Title: Mapping and Identifying Quality and Inequality in Prehabilitation for Cancer Surgery: Evidence for Improvement
Funder: Department of Health and Social Care

Abstract: Prehabilitation is the name given to a programme of different activities, such as exercise, diet, and psychological support. It is designed to help an individual be better prepared, physically and emotionally, for a major event such as cancer treatment. However, the scientific evidence to support its use before cancer treatment is mixed, and the detail of what a prehabilitation programme involves if often not well explained._x000D_ _x000D_ Patients’ views on how prehabilitation is delivered vary, and little is known about what patients want from these services. Despite these uncertainties, many areas of the NHS recommend and provide prehabilitation for patients awaiting cancer surgery. Some of these are run across a whole city or region, but many are very small and limited to a particular hospital or even particular types of cancer. Different services are available to different people in different parts of the country, with some people having no suitable services available at all._x000D_ _x000D_ We aim to make a major contribution towards addressing the problem of variation in prehabilitation before cancer surgery. We will work with patients, carers and healthcare professionals to find ways to describe, measure and assess the quality of services. We will also identify and share examples of best practice about how services are developed, funded and delivered. This project answers the call made by the NIHR, Royal College of Anaesthetists and Macmillan to “gather examples of how local areas have had prehabilitation commissioned as part of the cancer pathway”._x000D_ _x000D_ People from underserved and minority backgrounds often have poorer health outcomes and prehabilitation has the potential to worsen inequalities, which may mean that it works better for some than others. For example, some people may find it harder to engage with prehabilitation because of limited access to exercise facilities, the internet, transport, funding and time. This project will specifically aim to describe the ways in which prehabilitation is affected by health inequalities, and capture any solutions developed to address them and make services more equitable._x000D_ _x000D_ The project has four main parts:_x000D_ 1. Defining aims, objectives and values: we will work with patients, clinicians and researchers to co-develop criteria that explain what is important about prehabilitation, in order to describe and evaluate services. _x000D_ 2. Mapping: making use of the co-developed criteria, we will produce a national map of prehabilitation services. This will also record data about how services are funded, who delivers them, and how they are delivered. _x000D_ 3. Case studies: using the national map, we will identify 8 services for in-depth analysis through observations and interviews with patients, carers and staff. This will allow us to identify areas of best practice. _x000D_ 4. Informing policy and practice: drawing on the results of the project, we will produce a set of best practice principles for prehabilitation prior to cancer surgery. We will also make the national map available as a resource for others to use. _x000D_ _x000D_ By understanding what ‘quality’ means in prehabilitation, and how healthcare inequalities may be best addressed by prehabilitation services, this project is a vital step in making sure that all patients have equitable access to high-quality prehabilitation services prior to cancer surgery, regardless of their geographical location or personal circumstances.

Lay abstract: Background: In the setting of cancer surgery, prehabilitation can be described as ‘the practice of enhancing a patient’s functional capacity before surgery, with the aim of improving postoperative outcomes’. Typically, prehabilitation programmes focus on physical activity, diet, and psychological support, alone or in combination. In recent years prehabilitation has become an accepted component of many cancer surgery pathways. However, the scientific evidence to support its use is variable and the descriptions of prehabilitation interventions are often imprecise, making it difficult to translate research into practice and compare services. Furthermore, patients’ views on how the services are delivered vary, and little is known about what patients want from prehabilitation. There is also wide geographical variation in provision and type of service, compounded by substantial inequities resulting from existing disadvantage. This project will address these gaps in understanding and provision._x000D_ Research questions: What prehabilitation services are available before cancer surgery? What defines quality in such services, and what values and assumptions underpin successful delivery? What inequities exist in provision, and how might they best be addressed?_x000D_ Methods: We will use the Promoting Action on Research Implementation (PARIHS) framework as an overarching explanatory structure (Rycroft-Malone et al 2002). Within this are four linked work packages._x000D_ 1. We will use an inclusive, participatory methodology incorporating intelligence gathering, value-driven workshop events and a modified Delphi consensus process (Taylor 2020) to co-develop criteria describing what is important about prehabilitation, in order to characterise and evaluate services._x000D_ 2. We will draw on these criteria as we conduct a national survey to map out and describe existing prehabilitation services, guided by the Template for Intervention Description and Replication (TIDieR) checklist (Hoffman et al 2014). _x000D_ 3. We will purposively select sample services for closer scrutiny using case study methodology (Crowe et al 2011), and undertake in-depth analysis through interviews and observations with patients, carers and staff. This will allow us to identify areas of best practice, including how inequalities are addressed, as well as understanding the contextual factors which make services ‘work’ (Williams and Glaseby 2010, Head 2008)._x000D_ 4. We will refine the findings of the foregoing work packages through a modified nominal group process (Masterson-Algar 2018) to create a set of best practice principles, and will make this resource available for all to use. Stakeholder engagement and knowledge mobilisation will thread throughout the project._x000D_ Timelines: This study will be conducted over 30 months. Robust interim findings will be made available for NHS use as and when they become available, as part of the ongoing knowledge mobilisation approach in work package 4. _x000D_ Anticipated impact and dissemination: Cancer surgery is common, being part of the treatment received by 45% of patients with a cancer diagnosis (National Cancer Registration and Analysis Service 2017) and there is scope for improvement in longer-term outcomes. Effective prehabilitation has the potential to cost-effectively transform patients’ lives before and after such surgery, and our work will allow this benefit to be extended to all patients, including those who may be otherwise disadvantaged or excluded.

Research activity codes: 8.1 ORGANISATION AND DELIVERY OF SERVICES
Health categories: CANCER AND NEOPLASMS