Prehabilitation focuses on reducing risks and complications of planned procedures and enabling lifestyle changes for citizens through pre- and post procedure interventions where the healthcare sector and the citizens share the responsibility. Prehabilitation interventions include e.g. physical training, nutritional optimisation, reduction of smoking and alcohol consumption etc. Pioneer examples of prehabilitation are ongoing in Denmark to prove the effect of the concept, however the implementation is still poor.
Some of the challenges are documenting the effect and collaborating across sectors, however there is a general consensus on the potential of prehabilitation, and the gradual integration of healthcare services may aid the implementation of prehabilitation. For companies there are good opportunities for targeting an international prehabilitation market and finding collaboration partners for research and development. The main advice for developing particularly prehabilitation solutions are understanding all of the stakeholders, designing the full solution and service, as well as investing in the long term.
The future of prehabilitation
What is prehabilitation and why is it relevant? Go along as the experts dive into the potentials and challenges for prehabilitation in Denmark today and in 2025.
The term “prehabilitation”, or “prehab”, is a combination of the words “pre-“ and “rehabilitation”. Prehabilitation concerns a combination of preparational and post-procedure measures to improve the outcome of a planned procedure, such as major surgery or chemotherapy, e.g. pre- and post-operative interventions to enhance the readiness of a patient to undergo a succesful surgery and to improve and accelerate the post-operative recovery.
Erik Jylling from Danish Regions explains prehabilitation as:
Prehabilitation expands the concept of treatment to incorporate the full service surrounding a procedure across primary- and secondary care, inline with the trend of Integrated Healthcare Services. In this connection the division of prehabilitation roles and responsibilities between primary- and secondary care are relevant to consider further. Prehabilitation also empowers the citizens and utilises their resources inline with the active role of the patient outlined in Health Consumerism.
The primary focus of prehabilitation is on achieving lifestyle changes and reducing risks and complications.
Prehabilitation measures are often lifestyle changes such as physical exercise, nutritional optimisation, and reduction of smoking and alcohol consumption. However, increasingly psychological interventions and medical optimisation are incorporated in prehabilitation programs.
In the case of prehabilitation for surgical patients, the pre-operative period is considered a more appropriate time for interventions such as lifestyle changes, as the patient is likely to be more motivated while awaiting surgery. The post-operative period can often be charaterised by post-surgery tiredness and pain, which can affect the motivation of the patient negatively (Wynter-Blyth & Moorthy, 2017)Wynter-Blyth, V. & Moorthy, K. (2017). Prehabilitation: preparing patients for surgery. BMJ, 358. Retrieved from http://www.bmj.com/content/358/bmj.j3702. Prehabilitation presents a potential to utilise the pre-procedure motivation of patients to not only optimise the outcome of the procedure but perhaps even spur a long-term lifestyle change, which may improve the health of the citizen and potentially contribute to prevention, which will be a focus area in the future Danish healthcare sector. Erik Jylling expresses:
Josep Roca argues that prehabilation has a potential impact on several levels; decreasing risk during a procedure, preventing complications of a procedure and reducing the hospital stay in connection with a procedure (Roca, 2017)Roca, J. (2017, January 12). Josep Roca. Interview performed by Health Innovation Centre of Southern Denmark.
According to the McGill Peri Operative Program, which is considered a front-runner within prehabilitation, poor nutritional status and poor physical strength has been shown to “increase the risk of complications after major surgery and prolong recovery”. For example, poor physical fitness is associated with higher mortality, postoperative complications, longer hospital stays and healthcare costs (McGill Peri Operative Program)McGill Peri Operative Program. What is Prehabilitation?. Retrieved from https://www.mcgill.ca/peri-op-program/patient-information/what-prehabilitation. It is therefore hypothesised that improving the nutritional and physical status of a patient prior to surgery could give them a better possibility of withstanding the stress of e.g. surgery (McGill Peri Operative Program)McGill Peri Operative Program. What is Prehabilitation?. Retrieved from https://www.mcgill.ca/peri-op-program/patient-information/what-prehabilitation. The effects of prehabilitation still need to be investigated and documented further, however some of the first randomised controlled trials, such as ‘Personalised Prehabilitation in High-risk Patients Undergoing Elective Major Abdominal Surgery: A Randomized Blinded Controlled Trial’ show that “(p)rehabilitation enhanced postoperative clinical outcomes in high-risk candidates for elective major abdominal surgery, which can be explained by the increased aerobic capacity” (Barberan-Garcia)Barberan-Garcia, A. Personalised Prehabilitation in High-risk Patients Undergoin… : Annals of Surgery. Retrieved from https://journals.lww.com/annalsofsurgery/citation/2018/01000/personalised_prehabilitation_in_high_risk_patients.11.aspx.
