NIHR Applied Research Collaboration, North East and North Cumbria, United Kingdom.
Population Health Sciences Institute, Newcastle University, Newcastle Upon Tyne, United Kingdom.
PLoS One. 2023 Jul 5;18(7):e0286757. doi: 10.1371/journal.pone.0286757. eCollection 2023.
Prehabilitation interventions are being delivered across surgical specialities to improve health risk behaviours leading to better surgical outcomes and potentially reduce length of hospital stay. Most previous research has focused on specific surgery specialities and has not considered the impact of interventions on health inequalities, nor whether prehabilitation improves health behaviour risk profiles beyond surgery. The aim of this review was to examine behavioural Prehabilitation interventions across surgeries to inform policy makers and commissioners of the best available evidence.
A systematic review and meta-analysis of randomised controlled trials (RCTs) was conducted to determine the effect of behavioural prehabilitation interventions targeting at least one of: smoking behaviour, alcohol use, physical activity, dietary intake (including weight loss interventions) on pre- and post-surgery health behaviours, health outcomes, and health inequalities. The comparator was usual care or no treatment. MEDLINE, PubMed, PsychINFO, CINAHL, Web of Science, Google Scholar, Clinical trials and Embase databases were searched from inception to May 2021, and the MEDLINE search was updated twice, most recently in March 2023. Two reviewers independently identified eligible studies, extracted data, and assessed risk of bias using the Cochrane risk of bias tool. Outcomes were length of stay, six-minute walk test, behaviours (smoking, diet, physical activity, weight change, and alcohol), and quality of life. Sixty-seven trials were included; 49 interventions targeted a single behaviour and 18 targeted multiple behaviours. No trials examined effects by equality measures. Length of stay in the intervention group was 1.5 days shorter than the comparator (n = 9 trials, 95% CI -2.6 to -0.4, p = 0.01, I2 83%), although in sensitivity analysis prehabilitation had the most impact in lung cancer patients (-3.5 days). Pre-surgery, there was a mean difference of 31.8 m in the six-minute walk test favouring the prehabilitation group (n = 19 trials, 95% CI 21.2 to 42.4m, I2 55%, P <0.001) and this was sustained to 4-weeks post-surgery (n = 9 trials, mean difference = 34.4m (95%CI 12.8 to 56.0, I2 72%, P = 0.002)). Smoking cessation was greater in the prehabilitation group before surgery (RR 2.9, 95% CI 1.7 to 4.8, I2 84%), and this was sustained at 12 months post-surgery (RR 1.74 (95% CI 1.20 to 2.55, I2 43%, Tau2 0.09, p = 0.004)There was no difference in pre-surgery quality of life (n = 12 trials) or BMI (n = 4 trials).
Behavioural prehabilitation interventions reduced length of stay by 1.5 days, although in sensitivity analysis the difference was only found for Prehabilitation interventions for lung cancer. Prehabilitation can improve functional capacity and smoking outcomes just before surgery. That improvements in smoking outcomes were sustained at 12-months post-surgery suggests that the surgical encounter holds promise as a teachable moment for longer-term behavioural change. Given the paucity of data on the effects on other behavioural risk factors, more research grounded in behavioural science and with longer-term follow-up is needed to further investigate this potential.
术前康复干预措施正在各外科专业中实施，以改善导致手术效果不佳的健康风险行为，并可能缩短住院时间。之前的大多数研究都集中在特定的手术专业上，没有考虑干预措施对健康不平等的影响，也没有研究术前康复是否能改善手术以外的健康行为风险状况。本研究旨在对所有手术中的行为性术前康复干预措施进行评估，以便为决策者和决策者提供最佳的可用证据。
进行了系统评价和随机对照试验（RCT）的荟萃分析，以确定针对以下至少一项行为的行为性术前康复干预措施的效果：吸烟行为、饮酒行为、体力活动、饮食摄入（包括减肥干预措施），以了解术前和术后健康行为、健康结果和健康不平等的情况。对照组为常规护理或不治疗。从建库开始到 2021 年 5 月，检索了 MEDLINE、PubMed、PsychINFO、CINAHL、Web of Science、Google Scholar、临床试验和 Embase 数据库，并在 2023 年 3 月对 MEDLINE 搜索进行了两次更新。两名审查员独立识别合格研究、提取数据，并使用 Cochrane 偏倚风险工具评估偏倚风险。结局指标包括住院时间、6 分钟步行测试、行为（吸烟、饮食、体力活动、体重变化和饮酒）和生活质量。纳入了 67 项试验；49 项干预措施针对单一行为，18 项干预措施针对多种行为。没有试验研究按平等衡量标准进行。干预组的住院时间比对照组短 1.5 天（n = 9 项试验，95%CI -2.6 至 -0.4，p = 0.01，I2 83%），但在敏感性分析中，术前康复对肺癌患者的影响最大（-3.5 天）。术前，六分钟步行测试中，预康复组的平均距离为 31.8 米（n = 19 项试验，95%CI 21.2 至 42.4m，I2 55%，P <0.001），并持续到术后 4 周（n = 9 项试验，平均差异= 34.4m（95%CI 12.8 至 56.0，I2 72%，P = 0.002））。术前康复组的戒烟率更高（RR 2.9，95%CI 1.7 至 4.8，I2 84%），且在术后 12 个月仍保持（RR 1.74（95%CI 1.20 至 2.55，I2 43%，Tau2 0.09，p = 0.004））。术前生活质量（n = 12 项试验）或 BMI（n = 4 项试验）无差异。
行为性术前康复干预措施可使住院时间缩短 1.5 天，尽管在敏感性分析中，仅发现肺癌术前康复干预措施存在差异。术前康复可以改善手术前的功能能力和吸烟结果。术后 12 个月时，吸烟结果的改善仍持续存在，这表明手术期间有机会进行更长期的行为改变。鉴于关于其他行为风险因素影响的数据很少，需要更多基于行为科学的、具有长期随访的研究来进一步调查这一潜在可能性。
