO (Zarate Rodriguez, Cos, Koenen, Cook, Kasting, Raper, Guthrie, Strasberg, Hawkins, Hammill, Fields, Chapman, Eberlein, Kozower, Sanford)
- the Alvin J Siteman Cancer Center, Washington University School of Medicine, St Louis, MO (Strasberg, Hawkins, Hammill, Fields, Chapman, Eberlein, Kozower, Sanford)
| | - Benjamin D Kozower
- From the Department of Surgery, Barnes-Jewish Hospital and Washington University School of Medicine, St Louis, MO (Zarate Rodriguez, Cos, Koenen, Cook, Kasting, Raper, Guthrie, Strasberg, Hawkins, Hammill, Fields, Chapman, Eberlein, Kozower, Sanford)
- the Alvin J Siteman Cancer Center, Washington University School of Medicine, St Louis, MO (Strasberg, Hawkins, Hammill, Fields, Chapman, Eberlein, Kozower, Sanford)
| | - Dominic E Sanford
- From the Department of Surgery, Barnes-Jewish Hospital and Washington University School of Medicine, St Louis, MO (Zarate Rodriguez, Cos, Koenen, Cook, Kasting, Raper, Guthrie, Strasberg, Hawkins, Hammill, Fields, Chapman, Eberlein, Kozower, Sanford)
- the Alvin J Siteman Cancer Center, Washington University School of Medicine, St Louis, MO (Strasberg, Hawkins, Hammill, Fields, Chapman, Eberlein, Kozower, Sanford)
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Cos H, Zárate Rodríguez JG, Srivastava R, Bewley A, Raper L, Li D, Dai R, Williams GA, Fields RC, Hawkins WG, Lu C, Sanford DE, Hammill CW. 4,300 steps per day prior to surgery are associated with improved outcomes after pancreatectomy. HPB (Oxford) 2023; 25:91-99. [PMID: 36272956 DOI: 10.1016/j.hpb.2022.09.011] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2022] [Revised: 06/04/2022] [Accepted: 09/28/2022] [Indexed: 01/18/2023]
Abstract
BACKGROUND Decreased preoperative physical fitness and low physical activity have been associated with preoperative functional reserve and surgical complications. We sought to evaluate daily step count as a measure of physical activity and its relationship with post-pancreatectomy outcomes. METHODS Patients undergoing pancreatectomy were given a remote telemonitoring device to measure their preoperative levels of physical activity. Patient activity, demographics, and perioperative outcomes were collected and compared in univariate and multivariate logistic regression analysis. RESULTS 73 patients were included. 45 (61.6%) patients developed complications, with 17 (23.3%) of those patients developing severe complications. These patients walked 3437.8 (SD 1976.7) average daily steps, compared to 5918.8 (SD 2851.1) in patients without severe complications (p < 0.001). In logistic regression analysis, patients who walked less than 4274.5 steps had significantly higher odds of severe complications (OR = 7.5 (CI 2.1, 26.8), p = 0.002). CONCLUSION Average daily steps below 4274.5 before surgery are associated with severe complications after pancreatectomy. Preoperative physical activity levels may represent a modifiable target for prehabilitation protocols.
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Affiliation(s)
- Heidy Cos
- Department of Surgery, Barnes-Jewish Hospital and the Alvin J. Siteman Cancer Center, Washington University School of Medicine, St. Louis, MO, USA; McKelvey School of Engineering, Washington University, St. Louis, MO, USA
| | - Jorge G Zárate Rodríguez
- Department of Surgery, Barnes-Jewish Hospital and the Alvin J. Siteman Cancer Center, Washington University School of Medicine, St. Louis, MO, USA; McKelvey School of Engineering, Washington University, St. Louis, MO, USA
| | - Rohit Srivastava
- Department of Surgery, Barnes-Jewish Hospital and the Alvin J. Siteman Cancer Center, Washington University School of Medicine, St. Louis, MO, USA; McKelvey School of Engineering, Washington University, St. Louis, MO, USA
| | - Alice Bewley
- Department of Surgery, Barnes-Jewish Hospital and the Alvin J. Siteman Cancer Center, Washington University School of Medicine, St. Louis, MO, USA; McKelvey School of Engineering, Washington University, St. Louis, MO, USA
| | - Lacey Raper
- Department of Surgery, Barnes-Jewish Hospital and the Alvin J. Siteman Cancer Center, Washington University School of Medicine, St. Louis, MO, USA; McKelvey School of Engineering, Washington University, St. Louis, MO, USA
| | - Dingwen Li
- Department of Surgery, Barnes-Jewish Hospital and the Alvin J. Siteman Cancer Center, Washington University School of Medicine, St. Louis, MO, USA; McKelvey School of Engineering, Washington University, St. Louis, MO, USA
| | - Ruixuan Dai
- Department of Surgery, Barnes-Jewish Hospital and the Alvin J. Siteman Cancer Center, Washington University School of Medicine, St. Louis, MO, USA; McKelvey School of Engineering, Washington University, St. Louis, MO, USA
| | - Gregory A Williams
- Department of Surgery, Barnes-Jewish Hospital and the Alvin J. Siteman Cancer Center, Washington University School of Medicine, St. Louis, MO, USA; McKelvey School of Engineering, Washington University, St. Louis, MO, USA
| | - Ryan C Fields