The potential improvement of procedure success and recovery level and -length has positive implications for both healthcare costs and risk management, which are both of high priority for the Danish healthcare sector in the future. According to Erik Jylling the Danish healthcare sector is interested in “bringing in new technological solutions that could help us with declining the spendings and at the same time give us a better healthcare system” (Jylling, 2017)Jylling, E. (2017, December 13). Erik Jylling. Interview performed by Health Innovation Southern Denmark. As early as 2008, on the basis of a randomised controlled test, one of the leading prehabilitation experts in Denmark, Hanne Tønnesen, among others concluded that:
Prehabilitation as a concept is influenced by the megatrends of democratisation, increased health focus and the paradigm shift in patient groups, while the trends of acceleration and digitalisation enable prehabilitation solutions.
At the same time the demographic change and the increase in chronic diseases lead to more elderly or chronically ill patients needing to undergo procedures such as major surgery, which prehabilitation can support.
Kevin Dean argues that:
Kevin Dean advocates that rehabilitation will lead to better health outcomes for the benefit of all actors.
Kevin Dean and Niels Jørgen Langkilde both further touch upon an important discussion regarding the future ‘co-responsibility’ between citizens, service providers and society as whole. Can the healthcare system and society as whole afford to provide extensive treatments for patients who do not take their responsibility seriously during the recovery and rehabilitation period (Kevin Dean, 2018 and Niels Jørgen Langkilde 2018)? If a citizen expects and demands a certain treatment from their service provider, can the service provider not make demands in return, argueing that the treatment will not be effective if you do not comply?
Venetia Wynter-Blyth, Consultant Nurse, and Krishna Moorthy, Consultant Surgeon, from the BMJ award-winning PREPARE for surgery team at Imperial College Healthcare, employ a marathon analogy to argue the relevance of prehabilitation. Their argument in a British Medical Journal editorial from 8th August 2017 is that “major surgery is like running a marathon – and both require training”. As they argue, “training for sport includes mental preparation and confidence building to maintain a positive attitude and self motivation” in addition to nutrition and exercise (Wynter-Blyth & Moorthy, 2017)Wynter-Blyth, V. & Moorthy, K. (2017). Prehabilitation: preparing patients for surgery. BMJ, 358. Retrieved from http://www.bmj.com/content/358/bmj.j3702, and the same could be said for major surgery and other major procedures.
As previously mentioned, the lifestyle changes incorporated in prehabilitation measures are especially focused on physical training, nutritional intervention, smoking and alcohol cessation, and increasingly psychological intervention and medical optimisation.
Physical training can increase strength and aerobic capacity so that a patient has more strength and energy for going through the procedure and for the post-procedure recovery.
Nutritional intervention concerns optimisation of the nutritional intake of a patient prior to a procedure. Diseases can affect the nutritional status of patients, and undernourishment can pose higher risks in procedures such as major surgery. Nutritional intervention aims to optimise the nutrient stores prior to an operation to compensate for the catabolic response of the procedure and prevent loss of lean body mass (McGill Peri Operative Program)McGill Peri Operative Program. What is Prehabilitation?. Retrieved from https://www.mcgill.ca/peri-op-program/patient-information/what-prehabilitation.
Smoking and alcohol consumption can strongly influence the general health of a patient, their capacity to handle the stress of a procedure and their long-term state of health. Hanne Tønnesen explains that research has e.g.
Psychological intervention can include anxiety and stress reduction strategies as well as breathing and relaxation techniques to optimise the mental readiness for a procedure and increase the motivation to actively participate in the recovery process and adopt a healthier lifestyle longterm (McGill Peri Operative Program)McGill Peri Operative Program. What is Prehabilitation?. Retrieved from https://www.mcgill.ca/peri-op-program/patient-information/what-prehabilitation.
Medical optimisation focuses on adjusting the intake of medicine and monitoring vital signs in order to achieve the optimal status for procedures such as major surgery (McGill Peri Operative Program)McGill Peri Operative Program. What is Prehabilitation?. Retrieved from https://www.mcgill.ca/peri-op-program/patient-information/what-prehabilitation.
