Pre-admission interventions (prehabilitation) to improve outcome after major elective surgery: a systematic review and meta-analysis

Research output: Contribution to journalArticle (Academic Journal)peer-review


Objective To determine the benefits and harms of pre-admission
interventions (prehabilitation) on postoperative
outcomes in patients undergoing major elective surgery.
Design Systematic review and meta-analysis
randomised controlled trials (RCTs) (published or
unpublished). We searched Medline, Embase, CENTRAL,
DARE, HTA and NHS EED, The Cochrane Library, CINAHL,
PsychINFO and ISI Web of Science (June 2020).
Setting Secondary care.
Participants Patients (≥18 years) undergoing major
elective surgery (curative or palliative).
Interventions Any intervention administered in
the preoperative period with the aim of improving
postoperative outcomes.
Outcomes and measures Primary outcomes were
mortality, hospital length of stay (LoS) and
postoperative complications. Secondary outcomes
included LoS in intensive care unit or high dependency
unit, perioperative morbidity, hospital readmission,
postoperative pain, heath-related
quality of life, outcomes
specific to the intervention, intervention-specific
events and resource use.
Review methods Two authors independently extracted
data from eligible RCTs and assessed risk of bias and the
certainty of evidence using Grading of Recommendations,
Assessment, Development and Evaluation. Random-effects
were used to pool data across trials.
Results 178 RCTs including eight types of intervention
were included. Inspiratory muscle training (IMT),
immunonutrition and multimodal interventions reduced
hospital LoS (mean difference vs usual care: −1.81 days,
95% CI −2.31 to −1.31; −2.11 days, 95% CI −3.07 to
−1.15; −1.67 days, 95% CI −2.31 to −1.03, respectively).
Immunonutrition reduced infective complications (risk
ratio (RR) 0.64 95% CI 0.40 to 1.01) and IMT, and exercise
reduced postoperative pulmonary complications (RR 0.55,
95% CI 0.38 to 0.80, and RR 0.54, 95% CI 0.39 to 0.75,
respectively). Smoking cessation interventions reduced
wound infections (RR 0.28, 95% CI 0.12 to 0.64).
Conclusions Some prehabilitation interventions may
reduce postoperative LoS and complications but the
quality of the evidence was low.
PROSPERO registration number CRD42015019191.
Original languageEnglish
JournalBMJ Open
Publication statusPublished - 30 Sep 2021


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