A Cost-Effectiveness Analysis of Prehabilitation for High-Risk Surgical Patients in Canada: Results from a Nonrandomized Clinical Trial

Research Objectives: To evaluate the cost-effectiveness of a pragmatic model of prehabilitation for high-risk surgical candidates from a hospital perspective.

Design: A cost-effectiveness analysis (CEA) from a hospital perspective was performed using data from a nonrandomized clinical trial of a pragmatic model of prehabilitation compared to usual care (UC) for high-risk surgical patients.

Setting: A large academic hospital in Toronto, Ontario, Canada.

Participants: High-risk surgical candidates referred by their physician at the time of surgical planning.

Interventions: The prehabilitation group underwent baseline assessments from a multidisciplinary healthcare team followed by shared-decision making concerning allocation to facility-based, home-based, or virtual prehabilitation. Prehabilitation modalities included individualized exercise, nutrition, psychological support, and smoking cessation over the preoperative period. The control group received UC.

Main Outcome Measures: The primary endpoint was an incremental cost-effectiveness ratio (ICER) with surgical complications as the effect measure. Nonparametric bootstrapping methods were employed to investigate the joint distribution of incremental costs and incremental effects, estimate ICER uncertainty, and generate cost-effectiveness acceptability curves (CEACs). Results were presented for overall prehabilitation and stratified by each prehabilitation delivery strategy.

Results: Sixty-seven patients were included (prehabilitation n=49; UC n=18). Prehabilitation was associated with averting more surgical complications but came at greater costs compared to UC. Results indicate the potential cost-effectiveness of prehabilitation for reducing surgical complications, although data limitations and point-estimate uncertainty preclude conclusive recommendations. When stratified by prehabilitation delivery strategy, estimated cost-effectiveness varied considerably, and beckon future research to clarify economically optimal prehabilitation protocols within an implementation context.

Conclusions: This was the first CEA of a pragmatic model of prehabilitation for high-risk surgical patients, contributing an increasingly relevant economic perspective regarding the potential role of prehabilitation implementation from a hospital perspective. Future economic evaluations of prehabilitation are necessary to clarify optimal prehabilitation protocols and definitively inform implementation decisions.

Author(s) Disclosures: No disclosures.