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Dr. Miller: Prehabilitation. What is that? We're going to talk about that next on Scope Radio.

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Dr. Miller: Hi. I'm Dr. Tom Miller. I'm here with Dr. Dan Vargo. He's a surgeon here at the University of Utah. Dan, what is prehabilitation?

Dr. Vargo: What we are trying to accomplish is to improve patient outcomes with surgery. Can patients do anything to help improve their outcomes with their operations.

Dr. Miller: Well, it sounds like you're going to tell me what those things might be.

Dr. Vargo: We focus on some very specific things. So the first thing is to just stop smoking before surgery. There's no question, there have been multiple studies that have shown that smoking cessation is the number one thing you can do to improve wound infection rates, to improve pulmonary complications.

There's actually an interesting application for a smartphone that it's specific for hernia operations. But it would be applicable to almost any operations where you can type in various risk factors for the patients before surgery, and you can show what their risk of a complication is after surgery.

So it's very easy to punch in smoking as one of the risk factors in that application. And show them what their chance of having a complication after surgery and then eliminating smoking and showing them what their risk is for having a complication. And for things like pneumonia it goes down about six times, for wound infections it goes down about three times.

Dr. Miller: Now, how long before the surgery would they have to quit smoking to show that that's effective?

Dr. Vargo: We typically will recommend about six weeks before surgery.

Another one of the risk factors that we know that patients can work on is their blood sugar control. This is specific for diabetics and we have taken the approach of absolute glucose control before surgery. Bacteria and various things inside your wound need sugar to survive and if you have elevated levels of sugar in your wound after surgery, then that gives them a better chance of setting up shop and causing an infection.

So if we can get patients to have good blood sugar control which we measure with something called a hemoglobin A1C level which most diabetics are already very familiar with. If we can get that level below seven before surgery then people's risk of infection is equivalent to the normal population.

Dr. Miller: So do you end up working with the patient directly on that or do you usually work through their primary care physician or how do you make sure that they get best control of the diabetes?

Dr. Vargo: It's a good question. We work with both actually. We found that for some patients who are very, very good at monitoring their own sugars they are fairly easy to work with. Other folks maybe aren't as compliant with their blood sugar regimen, with their insulin or their medications for their diabetes. We will reach out to their primary care doctors to assist. Then occasionally we actually refer people to our own diabetes center.

Dr. Miller: Now, how about physical exercise? Do you work with them on their stamina?

Dr. Vargo: There is, there is a program, a true prehabilitation program where people will start to increase their activities before surgery. I deal mostly with abdominal wall problems and hernias and a lot of people have actually stopped their physical activity because of the discomfort that they have because of these abdominal wall problems that they have.

So it can be difficult sometimes to get them going with regards to an exercise program. But we have the ability of using things like arm ergometers, even getting people just on a treadmill and starting to walk.

Dr. Miller: You mean things like Fitbit or Jawbone. Some of those products that are out there now.

Dr. Vargo: Exactly, exactly. And have people monitor what they do with the idea that with as little as six weeks of activity before surgery, similar to the smoking cessation, patients will show an improved outcome after surgery with regards to getting back up on their feet, not being as dependent. They have overall better function outcomes after surgery.

Dr. Miller: Now, do you talk to them about medications or medications that they would need to stop prior to surgery so that doesn't have an adverse effect on the outcome?

Dr. Vargo: There are. There are a lot of supplements that patients take now. And being in Utah we have a lot of folks who do engage in trying to improve their own health by taking these supplements and in surgery some of these supplements can actually increase their risk of bleeding.

There are seven or eight that exist that do do that. We talk about the G's for general surgery, ginkgo biloba is one of them, garlic, ginseng, saw palmetto, was another one. But there are some things that patients definitely need to stop before undergoing a bigger operation.

Dr. Miller: So part of prehabilitation is that they work with patients to tell them to go off those medicines before they enter the operating arena.

