3/6/2017. Objectives. Prehabilitation Training the Frail. I have no financial relationships with commercial interests to disclose.

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1 Prehabilitation Training the Frail Christopher J. Sonnenday, MD, MHS Surgical Director of Liver Transplantation University of Michigan Health System Christopher J. Sonnenday, MD, MHS Surgical Director of Liver Transplantation University of Michigan Health System I have no financial relationships with commercial interests to disclose. My presentation does not include discussion of off-label or investigational use. Objectives At the conclusion of this presentation, the learner will be able to: To identify validated metrics for the measurement of frailty and sarcopenia among transplant candidates and recipients. To define the feasibility and impact of prehabilitation programs among transplant candidates. 1

2 Question What is the incidence of death within one year for a 56 year old liver transplant candidate, MELD 16, with a frailty score of 4(frail)? 1. 10% 2. 20% 3. 30% 4. 40% 5. 50% Current challenges in recipient selection Obesity Elderly Cardiovascular disease Changing patient population Median age of adult liver transplant recipients

3 Novel domains of risk measurement Frailty Sarcopenia Frailty is a biologic syndrome of decreased reserve and resistance to stressors, resulting from cumulative declines across multiple physiologic systems, and causing vulnerability to adverse outcomes. Fried LP et al., J Gerontology Elements of frailty 0 Not frail Frailty measure Shrinkage Weakness Exhaustion Slowness Diminished activity Test Unintentional weight loss Grip strength Self-reported index Walking time Kcals/week 5 Very frail 3

4 Frailty in the geriatric population: The Cardiovascular Health Study N = 5,317 High frailty score (3-5) was independently associated with: Increased hospital admissions Increased fall risk Decreased independent living Decreased 3 and 7 year survival Fried LP et al., J Gerontology University of Michigan Frailty in Liver Transplantation Study Established Patients referred for liver transplant evaluation Patients listed for liver transplantation Liver transplant recipients Median follow-up 42 months (range 6-69 months) Frailty follows a normal distribution among patients considered for liver transplant Low frailty (0-2) High frailty (3-5) 4

5 Are the very frail notably different from the rest of the study population? N = 843 Low Frailty (0-2) High Frailty (3-5) Median age Female 42% 35% MELD score No correlation of high frailty with BMI, cause of liver disease, cancer, number of comorbidities MELD distribution by frailty score Frailty predicts survival from time of assessment in patients with end-stage liver disease 5

6 High MELD / High Frailty Predicts Poor Waitlist Survival Post-transplant complications by frailty status N=161 Low Frailty (0-2) High Frailty (3-5) Bacterial infection* 40% 58% Fungal infection* 8% 21% Renal failure requiring dialysis* Reoperation for bleeding* 11% 28% 7% 31% Acute rejection 11% 9% * P<

7 Post-transplant resource utilization $197,194 $215, All differences P< day median costs Non-Frail Frail Median Length of Stay Non-Frail Frail 48% 67% 7% 20% Non-home discharge90 day readmissions Non-Frail Frail Post-transplant survival by frailty score N=161, median follow-up 24 months P=0.03 One year post-transplant survival Frailty 0-2 (N=85) 92% Frailty 3-5 (N=75) 79% American Journal of Transplantation Volume 15, Issue 1, pages , 30 OCT 2014 DOI: /ajt

8 Analytic Morphomics Analytic Morphomics to Assess Risk 58 yo, cryptogenic cirrhosis; markedly debilitated, multiple hospitalizations over year prior to txp; chronic renal failure; MELD 28 at transplant 58 yo, cryptogenic cirrhosis; acute on chronic liver failure; working 2 weeks prior to admission; acute renal failure; MELD 38 at transplant Analytic morphomics: Measurable components 8

9 Trunk muscle size and liver transplant survival Adjusted 1 Year Survival (%) Small Muscles Large Muscles J Am Coll Surg 2010;211(2): Analytic morphomics improves existing risk prediction models 9

10 Can we fix frailty? Prehabilitation for Transplant Candidates Rehab or Prehab? Illness Surgery Rehab Health Illness Prehab SurgeryRehab Health Adjusted Hospital Margin $3,197 $4,261 $1,431 $(2,196) $(711) Percentile of Lean Psoas Area 10

11 Prehabilitation: Michigan Surgical & Health Optimization Program (MSHOP) Michael Englesbe, MD Prehabilitation Walking Program Smoking Cessation Education Care Team management Nutrition Patient empowerment 1,166 patients have been enrolled in MSHOP 120 Total MSHOP Enrollments by Month 100 Patient Volume Active Disenrolled 11

