Implementing Surgery School Prehabilitation Using Telehealth

Diagnosis of pneumonia

Diagnosis of pneumonia (Y/N) classified according the centre for disease control definition.

Time frame: Daily up to postoperative day 7 or until hospital discharge

Postoperative complications

Complications after surgery will be defined as any deviation from the normal postoperative course and classified according to the Clavien-Dindo classification. from Grade I through GradeV. Higher classifications indicating complications that require more complex interventions.

Time frame: Postoperative day 3,5,10 unless discharge prior and 30 days post operative.

Number of days alive and out of hospital

DAoH-30, DAoH-180, DAoH-365 (days alive and out of hospital 30, 180, 365 days post operatively): a patient centric metric and composite outcome that integrates several clinically important outcomes: hospital length of stay, re-admission or discharge to a destination other than origin (usually home) as well as survival. Higher numbers indicate a greater time alive and out of hospital post operatively.

Time frame: 30 days, 6 months and 12 months post operative

Maximal Inspiratory Pressure (MIP)

Maximal Inspiratory Pressure (cm H2O) will be assessed using a small handheld device using 3 tests of inspiratory muscle strength recording the highest value. Undertaken at centres participating in the sub study.

Time frame: Baseline and preoperatively at centres participating in the inspiratory muscle training sub study

Physical activity levels - subjective

Physical activity levels will be documented subjectively using the International Physical Activity Questionnaire - Short Form (IPAQ-SF). The IPAQ-SF is a questionnaire used internationally to obtain comparable estimates of physical activity. The questionnaire comprises seven questions related to physical activity at different levels of intensity and sitting time. Results will be reported in categories (low activity levels, moderate activity levels or high activity levels) and a continuous variable (MET minutes a week). Higher METs or categories indicate higher levels of physical activity.

Time frame: Baseline, Preoperatively, 30 days post operative

Physical activity levels - objective

Physical activity levels will be collected objectively using wearable monitors, such as fitbits for three days at baseline, three days after the intervention and at 30 days postoperatively. Physical activity variables will include the total number of daily steps, daily minutes of moderate to vigorous physical activity (MVPA), peak 1-minute cadence (the highest single minute of steps recorded), and peak 30-minute cadence (the average steps/min for the highest non-consecutive 30 minutes in a day). A minimum of 8 hours over 3 days is considered valid wear time for physical activity data. Values are described using mean +/- standard deviation and mean difference (MD) with 95% confidence intervals (95% CI).

Time frame: Baseline, Preoperatively, 30 days post operative

Video and Surgery School Session Attendance (Intervention group only)

Attendance at Surgery School session, length of time attended the Surgery School session and number of questions asked during Surgery School session.

Time frame: Preoperative timepoint

Access to video outside the Surgery School Session (Intervention group only)

The number of times the videos are accessed outside of the Surgery School session, site, day of week, time of day will be collected. Number of questions asked during Surgery School session.

Time frame: Preoperative timepoint

Symptoms: electronic Edmonton Symptom Assessment System-revised ((e)ESAS-r)

The electronic Edmonton Symptom Assessment System-revised ((e)ESAS-r) is a 10-item assessment tool for self-reporting symptom intensity via electronic platforms for digital use. The (e)ESAS-r allows participants to rate the severity of common symptoms as well as the opportunity to rate 'other problems' as nominated by the participant on a scale from 0 to 10 with higher score indicating higher severity of symptoms

Time frame: Baseline (and repeated every 4 weeks for participants having treatment before surgery), Preoperative, Postoperative: 30 days.

Behaviour Change

Behaviour change will be measured using a bespoke questionnaire: STTARRS behaviour change questionnaire (SBCQ) developed to assess patient action related to information (a) contained within the videos and surgery school session (intervention group) and (b) for usual care participants information provided to them through educational materials. This patient reported experience measure will measure responses to questions on a 5-point Likert scale (strongly disagree to strongly agree). Results will be presented descriptively. Higher responses on the likert scales indicates a higher agreement.

Time frame: Preoperative timepoint, at hospital discharge (+3 days)

Self-efficacy: Patient Activation Measure

Patient Activation Measure (PAM) is a questionnaire assessing three key domains: knowledge, skills, confidence to understand self-management ability. The PAM is a 13-item survey scored on a 100 point scale, with 4 activation levels validated for across time measures and used world-wide. PAM Levels 1 and 2 indicate lower patient activation, while PAM levels 3 and 4 indicate higher patient activation.

Time frame: Baseline, preoperative timepoint, 30 days and 6 months postoperative.

Treatment Burden: Multimorbidity Treatment Burden Questionnaire (MTBQ)

Multimorbidity Treatment Burden Questionnaire (MTBQ) is a 13 item questionnaire that assesses the perception of the effort required to self-manage their medical conditions and the impact that this has on their wellbeing. The MTBQ has demonstrated good content and construct validity, reliability and responsiveness. The MTBQ is scored from 0-100 with higher scores indicating higher treatment burden which fall into four categories: no burden (score 0), low burden (score \<10), medium burden (10-22) and high burden (\>=22).

Time frame: Baseline, preoperative timepoint, 30 days postoperative

Viewer perceptions of the intervention (intervention group only)

Viewer perceptions of the intervention including perceived personal relevance will be assessed using a previously published questionnaire. The questionnaire includes questions on four domains: helpfulness, believability, novelty, and relevance of information. A total of 7 questions all rate on 0-6 Likert scales from strongly disagree to strongly agree, with higher score indicating stronger agreement and an additional yes/no question asked regarding whether participants intend to change any behaviours.

