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Socioeconomic status influences participation in cancer prehabilitation and preparation for surgical recovery: A pooled retrospective analysis using a validated area-level socioeconomic status metric

Published:November 02, 2022DOI:https://doi.org/10.1016/j.ejso.2022.10.023

      Abstract

      Background

      Prehabilitation employs exercise, nutrition, and psychological interventions to optimize physiological status in preparation for surgery. First, we described the extent to which material deprivation index score (MDIS) influenced prehabilitation participation. Second, we evaluated the extent to which prehabilitation influenced recovery as compared to control.

      Methods

      Pooled patient records from prospective multimodal prehabilitation studies in oncologic surgery were retrospectively examined. Patient postal codes were linked to their MDIS, a validated area-level socioeconomic status (SES) metric, as quintiles 1-5 (1 = highest SES). Functional capacity was evaluated with the 6-min walking test (6MWT) at baseline, before, and 8 weeks post-surgery. Influence of prehabilitation on length of hospital stay (LOS) was explored using generalized linear models with a negative binomial distribution adjusted for age, sex, surgical population, and MDIS.

      Results

      Recruitment records were available from 2014 onwards, yielding 1013 eligible patients for prehabilitation participation with MDIS data. Fewer patients with a low SES enrolled (Q1:62% vs. Q5:47%; P = 0.01) and remained in prehabilitation studies (Q1: 59% vs. Q5: 45%; P = 0.07). Prehabilitation study records were available from 2008 onward, yielding 886 enrolled patients with MDIS data (n = 510 prehabilitation, n = 376 control). Preoperative 6MWT similarly improved by > 20 m in response to prehabilitation across SES strata (P < 0.05). Postoperative 6MWT could not be evaluated due to substantial missing data. Prehabilitation had a significant protective influence on LOS, as compared to control, in unadjusted and adjusted models [adjusted IRR:0.77 (95% CI:0.68 to 0.87; P < 0.001].

      Conclusion

      Findings suggest that prehabilitation is effective across all SES; however, participation across SES quintiles was not equal. Barriers to participation must be identified and addressed. Once these barriers are addressed, prehabilitation may reduce surgical disparities among SES.

