Willie Walters, who has diabetes, is in a program at Duke Health to manage his blood sugar and weight prior to knee surgery scheduled for November. PHOTO: SHAWN ROCCO/DUKE HEALTH

By Laura Landro

Are you healthy enough to have surgery?

More hospitals are asking that question before patients undergo elective procedures such as hip and knee replacements. They are identifying those at higher risk of infections and other complications due to diabetes, heart disease and anemia—or simply being sedentary and out of shape. And they are steering them to “pre-habilitation” programs that include medical treatments, diets and exercise regimens to improve their chances of a successful surgery.

Surgeons have been advising patients for years to get into shape or quit smoking before surgery. But now researchers are focusing on a wider array of risks that should be addressed before going under the knife, including nutritional deficiencies, mental health problems and sleep disorders.

“In health care, we often bring patients into surgery without fully addressing their chronic medical conditions,” says Dr. Solomon Aronson, executive vice chair in the anesthesiology department at Duke University School of Medicine in Durham, N.C. By improving their health before surgery, he says, “we can significantly diminish the risk of complications.”

Dr. Tracy Setji, medical director for Duke's inpatient endocrinology consultation services, helps diabetes patients get blood sugar in good control before surgery. PHOTO: SHAWN ROCCO/DUKE HEALTH

That can mean postponing surgical procedures for days, weeks or even months. But hospitals have found the benefits include fewer complications, reduced days in the hospital and fewer readmissions after discharge. That saves costs and avoids financial penalties from insurers. Medicare has started to pay a set fee for knee and hip replacements so hospitals are on the hook for any additional costs, including complications. Infections and other adverse events after surgery can also lead to costly malpractice claims.

If a diabetic patient’s blood sugar is too high, it can impair the body’s ability to heal and increase the chance of infection. Studies have shown that obese patients have more wound-healing complications and deep infections after joint replacement surgery. A 2015 study in the Journal of Arthroplasty found that patients with anemia had more infections, longer postoperative hospital stays and were more likely than non-anemic patients to require blood transfusions, which are linked to complications. Patients who take narcotics for chronic pain are at increased risk for problems with anesthesia.

Duke Health, which includes three hospitals, a network of clinics and medical practices and the medical school, recently began an initiative to refer high-risk surgery candidates to Duke clinics for treatment. The program, called Poet, for Peri-Operative Enhancement Team, is currently targeting patients with diabetes, anemia, malnourishment, complex pain syndromes and poor exercise tolerance.

Dr. Solomon Aronson, executive vice chair of the Dept. of Anesthesiology at Duke University School of Medicine says improving chronic conditions before surgery 'can significantly diminish the risk of complications.' PHOTO: DUKE PHOTO

Sometimes the fixes are simple, such as IV iron infusions before surgery for anemic patients to reduce the need for a blood transfusion. A regimen of protein shakes can help malnourishment in older patients who don’t get enough protein in their diet. Studies suggest that patients with vitamin D deficiency can benefit from supplements to help improve recovery after knee replacement.

Weight reduction and blood sugar control in diabetes patients can take longer, but are worth the effort, Duke experts say. “Even if we have only a few days or weeks to get on the right track, they are going to do better in the hospital and go home better as well,” says Dr. Tracy Setji, medical director of inpatient endocrinology consultation services at Duke.

Willie Walters, 68, had knee replacement surgery in 2013, but the hardware began to come apart, leaving him hobbling and in pain. His primary care doctor referred him to Duke, where surgeon Thorsten Seyler saw him last February. Mr. Walters, who has diabetes and weighed 331, also had a stress fracture in his tibia.

Dr. Seyler, assistant professor in the department of adult reconstruction, removed the failed knee in April. He stressed the importance of overall good health and warned Mr. Walters about the increased risk for an infection after surgery due to his weight and poor blood sugar control. “No one had ever mentioned to me that this might be a problem,” says Mr. Walters. “They told me a lot about diabetes that I didn’t know.”

In June, Dr. Seyler referred Mr. Walter to the endocrinology clinic and Duke’s diet and fitness center for a physician-supervised diet. By August, he was down to 302 lbs., which improved his blood sugar levels and enabled him to stop his oral diabetes medications. Mr. Walters recently told Dr. Seyler he was happy he joined the program. He is working toward his goal of getting down to 280 to 290 lbs., and “is doing great,” Dr. Seyler says. Surgery is scheduled for November.

About 80% of patients who are referred to a pre-surgical improvement program follow up and attend the appointments, says Dr. Seyler. Some patients are resistant to the idea, which can involve expenses not covered by insurance. “The key is to take the time to counsel patients and explain the benefits,” Dr. Seyler says.

Duke is now developing additional preoperative programs for conditions including mental health disorders. Dr. Seyler co-wrote a study of Medicare patients with bipolar disorder, depression and schizophrenia who had knee replacements from 2005 to 2011.The study, published in the October 2016 journal The Knee, found significantly increased medical and surgical complication rates compared with patients without psychiatric diagnoses, and higher odds of developing infections and fractures.

One possible explanation is that depression can lead to stress and exacerbate existing medical conditions. Preoperative mental health screening might identify patients at risk for increased complications, but more research is needed to determine if psychiatric disease can be modified to help prevent such complications, the study found.

At the University of Michigan Health System, a program known as MSHOP, for Michigan Surgical and Health Optimization Program, assesses patients’ risk for surgical complications based on their CT-scans, personal characteristics and a surgical outcomes database. It then assigns a regimen they can complete at home for a week to a month before surgery, to improve fitness, nutrition, and breathing capacity, with inexpensive aids like DVDs and text message reminders.

Dr. Michael Englesbe, a transplant surgeon at the University of Michigan, advises patients to train for surgery just as they would for an athletic competition. PHOTO: UNIVERSITY OF MICHIGAN

Data from 500 patients in the program from 2011 to 2013, published last December in Annals of Surgery, showed hospital costs were reduced by $2,308, and the average length of stay was reduced to four days from six.

“The reason many patients don’t do well is because they are already deconditioned as couch potatoes, and then they get a big operation which makes them even more frail,” says Michael Englesbe, a University of Michigan transplant surgeon and associate professor who led the study and directs the MSHOP program. Dr. Englesbe says that the program “empowers patients to have control over their outcome,” and recommends all patients train for elective surgery, much as they would before athletic competition.

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