Which interventions are incorporated in a prehabilitation programme depend on the type of procedure and on the individual patient. Venetia Wynter-Blyth, Consultant Nurse, and Krishna Moorthy from the PREPARE for surgery team argue that one of the main success factors is whether the prehabilitation programme is personalised (Wynter-Blyth & Moorthy, 2017)Wynter-Blyth, V. & Moorthy, K. (2017). Prehabilitation: preparing patients for surgery. BMJ, 358. Retrieved from http://www.bmj.com/content/358/bmj.j3702. They also argue that “(p)rehabilitation represents a shift away from the impairment driven, reactive model of care towards a proactive approach that enables patients to become active participant in their care” (Wynter-Blyth & Moorthy, 2017)Wynter-Blyth, V. & Moorthy, K. (2017). Prehabilitation: preparing patients for surgery. BMJ, 358. Retrieved from http://www.bmj.com/content/358/bmj.j3702. In other words, the patient has an active role in prehabilitation and is given the opportunity to and empowered to contribute to managing their own healthcare, and the success of the prehabilitation interventions therefore also depend on the motivation and capabilities of the patient.
Hanne Tønnesen explains:
The personalised approach and support of the active role of the patient is inline with the general trends of personalisation and the new role of the patient in Danish healthcare described in Integrated Healthcare Services and Health Consumerism.
Post-procedure rehabilitation has long been acknowledged for its effect on the recovery of e.g. surgical patients. Prehabilitation, on the other hand, is still not used widely in Denmark. However, clinical trials are being carried out to prove the viability and effect of prehabilitation, e.g. by Hanne Tønnesen, particularly in improving the outcome of orthopedic surgery, high-risk surgery and cancer treatment. There are also strong pioneer examples such as the Municipality of Copenhagen, which, as of June 2017, offer free prehabilitation for patients with a planned knee- , shoulder-, chest- or abdominal surgery and who are less physically active, smoke on a daily basis or have heavy alcohol consumption (Sundhedshusene i Københavns Kommune)Sundhedshusene i Københavns Kommune. Præhabilitering – nyt tilbud til patienter, der skal opereres. Retrieved from https://sundhed.kk.dk/nyheder/praehabilitering-nyt-tilbud-til-patienter-der-skal-opereres.
These pioneer efforts indicate an increasing focus on the potential of prehabilitation as an effective tool to reduce procedure risks and hospital stays and speed up the process of patients returning to general health, to their home and back to work. All of which represent cost reduction potential for the healthcare sector and society as a whole.
However, Denmark still has quite a way to go. Hanne Tønnesen explains:
Although prehabilitation has not been implemented widely in Denmark yet, there is a general consensus that we will see more prehabilitation in the future. When asked about the future potential of prehabilitation, Kevin Dean argues that “educational services has been around for a while and I think they will become more and more pervasive” (Dean, 2018)Dean, K. (2018, January 4). Kevin Dean. Interview performed by Health Innovation Centre of Southern Denmark.
Erik Jylling believes that
Inline with Integrated Healthcare Services in general, the division of responsibilities and roles of the municipal and regional healthcare providers is an ongoing process.
Hanne Tønnesen argues that prehabilitation programs have a huge effect, for example:
Hanne Tønnesen has made calculations that 8,000 to 10,000 Euro can be saved by reducing smoking-related complications per patient. In her opinion it is therefore:
As previously mentioned, despite the expected benefits of prehabilitation, it is still not widely used and implemented. Hanne Tønnesen says:
So why has prehabilitation not been implemented widely yet? The challenges for implementing prehabilitation are multifaceted. Some of the main challenges are documentation of effect, cross-sectorial collaboration and co-responsibility.
As a new additional service for the citizens, prehabilitation represents an extra cost in comparison to procedures without prehabilitation. There is therefore a need for investment in prehabilitation. As with other new services in the healthcare sector, the decision regarding this investment will be dependent on evidence the effects that can be achieved. Peder Jest explains:
Proving the effects of prehabilitation through e.g. randomised controlled tests is still ongoing.
Josep Roca argues that:
The introduction of a new service, and particularly one that spans across multiple sectors, will demand a reorganisation of the services and workflows within each involved organisation and the cooperation between them. It will be imperative to work on how prehabilitation is integrated into existing workflows, and who does what. According to Erik Jylling, the intersectorial nature of prehabiliation may present challenges for the implementation, as intersectorial collaboration in general is still challenging (Jylling, 2017)Jylling, E. (2017, December 13). Erik Jylling. Interview performed by Health Innovation Southern Denmark. Although he thinks there are great possibilities for “introducting prehab more systematically in Denmark”, he believes that:
Erik Jylling explains that it will of course:
The general movement towards Integrated Healthcare Services may in turn improve the conditions for prehabilitation.