      Keywords

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      References

        • Abbott T.E.F.
        • Fowler A.J.
        • Dobbs T.D.
        • Harrison E.M.
        • Gillies M.A.
        • Pearse R.M.
        Frequency of surgical treatment and related hospital procedures in the UK: a national ecological study using hospital episode statistics.
        Br J Anaesth. 2017 Aug 1; 119 ([cited 2022 Jul 6]) (249–57. Available from:)
        • Foster C.
        • Haviland J.
        • Winter J.
        • Grimmett C.
        • Seymour K.C.
        • Batehup L.
        • et al.
        Pre-surgery depression and confidence to manage problems predict recovery trajectories of health and wellbeing in the first two years following colorectal cancer: results from the CREW cohort study.
        PLoS One. 2016 May 1; 11 ([cited 2022 May 12]) (Available from:)
        • Lawrence V.A.
        • Hazuda H.P.
        • Cornell J.E.
        • Pederson T.
        • Bradshaw P.T.
        • Mulrow C.D.
        • et al.
        Functional independence after major abdominal surgery in the elderly.
        J Am Coll Surg. 2004 Nov; 199 ([cited 2022 May 12]) (762–72. Available from:)
        • Gillis C.
        • Ljungqvist O.
        • Carli F.
        Prehabilitation, enhanced recovery after surgery, or both? A narrative review.
        Br J Anaesth. 2022 Mar 1; 128 ([cited 2022 May 12]) (434–48. Available from:)
        • Bamdad M.C.
        • Brown C.S.
        • Kamdar N.
        • Weng W.
        • Englesbe M.J.
        • Lussiez A.
        Patient, surgeon, or hospital: explaining variation in outcomes after colectomy.
        J Am Coll Surg. 2022 Mar 1; 234 ([cited 2022 May 12]) (300–9. Available from:)
        • Mulloy C.D.
        • Hoffman R.D.
        • Danos D.M.
        • Lau F.H.
        Health disparities in incisional hernia presentation : an analysis of HCUP-NIS years 2012-2014.
        Am Surg. 2020; 86 (Available from:): 799-802
        • Schlottmann F.
        • Gaber C.
        • Strassle P.D.
        • Herbella F.A.M.
        • Molena D.
        • Patti M.G.
        Disparities in esophageal cancer: less treatment, less surgical resection, and poorer survival in disadvantaged patients.
        Dis esophagus Off J Int Soc Dis Esophagus. 2020; 33 (Available from:)
        • Sutherland J.M.
        • Kurzawa Z.
        • Karimuddin A.
        • Duncan K.
        • Liu G.
        • Crump T.
        Wait lists and adult general surgery: is there a socioeconomic dimension in Canada?.
        BMC Health Serv Res. 2019 Dec 13; 19 (Available from:): 161
        • Alter D.A.
        • Iron K.
        • Austin P.C.
        • Naylor C.D.
        Socioeconomic status, service patterns, and perceptions of care among survivors of acute myocardial infarction in Canada.
        JAMA. 2004 Mar 3; 291 ([cited 2022 May 12]) (1100–7. Available from:)
        • Cookson R.
        • Propper C.
        • Asaria M.
        • Raine R.
        Socio-economic inequalities in health care in england.
        Fisc Stud [Internet]. 2016 Sep 1; 37 ([cited 2022 Jul 6]) (Available from:): 371-403
        • Carli F.
        • Scheede-Bergdahl C.
        Prehabilitation to enhance perioperative care.
        Anesthesiol Clin. 2015 Mar 1; 33 ([cited 2022 May 12]) (Available from:): 17-33
        • McIsaac D.I.
        • Gill M.
        • Boland L.
        • Hutton B.
        • Branje K.
        • Shaw J.
        • et al.
        Prehabilitation in adult patients undergoing surgery: an umbrella review of systematic reviews.
        Br J Anaesth. 2022 Feb 1; 128: 244-257
        • Gillis C.
        • Li C.
        • Lee L.
        • Awasthi R.
        • Augustin B.
        • Gamsa A.
        • et al.
        Prehabilitation versus RehabilitationA randomized control trial in patients undergoing colorectal resection for cancer.
        Anesthesiology. 2014 Nov 1; 121 ([cited 2021 Jul 26]) (937–47. Available from:)
        • Gillis C.
        • Loiselle S.-E.
        • Fiore J.F.
        • Awasthi R.
        • Wykes L.
        • Liberman A.S.
        • et al.
        Prehabilitation with whey protein supplementation on perioperative functional exercise capacity in patients undergoing colorectal resection for cancer: a pilot double-blinded randomized placebo-controlled trial.
        J Acad Nutr Diet. 2016 May; 116 (Available from:): 802-812
        • Minnella E.M.
        • Awasthi R.
        • Loiselle S.-E.
        • Agnihotram R.V.
        • Ferri L.E.
        • Carli F.
        Effect of exercise and nutrition prehabilitation on functional capacity in esophagogastric cancer surgery.
        JAMA Surg. 2018 Dec 1; 153 (Available from:): 1081
        • Carli F.
        • Bousquet-Dion G.
        • Awasthi R.
        • Elsherbini N.
        • Liberman S.
        • Boutros M.
        • et al.
