Präoperative Physiotherapie vor viszeralen abdominalen Operationen digital umsetzen? – Eine qualitative Machbarkeitsstudie

Zusammenfassung

Hintergrund Große Operationen am Bauchraum stellen die größte Gruppe der Operationen in Deutschland dar. Besonders Patient*innen mit Komorbiditäten zeigen ein hohes Risiko für die Entwicklung postoperativer respiratorischer Komplikationen und damit einhergehend postoperativer Einbußen der körperlichen Funktionsfähigkeit. Obwohl präoperative Physiotherapie positiven Einfluss auf die Komplikationsrate nehmen kann, wird sie in Deutschland nicht regelhaft umgesetzt.

Ziel Untersuchung der Machbarkeit einer digitalen Umsetzung präoperativer Physiotherapie aus der Perspektive von Ärzt*innen, Physiotherapierenden und Patient*innen. Dazu werden Bedarfe an eine digitale Intervention sowie inhaltliche und technische Anforderungen erfragt.

Methode In einer qualitativen Studie wurden 2 Ärzt*innen, 5 Physiotherapierende und 2 Patienten interviewt. Die Daten wurden transkribiert und mittels qualitativer Inhaltsanalyse nach Schreier [35] ausgewertet.

Ergebnisse Die Ergebnisse bestätigten die hohe Relevanz der präoperativen Versorgung. Digitale Interventionen können die in diesem Zusammenhang existierende Versorgungslücke schließen. Die formulierten Anforderungen an eine Individualisierung und einen motivierenden Charakter können insbesondere durch Apps realisiert werden.

Diskussion Die zu entwickelnde App soll darauf abzielen 1.) eine Verhaltensänderung anzubahnen, 2.) Wissen zu vermitteln und 3.) Übungen anzuleiten. Vor dem Hintergrund der Zielsetzungen und dem Kontext, in dem die App Anwendung finden soll, ist von einer hohen Komplexität bei der Entwicklung und besonders der Implementierung auszugehen. Gleichzeitig ermöglicht die vorgelegte Analyse eine direkte Bearbeitung der identifizierten Herausforderungen.

Schlussfolgerung Die Entwicklung einer App als Teil der präoperativen Vorbereitung hat das Potenzial, eine aktuelle Versorgungslücke zu schließen und die möglichen negativen Folgen einer Operation zu adressieren. Die vorgelegte Studie gibt Hinweise für die nächsten Entwicklungsschritte.

Abstract

Background Major abdominal surgery builds the largest group of surgery in Germany. Especially patients with comorbidities are of high risk to develop postoperative respiratory complications associated with a decrease in functional capacity. Although preoperative physiotherapy can have a positive impact on complication rate, patients in Germany do not receive preoperative physiotherapy management in general.

Aim The feasibility of digitized preoperative physiotherapy will be studied from different stakeholder perspectives (physicians, physiotherapists, patients). Needs as well as content-related and technical requirements will be discussed.

Methods 2 physicians, 5 physiotherapists and 2 patients were interviewed for this qualitative study. Data were transcribed verbatim and analyzed using qualitative content analysis by Schreier [35].

Results Underlining the relevance of preoperative treatment. Digitized interventions have the potential to close the existing gap in current health services. Individualization and motivating design can be best achieved in developing an app. 

Discussion The preoperative physiotherapy app should 1) initiate behavioral changes, 2) impart knowledge and 3) instruct exercises. The development and implementation of the app is expected to be of high complexity, due to the context and unknown user and health-professional use in practice. Nevertheless, the identified challenges can be processed on the basis of this analysis.

Conclusion The development of an app as part of the preoperative management has the potential to close a gap in current health service and therefore address the possible negative consequences of a surgery. This study can inform the next steps in the development of this app. 