12 MSHOP Go-Live Date by Surgical Practice, State of Michigan Go-Live Date Health System/Hospital Practice 9/1/2014 UMHS UMHS 6/8/2015 Henry Ford Allegiance Health Allegiance General Surgery 7/20/2015 St. Joseph Mercy Oakland HospitalBloomfield Surgical Associates 7/22/2015 Munson Healthcare Surgical Associates of Traverse City 10/12/2015 Bronson Battle Creek Colon & Rectal Surgery Center 10/12/2015 Bronson Methodist Bronson Colon & Rectal Surgery* 11/9/2015 Mercy Health - Mercy Campus Surgical Associates of West Michigan 11/10/2015 Mercy Health - HackleyCampus Muskeon Surgical Associates, PC 12/28/2015 Henry Ford Allegiance Health Allegiance Thoracic Surgery 1/6/2016 Bronson Battle Creek Bronson General Surgery 1/14/2016 Genesys Surgical Associates PLC 1/20/2016 Holland Hospital Lakeshore Health Partners -General Surgery St. Mary Mercy Hospital Friedman Surgical Group 31 hospitals Genesys enrolling Grand general Blanc Surgical and Specialist vascular 1/20/2016 2/10/2016 Lakeland General Surgery of Niles* surgery Beaumont patients Health System in prehabilitation Grosse Pointe Physicians and programs Surgeons 2/29/2016 3/1/2016 3/10/2016 Genesys Douglas Iddings, PC 5/9/2016 Genesys colon and rectal surgery of geneseecounty 7/5/2016 Providence Hospital Comprehensive Vascular Care, P.C. 8/8/2016 Beaumont Health System Oakland Surgical Group 8/29/2016 Beaumont Health System Oakland Colon and Rectal Associates 8/29/2016 MidMichiganHealth MidMichiganPhysicians Group General Surgery -Midland 9/2/2016 Beaumont Health System Colon and Rectal Specialists 9/6/2016 Holland Hospital West Michigan Urological Associates 9/13/2016 Beaumont Health System Oakwood PhyscianSurgical Group 10/5/2016 McLaren Health Care Christopher Bruck, MD 10/11/2016 Genesys Women's Specialty Associates 11/7/2016 Beaumont Health System Surgery Specialists 11/11/2016 Mercy Health - HackleyCampus Comprehensive Women's Health 11/22/2016 St. Joseph Mercy Oakland HospitalMercy WomensCenter 12/12/2016 St Mary Mercy Hospital Dr.Hallal Outcomes following prehabilitation General and vascular surgery, UMHS $30,000 $25,000 $20,000 $15,000 $10,000 p<0.01 $19,377 $28,333 $14,126 p<0.02 $20,250 Days p< MSHOP Control $5,000 1 $0 0 Median Payer Reimbursement ($8,956 difference) Median Hospital Cost ($6,124 difference) Median Length of Stay (2 days difference) UM Liver Transplant Prehabilitation Program (N=12) Prehab Component Increasing daily steps Light strength and stamina exercises Counseling from dietician Counseling from prehab coach Average Patient Improvements 2832 steps/day > 1 Mile No Significant Change in Grip Strength 63 meter increase in 6MW Adherence to nutritional plan Patients reported feeling less exhausted 12

13 Prehabilitation is associated with high patient satisfaction Survey Item Likert score The addition of this program to my routine care for my liver disease is an improvement to my care at the University of Michigan. 5 I was MORE motivated to be active because of participation in the prehabprogram. 4.8 I feel I have more energy because of participation in the prehabprogram. 4.8 I would recommend this program to other people inmy similar condition. 5 I feel that participation in the prehabprogram increased my overall well-being. 5 Patient comments I feel like I might get called for a transplant, and my body just won t be ready, being a part of this program reassures me thati can be ready. Before being a part of the program I hadn t thought about physical activity a day in my life. This (prehabilitation)program has been a life changing experience for me. Coming the U of M and realizing I was sick and needed to lose weight was by far the most difficult experience of my life. Being a part of the program has helped me in so many more ways than just diet and physical activity. Prehabilitation on the kidney transplant waiting list Johns Hopkins, N = 19 Weekly 1 hour physical therapy program Actigraph TM actigraphymonitoring 19% increase in daily activity 21% increase on non-dialysis days 5% increase on dialysis days Abstract accepted for ATC 2017 Mara McAdams DeMarco, Hao Ying, Anthony Nastasi, Dorry Segev Challenges to Creating Prehabilitation Programs for Solid Organ Transplant Candidates Domain Elements Progress Needs Identifying high-risk candidates Creatingeffective programs Personnel and expertise Sustainability Frailty Sarcopenia +++ Activity Nutrition support Empowerment Caregiver Engagement Motivational interviewing Life coaching Registered dieticians Physical therapists Payer engagement Hospital resources Multicenter studies in varied populations Multicenter demonstration project Business case for prehabilitation among transplant centers and hospitals Engagement of CMS & transplant networks Validation studies 13

14 Thank you Christopher Sonnenday, MD, MHS 14