        Effect of multimodal prehabilitation vs postoperative rehabilitation on 30-day postoperative complications for frail patients undergoing resection of colorectal cancer: a randomized clinical trial.
        JAMA Surg. 2020; 155: 233-242
        • Bousquet-Dion G.
        • Awasthi R.
        • Loiselle S.È.
        • Minnella E.M.
        • Agnihotram R.V.
        • Bergdahl A.
        • et al.
        Evaluation of supervised multimodal prehabilitation programme in cancer patients undergoing colorectal resection: a randomized control trial.
        Acta Oncol (Madr). 2018; 57 (Available from:): 849-859https://doi.org/10.1080/0284186X.2017.1423180
        • Minnella E.M.
        • Ferreira V.
        • Awasthi R.
        • Charlebois P.
        • Stein B.
        • Liberman A.S.
        • et al.
        Effect of two different pre-operative exercise training regimens before colorectal surgery on functional capacity: a randomised controlled trial.
        Eur J Anaesthesiol. 2020; 37: 969-978
        • van Rooijen S.
        • Carli F.
        • Dalton S.
        • Thomas G.
        • Bojesen R.
        • Le Guen M.
        • et al.
        Multimodal prehabilitation in colorectal cancer patients to improve functional capacity and reduce postoperative complications: the first international randomized controlled trial for multimodal prehabilitation.
        BMC Cancer. 2019 Dec 22; 19 (Available from:): 98
        • Ferreira V.
        • Minnella E.M.
        • Awasthi R.
        • Gamsa A.
        • Ferri L.
        • Mulder D.
        • et al.
        Multimodal prehabilitation for lung cancer surgery: a randomized controlled trial.
        Ann Thorac Surg. 2021; 112 (Available from:): 1600-1608https://doi.org/10.1016/j.athoracsur.2020.11.022
        • Ferreira V.
        • Lawson C.
        • Carli F.
        • Scheede-Bergdahl C.
        • Chevalier S.
        Feasibility of a novel mixed-nutrient supplement in a multimodal prehabilitation intervention for lung cancer patients awaiting surgery: a randomized controlled pilot trial.
        Int J Surg. 2021 Sep; 93 (Available from:)106079
        • Santa Mina D.
        • Hilton W.J.
        • Matthew A.G.
        • Awasthi R.
        • Bousquet-Dion G.
        • Alibhai S.M.H.
        • et al.
        Prehabilitation for radical prostatectomy: a multicentre randomized controlled trial.
        Surg Oncol. 2018; 27 (Available from:): 289-298https://doi.org/10.1016/j.suronc.2018.05.010
        • Minnella E.M.
        • Awasthi R.
        • Bousquet-Dion G.
        • Ferreira V.
        • Austin B.
        • Audi C.
        • et al.
        Multimodal prehabilitation to enhance functional capacity following radical cystectomy: a randomized controlled trial.
        Eur Urol Focus. 2021; 7 (Available from:): 132-138https://doi.org/10.1016/j.euf.2019.05.016
        • Minnella E.M.
        • Baldini G.
        • Quang AT Le
        • Bessissow A.
        • Spicer J.
        • Carli F.
        Prehabilitation in thoracic cancer surgery: from research to standard of care.
        J Cardiothorac Vasc Anesth. 2021; 35 (Available from:): 3255-3264https://doi.org/10.1053/j.jvca.2021.02.049
        • Schram A.
        • Ferreira V.
        • Minnella E.M.
        • Awasthi R.
        • Carli F.
        • Scheede-Bergdahl C.
        In-hospital resistance training to encourage early mobilization for enhanced recovery programs after colorectal cancer surgery: a feasibility study.
        Eur J Surg Oncol. 2019; 45 (Available from:): 1592-1597https://doi.org/10.1016/j.ejso.2019.04.015
        • Li C.
        • Carli F.
        • Lee L.
        • Charlebois P.
        • Stein B.
        • Liberman A.S.
        • et al.
        Impact of a trimodal prehabilitation program on functional recovery after colorectal cancer surgery: a pilot study.
        Surg Endosc. 2013; 27: 1072-1082
        • Barrett-Bernstein M.
        • Carli F.
        • Gamsa A.
        • Scheede-Bergdahl C.
        • Minnella E.
        • Ramanakumar A.V.
        • et al.
        Depression and functional status in colorectal cancer patients awaiting surgery: impact of a multimodal prehabilitation program.
        Heal Psychol. 2019 Oct; 38 (Available from:): 900-909https://doi.org/10.1037/hea0000781
        • Gamache P.
        • Hamel D.
        • Blaser C.
        Material and social deprivation index: a summary. Inst Natl Santé Publique du Quebec.
        ([Internet]. Available from:)
      1. Postal CodeOM conversion file (PCCF), reference guide. Stat Canada cat no 92-154-G. 2017
        • Pampalon R.
        • Hamel D.
        • Gamache P.
        • Simpson A.
        • Philibert M.D.
        Validation of a deprivation index for public health: a complex exercise illustrated by the Quebec index.
        Chronic Dis Inj Can. 2014 Feb; 34: 12-22
