BeFitMe II: Applying User-Centered Co-Design and Implementation Science to Enhance Prehabilitation for Frail Older Adults Undergoing Lung Cancer Surgery

ABSTRACT Lung cancer, while the leading cause of cancer-related death in the United States, can, in up to 30% of patients, be treated by surgical resection. Yet, more than half of patients eligible for lung cancer resection are older adults (≥65 years), of which 70% 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. Despite prehab clinical trials providing strong evidence of efficacy, 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 studies of BeFitMe, a wearable technology-based prehab application that provides, encourages, and tracks self-guided, at-home exercise, based on the National Institute of Aging Go4Life exercises, uptake (enrollment of eligible patients) was 50%, adherence (exercising at least 50% of available preoperative prehab time) was 43%, and performance (exercising at least 150 min/week) was 35%. Lack of “end-user” participation in the design of an intervention, particularly a behavioral intervention such as prehab, can lead to poor uptake, adherence, and performance. Indeed, we are unaware of any current prehab program that applied a user-centered co-design approach to fully ascertain and address the specific needs, values, and preferences of the end-users, particularly the older adult patients. Furthermore, no prehab programs reported using any implementation science principles to integrate 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) Engage end-users (patients, caregivers, clinicians) in user-centered co-design to enhance BeFitMe and increase its uptake, adherence, and performance by older adults undergoing lung cancer surgery and (2) Apply an implementation framework to increase reach, adoption, and sustainability of the prehab program in clinical care. This project will provide me with experiential opportunity to gain new knowledge, skills, and expertise in user-centered co-design and usability testing, applied implementation science, and clinical trial methods. My long-term goal is to become a surgeon-scientist leader focused on optimizing the pre-hospital, in-hospital, and post-hospital phases of surgical care for prefrail/frail older adults with lung cancer and other surgical conditions.