gms | German Medical Science

Background and state of research: Despite evidence supporting the effectiveness of prehabilitation programs for various settings and procedures, the implementation of prehabilitation into routine health care is widely pending. Frail patients are characterized by reduced physiological reserves and might particularly benefit from prehabilitation, but it is crucial that facilitating and hindering factors are considered in the implementation process.

Research question and objectives, hypothesis: This realist review systematically assessed the literature to answer the research question “What are the facilitators and barriers to the implementation of prehabilitation programs for frail patients prior to elective surgery?”. The overall aim was to formulate recommendations for future implementation efforts.

Method: Following Pawson’s realist review approach [1], preliminary program theories on facilitators and barriers for the implementation of prehabilitation (in general) were established. Following registration in PROSPERO (CRD42022335282), Pubmed, Embase, the Cochrane Library, PEDro and grey literature sources were searched systematically for literature reporting on facilitators and barriers to the implementation of prehabilitation for frail patients specifically. Included documents were qualitatively analyzed to refine the preliminary program theories.

Results: From 2,609 unique titles, 34 were retained for the realist synthesis. Facilitating factors in the refined program theory included

1.

program individualization to meet the patients’ needs and abilities,

2.

multimodality,

3.

adaption to the local setting and health care system,

4.

endorsement by an ambassador and

5.

sharing of responsibilities among a multidisciplinary team.

Central barriers included transportation, lack of social support, and inadequate, overwhelming information provision.

Discussion: By drawing on various types of literature, this realist review combined multiple perspectives and experiences to create program theories that can be applied to many implementation settings. It is, however, possible that literature adding to the issue might have been missed. Furthermore, due to limited resources, screening and data extraction were partly performed by one researcher.

Implication for care: Prehabilitation is a complex intervention and to successfully implement it, many factors must be considered. Due to the limitations of frail patients, it is key that the intervention is individualized to fit the capacities and needs of the patient, e.g., by providing a home-based alternative. Additionally, organizational readiness (resource provision as well as commitment and endorsement) and adaptability to the local setting are required. It can thus be helpful to pilot a prehabilitation program and adapt it following a thorough evaluation.

Funding: Innovationsfonds/Versorgungsforschung; 01NVF18024