      2. Bureau d’information et d’études en santé des populations (BIESP).
        Mater Soc Depriv Ind. 2016; ([cited 2021 Aug 17]. Available from:)
        • Chen Y.C.
        • Chen K.C.
        • Lu L.H.
        • Wu Y.L.
        • Lai T.J.
        • Wang C.H.
        Validating the 6-minute walk test as an indicator of recovery in patients undergoing cardiac surgery A prospective cohort study.
        Med Interne. 2018 Oct 1; 97 ([cited 2022 May 12]) (Available from:)
        • Solway S.
        • Brooks D.
        • Lacasse Y.
        • Thomas S.
        A qualitative systematic overview of the measurement properties of functional walk tests used in the cardiorespiratory domain.
        Chest. 2001 Jan 1; 119 ([cited 2022 May 12]) (256–70. Available from:)
        • ATS Statement
        No Title.
        Am J Respir Crit Care Med. 2002; 166: 111-117
        • Lee L.
        • Tran T.
        • Mayo N.E.
        • Carli F.
        • Feldman L.S.
        What does it really mean to “recover” from an operation?.
        Surgery. 2014 Feb 1; 155 ([cited 2022 May 12]) (211–6. Available from:)
        • Carter E.M.
        • Potts H.W.
        Predicting length of stay from an electronic patient record system: a primary total knee replacement example.
        BMC Med Inform Decis Mak. 2014 Apr 4; 14 ([cited 2022 May 12]) (Available from:)
        • Moriello C.
        • Mayo N.E.
        • Feldman L.
        • Carli F.
        Validating the six-minute walk test as a measure of recovery after elective colon resection surgery.
        Arch Phys Med Rehabil. 2008 Jun 1; 89 ([cited 2022 May 12]) (1083–9. Available from:)
        • Martin L.
        • Hopkins J.
        • Malietzis G.
        • Jenkins J.T.
        • Sawyer M.B.
        • Brisebois R.
        • et al.
        Assessment of computed tomography (CT)-Defined muscle and adipose tissue features in relation to short-term outcomes after elective surgery for colorectal cancer: a multicenter approach.
        Ann Surg Oncol. 2018 Sep 1; 25: 2669-2680
        • Shanmugasegaram S.
        • Oh P.
        • Reid R.D.
        • McCumber T.
        • Grace S.L.
        Cardiac rehabilitation barriers by rurality and socioeconomic status: a cross-sectional study.
        Int J Equity Health. 2013; 12 (Available from:): 72
        • Suaya J.A.
        • Shepard D.S.
        • Normand S.-L.T.
        • Ades P.A.
        • Prottas J.
        • Stason W.B.
        Use of cardiac rehabilitation by medicare beneficiaries after myocardial infarction or coronary bypass surgery.
        Circulation. 2007 Oct 9; 116 (Available from:): 1653-1662
        • Dunlay S.M.
        • Witt B.J.
        • Allison T.G.
        • Hayes S.N.
        • Weston S.A.
        • Koepsell E.
        • et al.
        Barriers to participation in cardiac rehabilitation.
        Am Heart J. 2009 Nov; 158 (Available from:): 852-859
        • Lane D.
        • Carroll D.
        • Ring C.
        • Beevers D.G.
        • Lip G.Y.H.
        Predictors of attendance at cardiac rehabilitation after myocardial infarction.
        J Psychosom Res. 2001; 51: 497-501
        • Dunlay S.M.
        • Witt B.J.
        • Allison T.G.
        • Hayes S.N.
        • Weston S.A.
        • Koepsell E.
        • et al.
        Barriers to participation in cardiac rehabilitation.
        Am Heart J. 2009 Nov 1; 158: 852-859
        • Cooper A.F.
        • Jackson G.
        • Weinman J.
        • Horne R.
        Factors associated with cardiac rehabilitation attendance: a systematic review of the literature.
        Clin Rehabil. 2002; 16: 541-552
        • Missik E.
        Women and cardiac rehabilitation: accessibility issues and policy recommendations.
        Rehabil Nurs. 2001; 26 ([cited 2022 May 15]) (141–7. Available from:)
        • Gallagher R.
        • McKinley S.
        • Dracup K.
        Predictors of women's attendance at cardiac rehabilitation programs.
        Prog Cardiovasc Nurs. 2003 Jun 1; 18 ([cited 2022 May 15]) (121–6. Available from:)
        • Farley R.L.
        • Wade T.D.
        • Birchmore L.
        Factors influencing attendance at cardiac rehabilitation among coronary heart disease patients.
        Eur J Cardiovasc Nurs. 2003 Sep 1; 2 ([cited 2022 May 15]) (205–12. Available from:)
        • Evenson K.R.
        • Rosamond W.D.
        • Luepker R.V.
        Predictors of outpatient cardiac rehabilitation utilization: the Minnesota heart Survey registry.
        J Cardiopulm Rehabil. 1998 May; 18 (Available from:): 192-198
        • J B.
        • J S.
        • B S.
        Special considerations related to race, sex, gender, and socioeconomic status in the preoperative evaluation: Part 1: race, history of incarceration, and health literacy.
        Anesthesiol Clin. 2020 Jun 1; 38 ([cited 2021 Aug 17]) (247–61. Available from:)
        • Roy M.
        • Corkum J.P.
        • Urbach D.R.
        • Novak C.B.
        • von Schroeder H.P.
        • McCabe S.J.
        • et al.
        Health literacy among surgical patients: a systematic review and meta-analysis.
        World J Surg. 2018 Aug 13; 43 ([cited 2022 May 15]) (Available from:): 96-106
        • De Oliveira G.S.
        • McCarthy R.J.
        • Wolf M.S.
        • Holl J.
        The impact of health literacy in the care of surgical patients: a qualitative systematic review.
        BMC Surg. 2015 Jul 17; 15 ([cited 2022 May 15]) (Available from:): 1-7
        • Williams M.V.
        • Parker R.M.
        • Baker D.W.
        • Parikh N.S.
        • Pitkin K.
        • Coates W.C.
        • et al.
        Inadequate functional health literacy among patients at two public hospitals.
        JAMA. 1995 Dec 6; 274 ([cited 2022 May 15]) (1677–82. Available from:)
        • Gillis C.
        • Fenton T.R.
        • Gramlich L.
        • Sajobi T.T.
        • Culos-Reed S.N.
        • Bousquet-Dion G.
        • et al.
        Older frail prehabilitated patients who cannot attain a 400 m 6-min walking distance before colorectal surgery suffer more postoperative complications.
        Eur J Surg Oncol. 2021 Apr 1; 47: 874-881
        • Estabrooks P.A.
        • Lee R.E.
        • Gyurcsik N.C.
        Resources for physical activity participation: does availability and accessibility differ by neighborhood socioeconomic status?.
        BMC Surg. 2003 Apr; 25 (Available from:): 100-104
        • Gordon-Larsen P.
        Inequality in the built environment underlies key health disparities in physical activity and obesity.
        Pediatrics. 2006 Feb 1; 117 (Available from:): 417-424
        • Powell L.M.
        • Slater S.
        • Chaloupka F.J.
        • Harper D.
        Availability of physical activity–related facilities and neighborhood demographic and socioeconomic characteristics: a national study.
        Am J Public Health. 2006 Sep; 96 (Available from:): 1676-1680
        • Cavanaugh A.M.
        • Rauh M.J.
        • Thompson C.A.
        • Alcaraz J.
        • Mihalko W.M.
        • Bird C.E.
        • et al.
        Racial/ethnic disparities in physical function before and after total knee arthroplasty among women in the United States.
        JAMA Netw open. 2020; 3 (Available from:)e204937
        • Minnella E.M.
        • Liberman A.S.
        • Charlebois P.
        • Stein B.
        • Scheede-Bergdahl C.
        • Awasthi R.
        • et al.
        The impact of improved functional capacity before surgery on postoperative complications: a study in colorectal cancer.
        Acta Oncol. 2019 May 4; 58 ([cited 2022 May 12]) (573–8. Available from:)
        • Lambert J.E.
        • Hayes L.D.
        • Keegan T.J.
        • Subar D.A.
        • Gaffney C.J.
        The impact of prehabilitation on patient outcomes in hepatobiliary, colorectal, and upper gastrointestinal cancer surgery: a PRISMA-accordant meta-analysis.
        Ann Surg. 2021 Jul 1; 274 ([cited 2022 May 20]) (70–7. Available from:)
        • Gelormino E.
        • Bambra C.
        • Spadea T.
        • Bellini S.
        • Costa G.
        The effects of health care reforms on health inequalities: a review and analysis of the european evidence base.
        Int J Heal Serv. 2011 Jan 1; 41 ([cited 2022 May 19]) (209–30. Available from:)
        • Pampalon R.
        • Hamel D.
        • Gamache P.
        A comparison of individual and area-based socio-economic data for monitoring social inequalities in health.
        Stat Canada. 2009; 20
        • Pampalon R.
        • Hamel D.
        • Gamache P.
        Health inequalities in urban and rural Canada: comparing inequalities in survival according to an individual and area-based deprivation index.
        Health Place. 2010 Mar 1; 16: 416-420
        • Rajabiyazdi F.
        • Alam R.
        • Pal A.
        • Montanez J.
        • Law S.
        • Pecorelli N.
        • et al.
        Understanding the meaning of recovery to patients undergoing abdominal surgery.
        JAMA Surg. 2021 Aug 1; 156 ([cited 2021 Sep 4]) (758–65. Available from:)
        • Grace S.L.
        • Leung Y.W.
        • Reid R.
        • Oh P.
        • Wu G.
        • Alter D.A.
        The role of systematic inpatient cardiac rehabilitation referral in increasing equitable Access and utilization.
        J Cardiopulm Rehabil Prev. 2012 Jan; 32 (Available from:): 41-47
        • MacArthur SES & Health Network | Research
        ([Internet]. [cited 2021 Aug 17]. Available from:)
        • Shanmugasegaram S.
        • Gagliese L.
        • Oh P.
        • Stewart D.E.
        • Brister S.J.
        • Chan V.
        • et al.
        Psychometric validation of the cardiac rehabilitation barriers Scale.
        Clin Rehabil. 2012 Feb 21; 26 (Available from:): 152-164