Schlüsselwörter

präoperative Physiotherapie - Prähabilitation - Gesundheitsapps - Viszeralchirurgie - Komplikationen - Funktionsfähigkeit

Key words

preoperative physiotherapy - prehabilitation - mHealth - visceral surgery - complications - functional capacity

Publikationsverlauf

Eingereicht: 14. September 2021

Angenommen: 30. April 2022

Artikel online veröffentlicht:
22. Juli 2022

• Literatur

• 1 Baum P, Diers J, Lichthardt S. et al. Mortality and Complications Following Visceral Surgery: A Nationwide Analysis Based on the Diagnostic Categories Used in German Hospital Invoicing Data. Dtsch Arztebl Int 2019; 116: 739-746 DOI: 10.3238/arztebl.2019.0739.
• 2 Boden I, Robertson IK, Neil A. et al. Preoperative physiotherapy is cost-effective for preventing pulmonary complications after major abdominal surgery: a health economic analysis of a multicentre randomised trial. J Physiother 2020; 66: 180-187 DOI: 10.1016/j.jphys.2020.06.005.
• 3 Statistisches Bundesamt, Hrsg. Fallpauschalenbezogene Krankenhausstatistik (DRG-Statistik) Diagnosen, Prozeduren, Fallpauschalen und Case Mix der vollstationären Patientinnen und Patienten in Krankenhäusern. Fachserie 12 Reihe 6.4. , 2016
• 4 Martin D, Mantziari S, Demartines N. et al. Defining Major Surgery: A Delphi Consensus Among European Surgical Association (ESA) Members. World J Surg 2020; 44: 2211-2219 DOI: 10.1007/s00268-020-05476-4.
• 5 Hemmes SNT, Gama de Abreu M. PROVE Network Investigators for the Clinical Trial Network of the European Society of Anaesthesiology. et al. High versus low positive end-expiratory pressure during general anaesthesia for open abdominal surgery (PROVHILO trial): a multicentre randomised controlled trial. London (UK): Lancet 2014; 384: 495-503 DOI: 10.1016/S0140-6736(14)60416-5.
• 6 Jakobson T, Karjagin J, Vipp L. et al. Postoperative complications and mortality after major gastrointestinal surgery. Medicina 2014; 50: 111-117 DOI: 10.1016/j.medici.2014.06.002.
• 7 Fernandez-Bustamante A, Frendl G, Sprung J. et al. Postoperative Pulmonary Complications, Early Mortality, and Hospital Stay Following Noncardiothoracic Surgery: A Multicenter Study by the Perioperative Research Network Investigators. JAMA Surg 2017; 152: 157-166 DOI: 10.1001/jamasurg.2016.4065.
• 8 Brown SR, Mathew R, Keding A. et al. The impact of postoperative complications on long-term quality of life after curative colorectal cancer surgery. An Surgery 2014; 259: 916-923 DOI: 10.1097/SLA.0000000000000407.
• 9 Shander A, Fleisher LA, Barie PS. et al. Clinical and economic burden of postoperative pulmonary complications: patient safety summit on definition, risk-reducing interventions, and preventive strategies. Crit Care Med 2011; 39: 2163-2172 DOI: 10.1097/CCM.0b013e31821f0522.
• 10 Kim SP, Leibovich BC, Shah ND. et al. The relationship of postoperative complications with in-hospital outcomes and costs after renal surgery for kidney cancer. BJU Int 2013; 111: 580-588 DOI: 10.1111/j.1464-410X.2012.11122.x.
• 11 Reeve J, Boden I. The physiotherapy management of patients undergoing abdominal surgery. NZJP 2016; 44: 33-49 DOI: 10.15619/NZJP/44.1.05.
• 12 Tew GA, Ayyash R, Durrand J. et al. Clinical guideline and recommendations on pre-operative exercise training in patients awaiting major non-cardiac surgery. Anaesthesia 2018; 73: 750-768 DOI: 10.1111/anae.14177.
• 13 Scheede-Bergdahl C, Minnella EM, Carli F. Multi-modal prehabilitation: addressing the why, when, what, how, who and where next?. Anaesthesia 2019; 1: 20-26 DOI: 10.1111/anae.14505.
