Effects of Multimodal Prehabilitation on High-impact Surgery Outcomes: a prospective stepped-wedge, hospital-wide implementation study

Abstract Background Multimodal prehabilitation may improve surgical outcomes in selected populations, but its real-world effectiveness remains unclear. We evaluated the effect of hospital-wide implementation of multimodal prehabilitation on postoperative outcomes and length of stay in a diverse surgical population. Methods This single-centre, non-randomised stepped wedge study (F4S PREHAB) was conducted at Radboudumc, Nijmegen, the Netherlands from March 2019 to April 2024. Patients undergoing elective surgery across 20 clinical pathways received either standard preoperative care or multimodal prehabilitation comprising supervised exercise, nutritional support, psychological counselling, and smoking and alcohol cessation support. The primary outcome was the occurrence of postoperative complications within 30 days, measured by Clavien-Dindo (CD)≥2 and dichotomized Comprehensive Complication Index (CCI). The secondary outcome was length of hospital stay. Analyses used generalized linear models adjusted for time of inclusion, clinical pathway, and confounders. Subgroup analyses focused on high-risk gastrointestinal oncological surgery. Results During the study period, 4,131 patients received usual care (n=2,660) or prehabilitation (n=1,471). 367 patients (24.9%) attended ≥9 exercise sessions, indicating partial adherence. No significant differences were found in postoperative complications between groups for CD≥2 (adjusted risk ratio=1.02, 95%CI=0.90;1.16) and CCI22.6 (adjusted risk ratio=1.03, 95%CI=0.86;1.23), nor in hospital stay (adjusted ratio=1.04, 95%CI=0.92;1.18). In the high-risk gastrointestinal-oncological subgroup (n=1,198), complication risk (CD≥2) was 9% lower, but not statistically significant (adjusted risk ratio=0.91, 95%CI=0.75;1.10). Conclusion Hospital-wide implementation of multimodal prehabilitation did not reduce postoperative complications nor hospital stay. Greater effect in high-risk patients suggests a targeted approach may be more effective. Future research should identify such patients and evaluate effectiveness of prehabilitation in this population.