Applying User-centered Design and Implementation Science to Enhance Prehabilitation for Frail Older Adults Undergoing Lung Cancer Surgery
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Project Abstract Lung cancer is the leading cause of cancer-related death in the United States. Up to 30% of patients may be eligible for surgical resection for treatment. Currently, however, more than half of patients undergoing lung cancer resection are older adults (≥65 years) and 70% of thoracic surgery patients are “pre-frail” or “frail.” Frailty portends poor perioperative outcomes, such as increased postoperative complications, length of stay, hospital costs, post-discharge institutionalization and mortality. The American College of Surgeons and other international societies recommend frailty mitigation by offering patients prehabilitation (prehab) programs that focus on exercise, nutrition, and social support. Yet, despite evidence of efficacy in clinical trials, only 10-30% of patients actually adhere to prehab programs and the translation of these programs into clinical practice has been challenging. In our pilot study of BeFitMe™, a prehab smartphone application that provides, encourages, and tracks self-guided at-home exercise, based on the National Institute of Aging Go4Life exercise videos, only 14% of patients downloaded the app. However, those who did download the app averaged 38 ± 8.8 minutes of daily exercise, 1,862 ± 2000 steps per day, and 11.9 ±4.3 days of prehab activity; non-users were more likely to be older, male, and Black. Lack of robust “end-user” input into intervention design, particularly behavioral interventions, can lead to poor acceptability and adherence. Indeed, we are unaware of any current prehab program that applied a user-centered design approach to fully ascertain and address the specific needs, values, and preferences of the end-users, particularly older adults. Furthermore, no programs report using implementation science principles to introduce and adapt the intervention to varied clinical contexts. As a Stage I study in the NIH Stage Model for Behavioral Intervention Development, we propose to (1) Gather end-user (patients, caregivers, clinicians) perspectives and engage them as co-designers to redesign and enhance BeFitMe™ to increase its use and participation among older adults undergoing lung cancer surgery and (2) Use an implementation framework to increase reach, adoption, and sustainability of the prehab program. To achieve my immediate goal of enhancing the existing prehab app to optimize its use by prefrail/frail older adult lung cancer patients who will undergo resection, I have convened a team of experts in user-centered design, implementation science, qualitative research, prehab, geriatric oncology, lung cancer, and thoracic surgery. My long-term goal is to become an independent investigator focused on optimizing the pre-hospital, in-hospital, and post-hospital phases of surgical care for prefrail/frail older adults with lung cancer.