- Department of Surgery, Barnes-Jewish Hospital and the Alvin J. Siteman Cancer Center, Washington University School of Medicine, St. Louis, MO, USA; McKelvey School of Engineering, Washington University, St. Louis, MO, USA
| | - William G Hawkins
- Department of Surgery, Barnes-Jewish Hospital and the Alvin J. Siteman Cancer Center, Washington University School of Medicine, St. Louis, MO, USA; McKelvey School of Engineering, Washington University, St. Louis, MO, USA
| | - Chenyang Lu
- Department of Surgery, Barnes-Jewish Hospital and the Alvin J. Siteman Cancer Center, Washington University School of Medicine, St. Louis, MO, USA; McKelvey School of Engineering, Washington University, St. Louis, MO, USA
| | - Dominic E Sanford
- Department of Surgery, Barnes-Jewish Hospital and the Alvin J. Siteman Cancer Center, Washington University School of Medicine, St. Louis, MO, USA; McKelvey School of Engineering, Washington University, St. Louis, MO, USA
| | - Chet W Hammill
- Department of Surgery, Barnes-Jewish Hospital and the Alvin J. Siteman Cancer Center, Washington University School of Medicine, St. Louis, MO, USA; McKelvey School of Engineering, Washington University, St. Louis, MO, USA.
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Cos H, Li D, Williams G, Chininis J, Dai R, Zhang J, Srivastava R, Raper L, Sanford D, Hawkins W, Lu C, Hammill CW. Predicting Outcomes in Patients Undergoing Pancreatectomy Using Wearable Technology and Machine Learning: Prospective Cohort Study. J Med Internet Res 2021; 23:e23595. [PMID: 33734096 PMCID: PMC8074869 DOI: 10.2196/23595] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2020] [Revised: 11/18/2020] [Accepted: 02/17/2021] [Indexed: 01/08/2023] Open
Abstract
Background Pancreatic cancer is the third leading cause of cancer-related deaths, and although pancreatectomy is currently the only curative treatment, it is associated with significant morbidity. Objective The objective of this study was to evaluate the utility of wearable telemonitoring technologies to predict treatment outcomes using patient activity metrics and machine learning. Methods In this prospective, single-center, single-cohort study, patients scheduled for pancreatectomy were provided with a wearable telemonitoring device to be worn prior to surgery. Patient clinical data were collected and all patients were evaluated using the American College of Surgeons National Surgical Quality Improvement Program surgical risk calculator (ACS-NSQIP SRC). Machine learning models were developed to predict whether patients would have a textbook outcome and compared with the ACS-NSQIP SRC using area under the receiver operating characteristic (AUROC) curves. Results Between February 2019 and February 2020, 48 patients completed the study. Patient activity metrics were collected over an average of 27.8 days before surgery. Patients took an average of 4162.1 (SD 4052.6) steps per day and had an average heart rate of 75.6 (SD 14.8) beats per minute. Twenty-eight (58%) patients had a textbook outcome after pancreatectomy. The group of 20 (42%) patients who did not have a textbook outcome included 14 patients with severe complications and 11 patients requiring readmission. The ACS-NSQIP SRC had an AUROC curve of 0.6333 to predict failure to achieve a textbook outcome, while our model combining patient clinical characteristics and patient activity data achieved the highest performance with an AUROC curve of 0.7875. Conclusions Machine learning models outperformed ACS-NSQIP SRC estimates in predicting textbook outcomes after pancreatectomy. The highest performance was observed when machine learning models incorporated patient clinical characteristics and activity metrics.
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Affiliation(s)
- Heidy Cos
- Washington University in St Louis, St Louis, MO, United States
| | - Dingwen Li
- Washington University in St Louis, St Louis, MO, United States
| | | | - Jeffrey Chininis
- Washington University in St Louis, St Louis, MO, United States.,Barnes-Jewish Hospital and the Alvin J Siteman Cancer Center, St Louis, MO, United States
| | - Ruixuan Dai
- Washington University in St Louis, St Louis, MO, United States
| | - Jingwen Zhang
- Washington University in St Louis, St Louis, MO, United States
| | | | - Lacey Raper
- Washington University in St Louis, St Louis, MO, United States
| | - Dominic Sanford
- Washington University in St Louis, St Louis, MO, United States.,Barnes-Jewish Hospital and the Alvin J Siteman Cancer Center, St Louis, MO, United States
| | - William Hawkins
- Washington University in St Louis, St Louis, MO, United States.,Barnes-Jewish Hospital and the Alvin J Siteman Cancer Center, St Louis, MO, United States
| | - Chenyang Lu
- Washington University in St Louis, St Louis, MO, United States
| | - Chet W Hammill
- Washington University in St Louis, St Louis, MO, United States.,Barnes-Jewish Hospital and the Alvin J Siteman Cancer Center, St Louis, MO, United States
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