Time frame: Preoperative timepoint

Feasibility of the teleprehabilitation program: Proportion of eligible patients participating

Portion of eligible patients participating will be collected and reported as a percentage of all patients eligible for the trial.

Time frame: Time Frame: Through study recruitment, up to 2.5 years

Feasibility of the teleprehabilitation program: Representativeness

Representativeness relative to a wider group of eligible patients presented descriptively

Time frame: Time Frame: Through study recruitment, up to 2.5 years

Feasibility of the teleprehabilitation program: Referral rates

Actual teleprehabilitation referral rates as a % of total eligible to be referred

Time frame: Time Frame: Through study recruitment, up to 2.5 years

Feasibility of the teleprehabilitation program: reasons for declining

Reasons for declining will be reported descriptively.

Time frame: Time Frame: Through study recruitment, up to 2.5 years

Acceptability

Participants will be asked to complete a survey regarding trial acceptability. The survey questions will be based upon the Theoretical Framework of Acceptability. The framework comprises seven domains designed to assess acceptability elements: perceived effectiveness, self-efficacy, affective attitude, ethicality burden, intervention coherence and opportunity costs.

Time frame: Preoperative timepoint, at hospital discharge (+3 days), 30 days post operative

Fidelity (treatment delivery): Tele-prehabilitation education session duration

Treatment delivery: using duration of education session provided (minutes).

Time frame: Through study data collection, up to 2.5 years

Fidelity (treatment delivery): Number of videos accessed

Treatment delivery: total number of videos accessed, presented descriptively and also by video title.

Time frame: Through study data collection, up to 2.5 years

Fidelity (treatment delivery): Number of video views

Treatment delivery: using number of videos viewed, results presented descriptively .

Time frame: Through study data collection, up to 2.5 years

Fidelity (treatment delivery): Telehealth implementation process concordance with implementation protocol.

Treatment delivery (centre level): using process concordance with implementation protocol.

Time frame: Through study data collection, up to 2.5 years

Fidelity (treatment delivery): viewing time

Treatment delivery: using the time of participant viewing (minutes).

Time frame: Through study data collection, up to 2.5 years

Fidelity (treatment receipt): participant attendance at telehealth zoom meeting

Treatment receipt: % of participants who attend a session once booked in

Time frame: Through study data collection, up to 2.5 years

Fidelity (treatment receipt): number of questions

Treatment receipt: the number of questions per session will be recorded.

Time frame: Through study data collection, up to 2.5 years

Fidelity (treatment receipt): participant retention at follow up

Treatment receipt: the number of participants attending follow up will be recorded (% of total participants).

Time frame: Through study data collection, up to 2.5 years

Participant satisfaction: Australian Hospital Experience Question Set (AHPEQS)

The Australian Hospital Patient Experience Question Set (AHPEQS) is a 12-item questionnaire (ten core items and two sub-items) used to measure patient satisfaction with recent treatment. Questions are measured on responses from always to never or didn't apply. Results will be reported descriptively with positive responses indicating greater satisfaction with recent treatment.

Time frame: 30 days post operative

Health related quality of life: EORTC QLQ-C30

European Organisation for the Research and Treatment of Cancer (EORTC QLQ- C30) core questionnaire is a measure composed of five multi-item domains (physical, role, emotional, cognitive function and social functioning). All of the scales and single-item measures range in score from 0 to 100. A high scale score represents a higher response level. A high score for a functional scale represents a high/healthy level of functioning. A high score for the global health status / quality of life represents a high quality of life but a high score for a symptom scale / item represents a high level of symptomatology / problems. The EORTC QLQ-C30 Summary score will also be reported and is calculated from the mean of 13 of the 15 QLQ-C30 scale, with higher score indicating a higher quality of life. This tool has established validity and reliability in cancer.

Time frame: Baseline, Preoperative, 30 days, 6 months and 12 months post operative

Postoperative Quality of Recovery: Postoperative Quality of Recovery Score (PostopQRS)

The Postoperative Quality of Recovery Score (PostopQRS) is a multidimensional recovery assessment tool that is a verbal questionnaire. It has proven patient user acceptance and has been validated to be performed either face to face or over the telephone. The core domains include physiologic, nociceptive, functional, cognitive and emotional recovery and satisfaction with care, that is designed for use over multiple timepoints. The PostopQRS provides objective assessment of post-operative recovery, analysing the core domains of recovery, namely physiologic, nociceptive, functional, cognitive and emotional recovery compared to a unique individual preoperative baseline score. Recovery is then scored for each domain, and patients must recover in all tests within the domain to be scored as recovered. "All domains" recovery implies recovery in all of the five recovery domains.

Time frame: Preoperative timepoint, 3 days and 6 days postoperatively (if not discharged prior), 30 days and 6 months postoperative

Length of hospital stay

Length of hospital stay will be documented from the medical records by a blinded assessor at each centre.

Time frame: at hospital discharge

Health service use and costs

Captured in following ways: (i) hospital services and the use of health care services outside of hospital. (ii) Patients will be surveyed on their use of health services outside the hospital at 6 and 12 months postop follow-up using a questionnaire. (iii) Cost of program delivery

Time frame: at hospital discharge, 30 days, 6 and 12 months post operative

Exploratory Outcomes

Teleprehabilitation is an intervention suitable for patients of low to moderately high perioperative risk levels, however subgroup analyses based on risk provide the opportunity to explore if teleprehabilitation offers additional benefits to patients of increasing risk level. Surgical procedure: Differences in PPC rates between the two surgical groups (abdominal and lung) and between those receiving or not receiving neo-adjuvant therapy before abdominal cancer surgery will be explored.

Time frame: through study completion, up to 3 years