Dr. Vargo: Exactly, exactly. And then we also work with patients from a nutritional standpoint. As metabolic surgery, gastric bypass type surgery has become more popular, general surgeons are starting to have to operate on folks who've had these procedures. And what we have a much better understanding of now is that these patients come in with some fairly significant metabolic derangements which if you just look at somebody sitting in a chair you would never really recognize.

There are vitamin deficiencies that these patients have coming in, and so there really is some dietary counseling that we go through and some nutritional counseling that we go through. Not just with the gastric bypass patients but actually with all of our patients.

Dr. Miller: So Dr. Vargo, is this prehabilitation concept a local concept or a university concept? Is this more of a national construct that's being rolled out?

Dr. Vargo: It's becoming more and more popular across the country and actually around the world. This past May was the third world congress on these types of programs called Enhanced Recovery After Surgery and there is a listing of guidelines for people who are interested. You can go onto the web and you can look these up. And if you do have a surgery that's being planned for you, you can look through the list of things that you can do to help improve your own outcomes after surgery.

Dr. Miller: Would they Google prehabilitation? Would that be the thing that they would Google?

Dr. Vargo: Either prehabilitation or enhanced recovery after surgery. That would also be something that would work.

Dr. Miller: Now, you've given us the list of a number of things that you're having patients do or consider. In your experience does doing all that result in a better outcome?

Dr. Vargo: It actually does result in a better outcome. There have been multiple studies that have been done that show that patients have a significantly decreased risk of wound infections after surgery. For the elderly patients there's a decreased risk of falls after surgery and the consequences of having falls after surgery. And actually in my own patient population I was able to decrease the wound complication rate by about 50% just by implementing this type of a program.

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Dr. Miller: You've tried physical therapy for back pain, and you're not ready for surgery. What other options are there? We're going to talk about that next on Scope Radio.

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Dr. Miller: I'm here today with Dr. Richard Kendall. He's a professor of rehabilitative medicine, and he's also the Chair of the Department of Physical and Rehabilitative Medicine. Rich, tell us a little bit about what patients can do prior to surgery. I've heard about injections into the back for those patients who have sort of ongoing low back pain or pain in other parts of their back, but there are now injections that can be tried that might relieve their pain.

Dr. Kendall: So that's true. For people who have not done well with physical therapy program or medications like anti-inflammatories or Tylenol or even opiate medications, epidural injections are a tool for us to use to decrease pain. That's just what they are, they can decrease pain, they don't heal or cure a tissue, but getting rid or decreasing the pain is one option hopefully to let somebody go on, and further function before surgery.

Dr. Miller: So what exactly is an epidural injection? Where does that go on the back?

Dr. Kendall: The epidural space is the space around your spinal cord, and it's in the middle of the safe protection of the bones of the spine. It's a nice protected space that's filled with fat that we can put in some steroids and some Novocain in that can really help reduce inflammation as well as reduce pain.

Dr. Miller: Is this a difficult procedure or what does a patient expect when they come in to have this done?

Dr. Kendall: Honestly most of our patients expect the worst, but when we come in, we finish the procedure, and they say, "Wow, that's it? Are you kidding me? That's easier than the dentist." So . . .

Dr. Miller: That's pretty easy. If it's easier than the dentist, that's pretty easy.

Dr. Kendall: The thought of somebody poking a needle in your back is somewhat anxiety provoking but we do them with a lot of Lidocaine, and numbing under X-Ray guidance so most people really experience very little symptoms.

Dr. Miller: What are you injecting into that space that actually reduces the pain?

Dr. Kendall: We put in two medicines. One is corticosteroid or cortisone, and that gets rid of the inflammation. It'll sit in the fat cells for about two weeks around your spine and get rid of inflammation. The second is just a Novocain or a Lidocaine which is an anesthetic, and it'll numb those nerves and areas for several hours.

Dr. Miller: That lets you know that you're probably making a difference. I mean if the Novocain is working in the area where the back pain is emanating from, you'll know you're at the right place I guess, right?

Dr. Kendall: Yes, many people will be pain free when they leave. Some people that's only for four, five hours. However the Lidocaine does sometimes essentially stung the nerve if you will, and people's pain does disappear for much longer afterwards depending on the diagnosis.