Prehabilitation utilises the expected inner motivation of patients undergoing a major procedure and enables citizens to play an active part in the success of their procedure and recovery. As with prevention, motivating users to actively and consistently do prehabilitation, if they cannot see the immediate results throughout the process, could be a major challenge.
The relevant question may be how the responsibility for health, and prehabilitation interventions, should be shared or split between the citizens themselves and the public healthcare sector. And what role does the public healthcare sector have in enabling, motivating or demanding the individual health interventions of the citizen?
The prehabilitation trend in the Danish Healthcare Sector may offer the following opportunities for companies developing solutions for prehabilitation:
There are, however also som barriers for prehabilitation solutions to overcome:
When developing solutions for healthcare, particularly solutions that handle personal data, the following aspects will be relevant to consider.
In May 2018 the General Data Protection Directive from EU (GDPR) will enter into force in the EU (European Council, 2016)European Council. (2016). The General Data Protection Regulation. Retrieved from http://www.consilium.europa.eu/da/policies/data-protection-reform/data-protection-regulation/. The purpose of the directive is to strengthen citizens’ fundamental rights when it comes to data, privacy and digitalisation – but also to simplify rules for companies and thereby facilitate growth. Some of the more noteworthy changes enforced by the directive are the possibilities of issuing fines amounting to up to 4% of a company’s annual turnover.
In order to adhere to the GDPR, companies may look at the Guidelines for Cybersecurity (ISO 27032).
The regulation regarding data subject consent has been further strengthened and clarified. Consent must be explicit and the citizen must be clearly informed of the precise and defined purpose of data collection. Furthermore the citizen has the right to revoke consent. If consent is revoked the data must be deleted and proof that it has taken place presented to the citizen. This will affect all companies handling data pertaining to the citizen’s health.
Data portability is a new topic introduced by the GDPR. With GDPR the citizen will have the right to data portability. This means that if you collect personal data the citizen has the right to receive the personal data concerning him or her in a structured, commonly used and machine-readable format. They also have the right to transmit those data to another organisation that collects data about the citizen. The purpose of this obligation is to limit the number of times citizens have to answer questions about the same subject matter, e.g. age, height, gender etc.
This is particularly interesting from a healthcare perspective because data might be required to be shared across different organisations in the healthcare sector to a much greater extent than they are today. This might also prove a new business opportunity for companies, since there may be a whole new market emerging for solutions to support data portability, e.g. by providing system integration or sharing information between different IT systems.
In addition to the more general GDPR directive, an updated directive on Medical Devices will enter into force in the spring of 2020 and 2022. The two directives (EU) 2017/745 “MDR” & EU 2017/746 “IVDR” – (European Parliament & European Council, 2017a)European Parliament. & European Council. (2017a). (EU) 2017/745. Retrieved from http://data.europa.eu/eli/reg/2017/745/oj/eng and (European Parliament & European Council, 2017b)European Parliament. & European Council. (2017b). (EU) 2017/746. Retrieved from http://data.europa.eu/eli/reg/2017/746/oj/eng heavily regulate what is defined as medical devices, and how such devices can be tested and used within the boundaries of the EU. This is central for especially Data Analytics and Smart Health Technologies. ‘Medical purpose’ is defined as any type of diagnosis, prevention, monitoring or treatment or alleviation of disease or disability. The vast majority of devices which collect health information are likely to be considered medical devices, even if they do not process or analyse the data. Companies operating within the domain of health should proactively investigate compliance with these regulations and adjust development processes accordingly.
Bringing technology into the sphere of healthcare services brings with it relevant ethical considerations. The Health Innovation Centre of Southern Denmark has developed two videos that illustrate the expectations and challenges that may arise when new technology meets the healthcare sector. The videos focus on the perspectives of the patients at home and the clinicians working across sectors, respectively. Companies may consider these ethical aspects in their development process.
Companies developing solutions for prehabilitation in the Danish healthcare sector of 2025 should particularly consider the following.
As with rehabilitation, prehabilitation interventions will have a cross-sectorial nature, in that the actual procedures, such as major surgery, are carried out by the hospitals, whereas the prehabilitation interventions are done in the homes of the citizens, and as such concern primary care. As described in Integrated Healthcare Services, the coordination between hospitals and primary care can be a challenging field. Companies would therefore benefit from understanding the complexity of stakeholders, and the pros and cons that their solution will present for each stakeholder. Significant disadvantages or changes for one stakeholder may necessitate a political or management decision across sectors.