• 14 Boden I, Skinner EH, Browning L. et al. Preoperative physiotherapy for the prevention of respiratory complications after upper abdominal surgery: pragmatic, double blinded, multicentre randomised controlled trial. BMJ 2018; 360: j5916-j5916 DOI: 10.1136/bmj.j5916.
• 15 Thomas G, Tahir MR, Bongers BC. et al. Prehabilitation before major intra-abdominal cancer surgery: A systematic review of randomised controlled trials. Eur J Anaesthesiol 2019; 36: 933-945 DOI: 10.1097/EJA.0000000000001030.
• 16 Fagevik Olsen M, Hahn I, Nordgren S. et al. Randomized controlled trial of prophylactic chest physiotherapy in major abdominal surgery. British J Surgery 1997; 84: 1535-1538 DOI: 10.1111/j.1365-2168.1997.02828.x.
• 17 Boden I, El-Ansary D, Zalucki N. et al. Physiotherapy education and training prior to upper abdominal surgery is memorable and has high treatment fidelity: a nested mixed-methods randomised-controlled study. Physiotherapy 2018; 104: 194-202 DOI: 10.1016/j.physio.2017.08.008.
• 18 Barakat HM, Shahin Y, Khan JA. et al. Preoperative Supervised Exercise Improves Outcomes After Elective Abdominal Aortic Aneurysm Repair: A Randomized Controlled Trial. An Surgery 2016; 264: 47-53 DOI: 10.1097/SLA.0000000000001609.
• 19 Barberan-Garcia A, Ubre M, Roca J. et al. Personalised Prehabilitation in High-risk Patients Undergoing Elective Major Abdominal Surgery: A Randomized Blinded Controlled Trial. An Surgery 2018; 267: 50-56 DOI: 10.1097/SLA.0000000000002293.
• 20 Liang MK, Bernardi K, Holihan JL. et al. Modifying Risks in Ventral Hernia Patients With Prehabilitation: A Randomized Controlled Trial. An Surgery 2018; 268: 674-680 DOI: 10.1097/SLA.0000000000002961.
• 21 Carli F, Charlebois P, Stein B. et al. Randomized clinical trial of prehabilitation in colorectal surgery. Brit J Surgery 2010; 97: 1187-1197 DOI: 10.1002/bjs.7102.
• 22 Kaibori M, Ishizaki M, Matsui K. et al. Perioperative exercise for chronic liver injury patients with hepatocellular carcinoma undergoing hepatectomy. Am J Surgery 2013; 206: 202-209 DOI: 10.1016/j.amjsurg.2012.07.035.
• 23 Gillis C, Li C, Lee L. et al. Prehabilitation versus Rehabilitation: A Randomized Control Trial in Patients Undergoing Colorectal Resection for Cancer. Anesthesiology 2014; 121: 937-947 DOI: 10.1097/ALN.0000000000000393.
• 24 Dunne DFJ, Jack S, Jones RP. et al. Randomized clinical trial of prehabilitation before planned liver resection. Brit J Surgery 2016; 103: 504-512 DOI: 10.1002/bjs.10096.
• 25 Reeve J, Anderson L, Raslam Y. et al. The physiotherapy management of patients undergoing thoracic surgery: a survey of current practice in Australia and New Zealand. NZJP 2019; 47: 566-575 DOI: 10.1002/pri.354.
• 26 van der Meij E. Improving Postoperative Recovery by eHealth. Amsterdam: Diss vorgelegt an Vrije Universiteit Amsterdam; 2019
• 27 van der Velde M, Valkenet K, Geleijn E. et al. Usability and Preliminary Effectiveness of a Preoperative mHealth App for People Undergoing Major Surgery: Pilot Randomized Controlled Trial. JMIR Mhealth Uhealth 2021; 9: e23402 DOI: 10.2196/23402.
• 28 Herrera-Usagre M, Santana V, Burgos-Pol R. et al. Effect of a Mobile App on Preoperative Patient Preparation for Major Ambulatory Surgery: Protocol for a Randomized Controlled Trial. JMIR Res Protoc 2019; 8 DOI: 10.2196/10938.
• 29 Pfirrmann D, Tug S, Brosteanu O. et al. Internet-based perioperative exercise program in patients with Barrett’s carcinoma scheduled for esophagectomy [iPEP – study] a prospective randomized-controlled trial. BMC Cancer 2017; 17: 413 DOI: 10.1186/s12885-017-3400-8.