Dr. Miller: How effective is this in reducing pain? Is it 80% effective, 50%, 30%? What's the story on that for patients that might be considering an epidural injection?

Dr. Kendall: Well in certain conditions, it can be very effective with disc herniations and people with radiculopathy or pain down the leg from that disc herniation. If you take all patients who could be surgical candidates and you do the injection, 60% of them choose not to have surgery because their pain improves significantly with the injection, and they choose to just not have the surgery because they're doing better.

Dr. Miller: So a great option to may be postpone or prevent surgery.

Dr. Kendall: So a great option for more than half the people . . .

Dr. Miller: That's great.

Dr. Kendall: . . . to really decrease pain, get them on, and avoid a surgery that lays you up for a few weeks or more.

Dr. Miller: Now can you have repeated injections if necessary or is there a limit on the number of injections one can have?

Dr. Kendall: There's not an actual limit, however we usually say three or so a year would be the most we would consider. Some people, it does take one or two injections to really get rid of that leg pain that they have and avoid the surgery. However if we do two injections and your pain comes back within a week, then actually surgery is probably a much better choice.

Dr. Miller: So you do these under imaging, and that helps direct the shot into the area that needs to be infused I guess.

Dr. Kendall: We do these all under X-Ray guidance, so we know exactly where we're going, we know exactly where the needle tip is. We inject a little bit of contrast die to make sure we're not in a nerve or a blood vessel. So overall these are very, very safe injections.

Dr. Miller: Now how would a patient find a physician that would be qualified to do these kinds of treatments? I don't think they necessarily need to go to a surgeon per se, do they?

Dr. Kendall: No, in fact most surgeons don't do these epidural injections. Most are non-operative either anesthesiology or physical medicine rehabilitation physicians. Most people who are pain board certified have done significant amounts of injections, and finding a physician who specializes in back pain and pain will certainly have enough training to do these.

Dr. Miller: Now last question is, if the injection is effective, how long could someone expect to have the effect last?

Dr. Kendall: Most of the time, I tell people until they do something that irritates their back again, it's really not easy for us to say a time frame. It's mostly until you bend funny again or slip or shovel too much snow or do something again that may irritate that disc again.

Dr. Miller: I'm assuming you'd also have them follow up with exercise therapy and physical therapy as another modality to continue to strengthen the back and prevent further injury.

Dr. Kendall: Yes, we always have our patients continues with their exercise program throughout this even before and afterwards just because that's going to decrease the likelihood of you flaring it up again.

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Interviewer: You're having sinus surgery and you're wondering how you prepare. We're going to talk about those issues next on The Scope.

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Interviewer: The purpose of this podcast is to help you, the patient who's decided that you want to get sinus surgery, to understand what you can do to best prepare for the procedure. There are a lot of things to consider, like how much time do you get off work, do you need to fast before, will you need to arrange for somebody to drive you.
We're going to talk about those and other things right now with Dr. Richard Orlandi. He's one of the experts here in this type of surgery at University of Utah Healthcare. So what's the first consideration that somebody should think about or do before surgery?

Dr. Orlandi: I think the most important thing is they want to be sure about their decision, and I certainly want, in our practice we want to make sure that our patients' questions and concerns are fully addressed before they make this decision. We don't want them to have any second thoughts. And so, again, we try to address every concern that patients have and then certainly encourage them to seek a second opinion.
This is not a surgery, typically, that we have to rush into. Patients have typically had their symptoms for a long time. I think it's something that people can get a second opinion, take their time with this decision, talk to family and others who have had the surgery.

Interviewer: So if they're feeling a little uncomfortable with it or whatever that's a good indication maybe you should ask more questions beforehand.

Dr. Orlandi: Absolutely.

Interviewer: And the sooner the better, of course, because you don't lose your surgery day.

Dr. Orlandi: Well, asking those questions an hour before the surgery may be waiting a little bit too long.

Interviewer: Gotcha. What should I do leading up to surgery day and when does that all start?

