Transforming Frailty Care in Allo-HCT Candidates: A Prospective Assessment of a Tele-Prehabilitation Project
Authors: Salas Maria Queralt , Salinas González Raquel , Mestre Carla , Guardia Laia , Moreno Cristina , Sole Berta , Pinto Filipe , Charry Paola , Cid Joan , Lozano Miquel , Cascos Enric , Martinez-Sanchez Julia , Diaz-Ricart Maribel , Sebio Raquel , Laxe Sara , Carreras Enric , Esteve Jordi , Suarez-Lledo Maria , Rosiñol Dachs Laura , Closa Concepción , Martinez Munoz Maria Carmen , Fernández-Avilés Francesc , Rovira Montserrat 
Published: December 2024

Introduction

Frailty increases the risk of mortality and morbidity in allo-HCT patients. Therefore, the assessment for prevention and improving of frailty in allo-HCT candidates should improve transplant outcomes. With this premise, a Frailty Program for adult allo-HCT candidates has been developed at our institution. Starting in April 2021, all candidates were assessed for frailty using the HCT Frailty Scale at their first allo-HCT consultation and again at HCT admission. In June 2022, a pilot outpatient pre-habilitation (pre-hab) program (PreHabP) focusing on physical activity was launched. Enhancements were made in November 2023, incorporating a telematic physiotherapy app and pretransplant nutritional support.

This analysis prospectively evaluates the preliminary outcomes of the innovative outpatient pre-hab program supervised through telemedicine (T-PreHab) for adult allo-HCT candidates implemented at our institution.

Methods

Since November 2023, all allo-HCT candidates were included in the T-PreHab. A median of 7 days after the first allo-HCT consultation, a PM&R physician assesses and prescribes an individualized home-based exercise program tailored to the patient's frailty status (according to the HCT Frailty Scale) and medical history. A nutritional consultation provides personalized recommendations and protein supplements if needed. The T-PreHab is delivered via a dedicated app with comprehensive video instructions to enhance understanding and adherence. This program includes a minimum of 3 asynchronous e-training sessions/week until the HCT admission, with telematic weekly follow-ups. Its effectiveness is evaluated with the HCT Frailty Scale at admission

Ongoing results are evaluated prospectively, with all patients providing informed consent. The project that is part of a broader Frailty Program has been implemented using existing institutional resources. No external funding was obtained.

Results

From November 2023 to July 2024, 25 patients participated in the T-PreHab and were admitted for allo-HCT. The median age was 60 years. Acute myeloid leukemia (44%) was the most prevalent indications for allo-HCT. Seven patients (28%) had a KPS &lt;90%, 6 (24%) had an HCT-CI &gt;3, and 9 (36%) had a high/very high DRI. Most patients (n=18, 72%) received HLA-matched grafts, 14% (n=11) underwent MAC allo-HCT, and 96% (n=24) received PTCY. 24 (96%) patients were successfully discharged, though 2 (8%) died during follow-up, with one (4.0%) death due to NRM.

At first consultation, 9 patients (35.6%) were fit, 13 (52.0%) were pre-frail, and 3 (12.0%) were frail. After pre-hab and at HCT admission, 16 (64.0%) patients were fit, 8 (32.0%) were pre-frail, and 1 (4.0%) was frail. Specifically, all (100%) the fit patients remained fit, 6 (46.1%) of the 13 pre-frail patients became fit, 6 (46.1%) remained pre-frail, and 1 (7.6%) progressed to a frail state. All frail patients improved to better frailty states, with 1 (33.3%) patient progressing to a fit state and the other two (66.6%) to a pre-frail state. The median duration of the T-PreHab was 7 weeks, with no reported clinical complications. Patient program´s adherence was &gt;80%.

The effectiveness of the T-PreHab was assessed comparing the evolution of frailty in patients participating in the program with that of patients who did not underwent pre-hab, and with patients that participated in the pilot PreHab (without telemedicine). The frailty status of the 59 non-prehabilitated patients evaluated for frailty between April 2021 and May 2022, remained largely unchanged: 35.6% / 35.6% fit, 54.2% / 52.5% pre frail, and 10.2% / 11.9% frail. In the 54 patients participating in the pilot PreHabP (June 2022 - October 2022), the proportion of fit patients increased from 24.1% to 46.3%, and pre-frail and frail proportions decreased from 64.8% to 50.0% and from 11.1% to 3.7%. With the T-PreHab, the fit proportion increased even more, from 37.0% to 64.0%, and pre-frail and frail proportions decreased from 52.0% to 32.0% and from 12.0% to 4.0%. Reductions on frailty trend to be statistically significant (p=0.064).

Conclusion

The frailty status of allo-HCT candidates is dynamic and can be positively treated through cost effective frailty evaluations and with tailored pre-hab programs implemented before allo-HCT. Telemedicine together with accessible and personalized care can enhance the cost-effectiveness of pre-hab programs.