• 30 Rowland SP, Fitzgerald JE, Holme T. et al. What is the clinical value of mHealth for patients?. NPJ Digit Med 2020; 3: 4 DOI: 10.1038/s41746-019-0206-x.
• 31 Granja C, Janssen W, Johansen MA. Factors Determining the Success and Failure of eHealth Interventions: Systematic Review of the Literature. J Med Internet Res 2018; 20: e10235 DOI: 10.2196/10235.
• 32 Behrens J, Langer G. Evidence based Nursing and Caring. Methoden und Ethik der Pflegepraxis und Versorgungsforschung – Vertrauensbildende Entzauberung der „Wissenschaft“. 5. Aufl.. Bern: Hogrefe AG; 2022
• 33 Witzel A. Das problemzentrierte Interview. FQS 2000; 1: 1-13
• 34 Helfferich C. Die Qualität qualitativer Daten. Wiesbaden: VS Verlag für Sozialwissenschaften; 2011. DOI: 10.1007/978-3-531-92076-4
• 35 Schreier M. Qualitative content analysis in practice. London: Sage; 2012
• 36 Dresing T, Pehl T. Praxisbuch Interview, Transkription & Analyse: Anleitungen und Regelsysteme für qualitativ Forschende. 7. Aufl.. Marburg: Eigenverlag; 2017
• 37 Greenhalgh T, Abimbola S. The NASSS Framework – A Synthesis of Multiple Theories of Technology Implementation. Stud Health Technol Inform 2019; 263: 193-204 DOI: 10.3233/SHTI190123.
• 38 World Health Organization, Hrsg. mHealth: New horizons for health through mobile technologies: second global survey on eHealth. Im Internet (Stand: 30.06.2022): https://apps.who.int/iris/bitstream/handle/10665/44607/9789241564250_eng.pdf?sequence=1&isAllowed=y
• 39 Barberan-Garcia A, Ubre M, Pascual-Argente N. et al. Post-discharge impact and cost-consequence analysis of prehabilitation in high-risk patients undergoing major abdominal surgery: secondary results from a randomised controlled trial. Brit J Anaesthesia 2019; 123: 450-456 DOI: 10.1016/j.bja.2019.05.032.
• 40 McKinsey & Company, Hrsg. Report eHealth Monitor 2020. Deutschlands Weg in die digitale Gesundheitsversorgung – Status quo und Perspektiven. Im Internet (Stand: 30.06.2022): www.mckinsey.de/~/media/mckinsey/locations/europe%20and%20middle%20east/deutschland/news/presse/2020/2020-11-12%20ehealth%20monitor/ehealth%20monitor%202020.pdf
• 41 Simpao AF, Lingappan AM, Ahumada LM. et al. Perioperative Smartphone Apps and Devices for Patient-Centered Care. J Med Syst 2015; 39: 102 DOI: 10.1007/s10916-015-0310-7.
• 42 Bert F, Giacometti M, Gualano MR. et al. Smartphones and health promotion: a review of the evidence. J Med Syst 2014; 38: 9995 DOI: 10.1007/s10916-013-9995-7.
• 43 Martínez-Pérez B, La Torre-Díez de I, López-Coronado M. et al. Mobile clinical decision support systems and applications: a literature and commercial review. J Med Syst 2014; 38: 4 DOI: 10.1007/s10916-013-0004-y.
• 44 Moller AC, Merchant G, Conroy DE. et al. Applying and advancing behavior change theories and techniques in the context of a digital health revolution: proposals for more effectively realizing untapped potential. J Behav Med 2017; 40: 85-98 DOI: 10.1007/s10865-016-9818-7.
• 45 Hillen B, Simon P, Grimminger PP. et al. Use of a Perioperative Web-Based Exercise Program for a Patient with Barrett’s Carcinoma Scheduled for Esophagectomy. Case Rep Oncol 2019; 12: 755-764 DOI: 10.1159/000503558.
• 46 World Physiotherapy, Hrsg. Description of physical therapie. Policy statement.. Im Internet (Stand 30.06.2022): https://world.physio/sites/default/files/2020-07/PS-2019-Description-of-physical-therapy.pdf