Dr. Orlandi: We want the patients to have as much of the inflammation under control as possible, so we ask our patients to continue with the medications that they've been on before. We may stop them for a few days ahead of time for various reasons, but really, we think that continuing that medication ahead of time is really important to control the inflammation.
One of the other things that's really important for us and for our patients is to know what to expect after surgery, so we go through a lot of their post-operative care, actually, before the surgery to make sure they know how to rinse their nose out with salt water, take their medications, and make sure that, actually, even their medication prescriptions that they're going to need after surgery, we try to get those filled ahead of surgery so it's one less thing for them to worry about on the day of the surgery.

Interviewer: We've got a podcast, actually, that covers what to do and what you need to be aware about after surgery, so if you have any of those types of questions, not only check the information that you receive, but you could check out that podcast as well.
So are there any other considerations? It sounds like business as usual, take those medications. How far are you starting out in prep, a week before?

Dr. Orlandi: No, I think that again we're starting about a couple of weeks where we're continuing the medical therapy and then we may fine tune it within a few days prior to the surgery. But it is very similar to other surgeries where you're going to want to follow the instructions that you've been given as far as stopping eating or drinking, usually it's around midnight, sometimes a little later if your surgery is in the afternoon. Making sure someone can drive you. This is a surgery that's done typically under general anesthesia, meaning you're completely asleep. It can be done under local anesthesia if patients prefer. The vast majority prefer to be asleep, understandably.

Interviewer: Absolutely. That's a good consideration. You're going to have to have somebody to drive you home. How many days off of work should you take?

Dr. Orlandi: For sinus surgery, people typically take about a week, sometimes less, sometimes more, but on average about a week. Now if someone is having their septum corrected, the septum is the wall that runs down between the left and the right side of the nose, that septum, it's called a septoplasty to fix that. That septoplasty can actually be a little bit more painful. You're basically talking about kind of breaking the inside of the nose. Now, patients won't be black and blue after that on the outside, but it does cause a little bit more pain and sometimes patients will kind of lean more towards a 10-day time off work after that.

Interviewer: When I'm going in for my day of surgery I'm going to have somebody drive me. Hopefully I've already gotten my prescriptions. Do I need an overnight bag?

Dr. Orlandi: Nope, this is a surgery that's called an outpatient surgery. You come in and go home the same day. Sometimes patients will need to spend the night if they have another condition like sleep apnea or something like that, and that's discussed with the anesthesiologist, but most often this is something that's done in and out the same day, and when the patients do have to spend the night we make those plans ahead of time and so they know that.

Interviewer: For that person that's going to pick me up, can they just wait? Is it that quick of a procedure or should they go do something else?

Dr. Orlandi: It actually depends. There are four sinuses on either side and your surgeon may chose to operate on only one or all eight, so it really depends on the extent of the procedure. This is not a life-threatening surgery so people don't have to wait in vigil in the family waiting room. If they want to go and do something else, we'll call them ahead of time to come pick you up. That's certainly fine, too.

Interviewer: So it sounds like a question to ask and just something to be aware of.

Dr. Orlandi: Absolutely.

Interviewer: What other things do you tell your patients when it comes to preparing for the surgery?

Dr. Orlandi: You know, I think we've covered it. I think again that the most important point is to make sure you're comfortable with your decision. Don't feel rushed into this. This is something that you can take your time deciding on.

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Interviewer: A study finds that when it comes to choosing health care procedures, cost matters. More next on the Scope.

Announcer: Examining the latest research and telling you about the latest breakthroughs. The Science and Research Show is on The Scope.

Interviewer: I'm here with General Pediatric Surgeon, Dr. Eric Scaife. Dr. Scaife, tell me about your study.

Dr. Scaife: It occurred to me that unlike many other parts of our economy, the consumers don't really understand the cost of medicine despite the fact that it represents about a quarter of our economy. And so as a pediatric surgeon one of the most common things that we deal with is pediatric appendicitis. We take out one or two appendixes a day. And we have two different ways of taking out your appendix. One with an open technique and one with a laparoscopic technique which requires specialty instruments.

