Cost-effectiveness of prehabilitation prior to elective surgery: A systematic review of economic evaluations

Background Prehabilitation aims at enhancing patients’ functional capacity and overall health status to enable them to withstand a forthcoming stressor like surgery. Our aim was to synthesise the evidence on the cost-effectiveness of prehabilitation for patients awaiting elective surgery compared with usual preoperative care. Methods We searched PubMed, Embase, the CRD database, ClinicalTrials.gov, the WHO ICTRP and the dissertation databases OADT and DART. Studies comparing prehabilitation for patients with elective surgery to usual preoperative care were included if they reported cost outcomes. All types of economic evaluations (EEs) were included regardless of design, analysis type and completion status. The primary outcome of the review was cost-effectiveness based on cost-utility analyses (CUAs). The risk of bias of trial-based EEs was assessed with the Cochrane Risk of Bias 2 tool and the ROBINS-I tool, and the credibility of model-based EEs with the ISPOR checklist. Methodological quality of full EEs was assessed using the CHEC checklist. The EEs’ results were synthesised narratively using vote counting based on direction of effect. Results We included 45 unique studies: 25 completed EEs and 20 ongoing studies. Among the completed EEs, there were 22 trial-based EEs, and three model-based EEs, corresponding to four CUAs, three cost-effectiveness analyses, two cost-benefit analyses, 12 cost-consequence analyses and four cost-minimization analyses. Three of the four trial-based CUAs (75%) found prehabilitation cost-effective. Overall, 16/25 (64.0%) EEs found prehabilitation cost-effective based on direction of effects. When excluding studies of insufficient credibility/critical risk of bias, this number reduced to 14/23 (60.9%). In 8/25 (32.0%) cost-effectiveness was unclear, and in one EE prehabilitation was not cost-effective. Discussion We found some evidence that prehabilitation for patients awaiting elective surgery is cost-effective compared to usual preoperative care. However, we suspect a relevant risk of publication bias, and most EEs were of high risk of bias and/or low methodological quality. Furthermore, there was relevant heterogeneity depending on the population, intervention, and methods. Future EEs should be performed over a longer time horizon and apply a more comprehensive perspective. Funding information and systematic review registration Funding: Innovationsausschuss of the Federal Joint Committee (G-BA) (01NVF18024). Registration: PROSPERO CRD42020182813.