PRE:WEL: A qualitative study of patients and health care professionals needs and preferences for weight management before surgery

Approximately seven million operations take place annually within the NHS. One-third of patients on surgical waiting lists are living with obesity, which is known to be associated with multiple morbidities. People are experiencing poorer health due to the long wait for surgery which may affect surgical outcomes and quality of life (QoL). Living with obesity and undergoing surgery is also associated with greater risk of postoperative adverse events including myocardial infarction, wound infections, nerve injury, urinary infection, and longer operative time. Because of the potential risks, people who have high BMI, are sometimes prohibited from having surgery which may increase inequalities as there is a complex interaction between obesity, lower socioeconomic status and ethnicity. Making Every Contact Count is an NHS initiative that aims to use the millions of interactions health care professionals have with patients to promote behaviour change. The pre-operative period could be an occasion where patients are particularly motivated to change behaviours. Advice to lose weight (and referral to a service) by their surgical team may motivate patients to lose weight. Qualitative studies exploring weight loss before surgery support this as they have found that patients are highly motivated to avoid complications and that a recommendation from a health professional to lose weight is a motivating and important factor. Effective weight management interventions are available, but these are not routinely offered to patients before surgery. There have been few studies that have investigated the effectiveness of these programmes in the pre-operative period. In one feasibility randomised controlled trial (RCT) (n=60) before knee replacement surgery offering weight loss via total diet replacements found that participants lost on average 11.2 kg (SD 5.6). Qualitative feedback suggested the diet was easy to implement and stick to as participants were losing weight each week and seeing the benefits, which in turn increased motivation to adhere. The qualitative feedback for suggested that excessive face to face visits was a barrier to involvement in the study. This was also found in a qualitative study exploring support for weight loss (appointments every two weeks) before colorectal surgery. These findings suggest that too many visits affect participation and should be considered in interventions that are offered prior to surgery. Another pilot study before knee replacement surgery found it very difficult to recruit participants as the research team could not identify participants in sufficient time before their surgery. This suggests that the surgery care pathway needs to be explored when determining whether it is possible to feasibly offer weight management support to patients within the NHS. There is also very limited evidence about what weight management programmes patients would be willing to participate in, and at what point in the surgical pathway should they be offered. The views of the health care professionals on this question have also not been investigated. This is particularly important as endorsement by health care professionals (HCP’s) seems to be important for participation in weight loss programmes. Recently anti-obesity medications for weight loss have become readily available and the preferences of patients and healthcare professionals’ (stakeholders’) views of the use of these before surgery has not been investigated. The aim of this research is to explore patients and HCP needs and preferences for weight management before surgery. Aims To investigate needs and preferences of patients and HCPs for different weight management interventions pre-operatively and to co-produce what programmes, and when, they should be offered. A new intervention is not being designed, instead together we will decide which interventions to test in a feasibility randomised controlled trial, from those currently available. Objectives 1. Identify which weight loss interventions would be acceptable to patients and why? 2. Explore which weight loss interventions HCPs believe are acceptable and feasible to offer in the surgery care pathway. 3. Explore pathways for when and how the weight loss interventions could be offered and by whom? Methods and design A qualitative interview study. Work package 1: Understanding the experiences and needs of patients who are scheduled or had surgery, and HCP’s involved in surgical care about weight loss before surgery. Aims 1. Explore patients and health care professionals’ views about weight loss before surgery. 2. Identify which weight loss interventions would be acceptable to patients. 3. Explore which weight loss interventions HCP’s believe are acceptable and feasible. 4. Explore pathways for when and how the weight loss programme should be offered. Design Qualitative semi-structured interview study. Inclusion and exclusion criteria Patients will be included or excluded if they meet the following criteria: Inclusion • Adults aged ≥18 years • Referred or recently had (within the past year) for major elective surgery • Patients living with obesity, defined as a BMI ≥30 kg/m2 OR if in the past year before their surgery they report living with obesity. Exclusion • Bariatric surgery • Major elective surgery for pregnancy HCP’s will be included if they are involved in the treatment of patients who will have major elective surgery (except for pregnancy or bariatric surgery). HCPs could include but not be limited to surgeons, anaesthetist and nurses. Recruitment Patients will be recruited via invitations direct from their health care team (letters/phone/texts) and via advertisements at hospitals. Sites were selected as they were based in culturally and ethnically diverse cities. We will widen recruitment to other centres if we need to recruit more participants. All study documents and recruitment materials will illustrate diverse individuals and messaging tailored to ensure it is appealing to those from varied backgrounds. The healthcare team, with translators will call participants that are unable to speak English and materials will be translated to languages as required. Depending on need we will develop a video participation information sheet for those that cannot read. All study documents have been co-developed with our ethnically diverse patient advisory group in collaboration with the Centre for Ethnic Health Research (CEHR). Participants will be informed this is a study to explore patient views and choice of weight management interventions prior to surgery. If we struggle to recruit through hospital sites, we will widen our recruitment strategy and use the NIHR Be Part of Research service and use snowballing methods through existing networks, including social media. HCP’s will be recruited through the same hospitals as patients and existing networks. As care pathways and timings may differ by surgical treatment, we may focus on specific surgical treatments such as cardiac surgery, hip and knee replacement surgery and major abdominal surgery. However, we are currently completing a review of the association of BMI and surgical outcomes and may focus on specific surgical procedures depending on the evidence. Sample size We will conduct up to 30 interviews with patients across the surgical specialities. Final sample size will be informed by information power i.e., the depth and quality of information held by the participant sample. After completion of ten interviews, we will review our sample and initial themes to decide who to sample next and identify if there are additional topics to explore. We will conduct up to 30 interviews with healthcare teams across surgical treatments. We will follow the same procedure for assessing sample size as the patient interviews. Sampling framework For patients we will use maximum variation purposive sampling will capture a diverse range of experiences and perspectives. Participants will be sampled on the health inequalities identified in our equality impact assessment plan as well as the type of surgery. For health care professionals we envisage that it will be harder to recruit participants but will try to ensure we have representation from surgical treatments. Interviews Potentially distressing topic Weight and their upcoming surgery may be a distressing topic for some participants. If during the interview a participant experiences distress, we will stop the interview, offer support, and allow the person to re-group. If they are experiencing too much distress the interview will not continue at this time. We will pause and contact them again in a few days to see if continuing with the interview is the right approach for them at this time, or whether it should be discontinued. If the decision is to discontinue, we will ask them to contact their GP to seek support. We think it is appropriate that the decision is made in consultation with the participant rather than for them as they may be many reasons for the distress (e.g., bad day at work) that may or may not be related to issues of their weight and surgery. With participants’ consent the interviewer will provide a courtesy follow-up call or ask them to call the research team in a week to let them know how they are getting on. Patient interviews Semi-structured interviews will cover the views of weight loss, which weight loss interventions should be offered pre-operatively, when a programme should be offered, how patients should be referred and potential benefits/barriers of weight loss before surgery. Patients will be asked whether they have tried a weight management intervention before. We will provide short anonymous descriptions of real weight management programmes (including total diet replacements and anti-obesity medications) that are available. Patients will be asked to view these before the interview. We chose the programmes based on their availability, e