And the outcomes in children with non-perforated appendicitis turns out to be the same, but the cost is quite different. And so it presented a really unique model for us where we could have a procedure with similar outcomes, but a very big difference in terms of cost. And we thought why not allow the patients to consider the cost in terms of which operation they get.

Most of the time we actually make the decision for them. And so it would be an interesting experiment that a patient could actually behave like a consumer as they would in any other part of the market.

Interviewer: Right. And what kind of difference in cost are we talking about?

Dr. Scaife: So for our study the open operation was about $3,000 cheaper than the laparoscopic operation. And the primary difference there is that the open operation requires a scalpel and some sutures and some instruments to provide exposure whereas the laparoscopic operation requires a number of gadgets, most of which tend to be disposable.

Interviewer: Does the patient end up paying a difference in cost?

Dr. Scaife: Well, this is where medicine gets really complicated and it's hard to peel out all of these differences, but I can tell you when I spoke with Primary Children's accountants, so basically their answer is that at the end of the day these are direct cost differences in terms of materials that are charged to the patient. So theoretically they should be exposed to that difference in cost. Whether or not that actually happens or not gets a lot muddier.

Interviewer: What were the results of the study? What did the patients decide?

Dr. Scaife: We randomized patients to either be exposed to just the difference in the procedures versus other patients that saw the difference in procedures plus the

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Interviewer: I think it might surprise a lot of people that if you have a surgical procedure, that sometimes the coordination of care before and after the procedure can be a bit challenging. But out to solve the problem is Dr. Benjamin Brooke. He's an Assistant Professor of Surgery at the Division of Vascular Surgery at the University of Utah School of Medicine.
This story is interesting for a couple of reasons. Reason number one is the coordination of care issue, which really kind of surprises me that it's not better. And second of all, this research study that you're doing is a little unique in the fact that it's actually involving patients. That's kind of a novel idea. Tell me about your research.

Dr. Benjamin Brooke: As a surgeon I've had a lot of experience where many times patients aren't well informed with their diagnosis, what they're coming to see a surgeon for. Then after they have an operation their transitioning back to their medical providers they've seen for a long time, but there's not great communication between the surgical team and the medical team. So I wanted to look at this a little more carefully and try to find out why some of these patients aren't getting the right coordination of care as they transition to the surgical team and then follow-up care after surgery.

Interviewer: Other than maybe inconvenience and confusion, are there other detriments to this lack of good coordination?

Dr. Benjamin Brooke: There is a potential for harm or for errors to occur when patients don't understand exactly what they are seeking treatment for, or while they're undergoing treatment, making sure they are on the right medications, they are following the right treatment plans. If they're not actually engaged in their care plan, that can lead to poor medical outcomes, or medical errors.
The second thing is that if patients aren't engaged in the process, I think they are also less apt to follow-up with the recommended treatment plans and that's clearly related to their outcomes.
The third thing, I should say, is that we feel that patients are going to have better experiences and have better patient reported outcomes if they feel like they are more engaged in the process and that's what we're also trying to look at. Just because the patient receives an operation and we feel like everything goes smoothly, sometimes the patients might feel from their perspective that things actually didn't go very smoothly and they had a very poor experience while they were in the hospital, or when they were trying to have follow-up care arranged.

Interviewer: What are some common problems when it comes to coordination of care that you've seen so far?

Dr. Benjamin Brooke: Sometimes when we're trying to explain to patients what they are going to be undergoing before surgery, there is a lot of times poor communication between the providers and the patients, and perhaps they might not understand fully what they are in for. Then after receiving an operation, they might not receive the right coordination to understand what they should be doing after surgery.
Should they be doing certain things when they go home? Should they be seeing their primary care provider within a short time after leaving the hospital? When should they follow up with their surgical team? There are a lot of things that we do when we're discharging a patient in that discharge planning process that I think needs some improvement and that's why we sought to look at this a little more carefully.

Interviewer: I have a hard time believing that a patient could come in for a major procedure like surgery and be that confused. Is it the patients just not paying attention, or are we not doing a good enough job of explaining, or both?