As Hanne Tønnesen puts it:
Selling solutions to the public sector can be a lengthy and complex process due to the stakeholder complexity and procurement processes. In this connection Helle Aarøe Nissen underlines the importance of the promotion of a solution and explains that:
Adapting new prehabilitation programs may fundamentally change the related workflows and service delivery across sectors. It is essential that companies understand the impact that their solution has on workflows, patient pathways etc. Hal Wolf argues that:
One strategy for ensuring that a solution can be integrated in the daily operations could be to collaborate with the public customer in designing new context-specific workflows across sectors. According to Christian Bason (CEO of Danish Design Center), companies can use service design as a force of change from a product- to service oriented business strategy in order to survive in a highly competitive market that demands user satisfaction. In order to succeed companies must challenge their assumptions regarding their company and solution and take their point of departure in the user perspective as a motivating force for change. When taking this strategic approach companies can drive digital transformation through new products and services (Bason, 2017)Bason, C. (2017). Service design som forandringskraft. Retrieved from http://servicedesignignition.dk/program/. Chesbrough explains how companies in any industry can make the shift from product- to service-centric thinking, from closed to open innovation where co-creating with users enables sustainable business models that drive continuous value creation for users. He also pinpoints that an open service innovation approach must be applied because the healthcare system is a highly connected economy (Chesbrough, 2011)Chesbrough, H. (2011). Open Service Innovation – Rethinking Your Business to Grow and Compete in a New Era. Retrieved from https://www.wiley.com/en-us/open+services+innovation%3a+rethinking+your+business+to+grow+and+compete+in+a+new+era-p-9780470905746(Chesbrough, 2011).
Service design is active planning and organisation of people, infrastructure, communications, media and services. Service design therefore contributes to good coherent service experiences. Service design helps to read, understand and identify users’ needs, expectations, and dreams, so you have a solid foundation for developing new workflows, services and products that actually work. Service design puts the user at the center, whether they be staff, patients or relatives. It is absolutely essential that those who use the solution should also help define it. User involvement ensures that you solve the real issues. Not only what the supposed problem or need is. Service design gives you a fresh look into your own organization. It’s a set of fresh eyes that challenges your habits and what you usually do, which has become a part of everyday life and seems almost invisible to you (Schneider & Stickdorn, 2012)Schneider, J. & Stickdorn, M. (2012). This is Service Design Thinking. .
Hal Wolf underlines that integration of technology into the daily operations is imperative:
Prehabilitation is still a fairly new field, which is not adopted consistently and systematically in healthcare yet, neither internationally nor in Denmark. Companies should therefore expect the development and sale of prehabilitation solutions to involve a longterm strategy and a research foundation. The longterm strategy would benefit from project collaborations, in which the technology is matured and documented through continuous user involvement.
Prehabilitation is dependent on the motivation and active participation of the citizens/patients. Solutions that include (personal) mentoring or coaching based on monitoring and presenting progress and activity, either as embedded functions in the solutions or integrated with healthcare personnel, who use the solution to monitor and communicate with the citizen/patient in a coach-like role, may be more likely to encourage behavioural change and achieve results. Developing solutions that are attractive enough for the citizens to want to use them saves the healthcare sector the efforts of convincing, encouraging, or potentially even forcing, people to use them. For patients/citizens to take an active role in their care experience and choose their own care alternatives, companies could build in motivational aspect.
Hanne Tønnesen argues:
Motivational Elements, such as individualised/personalised solutions, continuum of care perspectives, flexibility, instant gratification etc. are relevant to consider, when companies aim to make solutions attractive enough to motivate users to participate actively in their own health. Gamification and game theory, amongst others, can help to conceptualise potential solutions, as these methods have the ability to activate patients and make them accountable for their health choices. (Monitor Deloitte (Issue 02/2016) ‘Boosting patient empowerment and motivational pull Achieving the next level in a gamified health environment’ (Deloitte, 2016)Deloitte. (2016). Boosting patient empowerment and motivational pull. Retrieved from https://www2.deloitte.com/de/de/pages/strategy/articles/boosting-patient-empowerment-and-motivational-pull.html. Peder Jest agrees: “what we see in the play and the game industry are also possible to use in the healthcare sector” (Jest, 2018)Jest, P. (2018, January 2). Peder Jest. Interview performed by Health Innovation Centre of Southern Denmark.
Not all citizens will have the same capabilities to engage in prehabilitation interventions, which could affect equality in healthcare. Developers of prehabilitation solutions should consider how and to what extent their solution can support those who do not have the capabilities themselves.
Prehabilitation may add value for the citizens, healthcare personnel, healthcare sector and society as a whole in relation to:
There are also potential risks to consider: