Multimodal prehabilitation improves short-term post-transplant outcomes while not increasing costs for heart transplant recipients

IntroductionLimited aerobic capacity, low exercise tolerance, and frailty are highly prevalent in patients awaiting heart transplantation (HT) and tightly related to negatively impacting postoperative outcomes and healthcare resource consumption. Prehabilitation (prehab) has shown efficacy in improving functional status and preventing postoperative complications in selected high-risk surgical populations. However, the implementation of these programs feasibility and efficacy has not been evaluated in advanced heart failure patients. Prehab could be health resource-consuming and represent an economic burden. This study aimed to investigate the impact of prehab on HT postoperative outcomes and to evaluate the cost-effectiveness of a multimodal prehab program for HT candidates.MethodsSingle-centre, ambispective cohort study including forty-six candidates for elective HT from 2017 to 2021 attending a multimodal prehab program (intervention) consisting of supervised exercise training, physical activity promotion, nutritional optimization, and psychological support. The postoperative outcomes and total cost of the prehab program (n=31) were compared with a group of twelve contemporaneous patients who did not join the program and those transplanted from 2014 to 2017 before the implementation of the program (n=51).Main postoperative measured outcomes: Comprehensive Complication Index (CCI), mechanical ventilation time, total hospitalization and intensive care length-of-stay, destination at discharge (home vs. rehabilitation facility), hospital readmissions at 30 days, and mortality at 30-days, 3-months, and 1-year.A prehab program cost analysis was performed. Healthcare use included HT surgical procedures, direct hospitalization (until discharge), and prehab costs. Data were obtained through micro-costing techniques according to resource use, combined with diagnostic-related centre-specific hospital fees. A bootstrapping approach was performed to control the skewness of the distribution.ResultsThirty-one prehab patients underwent HT. Their postoperative outcomes were compared to the previously described control group.Significant improvements were observed in functional capacity (endurance time: 293 vs. 632s, p<0.001) and quality-of-life (Minnesota score: 58 vs. 47, p=0.046) after prehab. No exercise-related events were registered. Five candidates were eventually removed from the waitlist due to significant functional capacity improvement after prehab.Prehab cohort showed a lower rate and severity of postoperative medical complications (CCI 37 vs. 31, p=0.033), lower mechanical ventilation time (37 vs. 20 hours, p=0.032), ICU stay (7 vs. 5 days, p=0.01), total hospitalization stay (23 vs. 18 days, p=0.008) and less need for transfer to nursing/rehabilitation facilities after hospital discharge (31% vs. 3%, p=0.009).The mean cost per prehab program patient was 2,195€ mainly driven by supervised exercise training (1,971€). The healthcare-related mean cost for the HT index hospitalization, including the cost of the prehab program, did not show differences between groups (prehab: 56,503€ vs. control: 66,556€; p=0.12). The difference in costs was only statistically significant when removing the outliers from the analysis.DiscussionOur findings support the beneficial impact of a multimodal prehabilitation intervention in the short-term postoperative outcomes of HT recipients without increasing direct healthcare costs, which may be interpreted as evidence of higher value for money (cost-effective intervention).