Dr. Benjamin Brooke: Well, it's a little bit of both. You could imagine a patient comes in for a major operation, and you're giving them a lot of information. They're trying to process it as much as they can, but clearly patients are stressed. They have a lot of things that they're thinking about. They might be worried about, "Am I going to die from this operation? Am I going to have a major complication?"
So a lot of what you tell them, I don't know if they actually walk away with. So I think we can do a better job with trying to focus on how to educate patients in environments where perhaps they're going to retain more information.

Interviewer: Now tell me about your research project in terms of using actual patients to be part of the research. You were explaining to me that they are actually going to be involved in the research, not just asked questions per se, but participants.

Dr. Benjamin Brooke: Correct. We received funding through an organization called PCORI, which is the Patient-Centered Outcomes Research Institute. It's a non-profit organization funded by the Affordable Care Act of 2010. It's funded by government money, but it's not tied to government funds.
The goal of this organization is to fund patient-centered research whereby patients are actually involved with designing the studies, and they are part of the research team. We're trying to form communities of patients that want to be part of our research team and what we're trying to do is to find patients who have had an experience with surgery, either as a caregiver or as a patient. Again, these are patients who are being worked up for an operation, or maybe they've already had an operation.
We want to find out what they're experience was. Did they feel like they had good access to care, or did they have a hard time finding a doctor to do an operation? And then after an operation, did they have good follow-up care? Did they have care coordinated between their team in the hospital and their outpatient care provider, such as a family doctor or an intern who might have been following them for the last 20 years?

Interviewer: So how could somebody who has fit the qualifications you said, somebody who has gone through surgery or is preparing to, if they've never done a research project, how can they design a research project?

Dr. Benjamin Brooke: Well, that's kind of the beauty of this. Patients can be as experienced or have very little experience with a research process, but what they can bring to the table is just their own experience. And what we're trying to do is to get enough patients that say, "This is a problem that happened to me," and develop common themes among different patients; and then design interventions to try to target those problems that they've identified. If we don't have the patients, we don't really have the ability to design the research.

Interviewer: I was being a little flip, I guess, earlier when I said is it the patient that doesn't get it, or are we not doing a good enough job explaining it. But there's not a lot of research that even tells you if either one of those is the case. You might find something else entirely.

Dr. Benjamin Brooke: I think this is the future of research, in that we are trying to look at things that are very important to patients, and things that are going to be affecting patients in a way that may be as physicians, providers, or even researchers, that we're not recognizing.

Interviewer: I think anybody who has been in any other sort of industry would kind of chuckle at that notion a little bit. But that's been a problem with healthcare, not involving the patient. Am I correct on that?

Dr. Benjamin Brooke: Right, I think it's this ivy tower mentality that we have all the solutions and we're the smartest people to address these problems. Well, in actuality there's a lot of problems that are just not being addressed, and patients are walking away not satisfied with the level of care they're receiving.

Interviewer: Yes, the customer would be another way of putting it as well. So if somebody is interested in participating are you actively looking right now?

Dr. Benjamin Brooke: Yes, we're having focus groups around the valley. We've had a couple so far, and again, we're trying to basically engage patients in this process. We have a website that we can provide a link to. We're just trying to get a good spectrum of patients from around the valley.
We are also looking at engaging patients up in surrounding areas, such as Evanston, Pocatello, Rock Springs, Vernal. We really want to get a nice broad representative patient population from around the state and around the region.
The other thing I should just point out is that Utah is very unique in that the University of Utah services almost four surrounding intermountain states. We are a tertiary medical that really gets a lot of patients that come from 200 to 500 miles away to receive care. And so, a lot of these problems that I brought up are really sort of exacerbated by these patients that might have to travel 300 miles to come down from Idaho to receive care but then they go back and it's hard to maintain that continuity of care.

Interviewer: Are you pretty excited about all this?

Dr. Benjamin Brooke: Yeah. I think it's a great project, and I think there are a lot of things that we can do to hopefully improve this care coordination problem.

Interviewer: Thank you very much for taking time and explaining your research, and good luck.

Dr. Benjamin Brooke: Thank you.

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