Introduction

Many people with obesity who seek bariatric surgery have related comorbidities, necessitating polypharmacy. In the UK, 64% of patients undergoing bariatric procedures have three or more obesity-related health conditions [1]. The malabsorptive and restrictive effects of bariatric surgical procedures and resultant rapid weight loss necessitate life-long vitamin and mineral supplementation surgery [2]. This often means altered pharmacokinetics of medications, e.g. dose, formulation and timing [3, 4] which vary according to the individual health status of patients. Additionally, there is a need for lifelong follow-up and nutritional supplementation. Bariatric surgery is time of immense physical, social and personal change [5, 6] which requires a period of adjustment for patients.

To prepare for surgery, UK patients attend appointments with members of the bariatric multi-disciplinary team (MDT) to ensure that they meet individualised targets, e.g. weight loss or changes to health behaviours, demonstrating their ability to adapt to post-surgical lifestyle changes [7]. Once a patient is cleared for surgery, they attend our pre-surgical assessment clinic which has an embedded pharmacist as part of our MDT. During pre-surgical assessment, all patients have an appointment with the pharmacist, who carries out a medication review, integrating changes to current medication post-surgery, discusses compliance with nutritional supplementation after surgery, highlighting issues regarding the timing, duration and interaction with specific medication and vitamins. The pharmacist actively encourages patients to ask questions and discuss their concerns. At the end of the appointment, a written summary is given to the patient, with copies sent to their General Practitioner and incorporated into their hospital records to ensure that information is available to all parties involved in the patients’ care.

There is an increasing drive to involve patients in clinical research to ensure that studies are carried out which are relevant to patients and provide opportunities for patients to be included in decisions about research from design to dissemination [8]. In the UK, as part of ethical approval process for research carried out in National Health Services (NHS) settings, applications must demonstrate patient involvement in the research as part of the approval process [9].

Our unit actively carries out patient-focused research, with and for patients. The idea for this study was based on findings from a previous study which explored how patients adjust to life after bariatric surgery [5]. Findings showed that patients reported issues around medication and supplementation compliance which warranted further investigation. Many participants discussed the importance of pre-surgical contact with the bariatric MDT in preparing for and adjusting to life after surgery which we decided to explore further with this study.

The inclusion of a pharmacist in pre-surgical pre-assessment is unique to our service and is not standard practice within UK bariatric surgical units. In order to further engage with patients to co-create research studies which incorporate the views and needs of our patients, the aim of this study was to explore the patient-reported impact of the pharmacist in pre-bariatric surgical assessment.

Methods

A retrospective, two phased, study design with participants randomly recruited from pre-surgical assessment clinic lists by an independent researcher in a large National Health Service (NHS) hospital in the UK. As all patients in our service attend pre-surgical assessment, all patients on the pre-surgical clinic lists were eligible to participate. The first phase involved individual, face to face semi-structured interviews, assisted by a topic guide, which were audio-recorded and transcribed verbatim. Participants were asked to voluntarily take part by discussing their experiences of seeing the pharmacist during pre-surgical assessment. Each interview was carried out by the same independent researcher and took between 30 and 45 min. A constant comparative approach was used, which means that data collection and analysis were undertaken concurrently, with analysis guiding further sampling [10]. This approach allowed researchers to discover areas of interest and to identify concepts of importance to participants and explore these further. Data collection and analysis continued until no new concepts were identified, meaning data was saturated and recruitment to phase 1 ceased. The findings informed the construction of the second phase, which consisted of a confidential survey to test the generalizability of the findings with a larger cohort of patients. During the interviews and data analysis for phase 1, it was noted that participants preferred to discuss the impact of the pharmacist appointment in terms of preparation for surgery, dealing with changes to health status and medication after surgery. Participants did not routinely discuss amount of weight loss, despite collecting data on this as part of the participant demographics. In order to focus on the aim of the study and to reduce the number of questions to encourage responses, questions around weight loss were not included in the survey. Prior to distributing study information, the survey was pilot tested with a representative group of patients, who confirmed that the emphasis should be on patient experiences and not on clinical outcomes.

For phase 2, participants were also identified from clinic lists, with an information pack containing the study information and a link to an on-line survey using Survey Monkey®, with the option of requesting a printed copy, by post. To protect confidentiality, no reminders were sent. Ethical approvals were granted by the National Health Service, Hospital and University research ethics committees. Data were collected between April 2017 and January 2018.

Results

A total of 40 participants (33 female, 7 male) took part in the study, with 12 being interviewed (phase 1) and 28 filling in on-line and printed surveys (phase 2). Owing to a continuous and varied flow of patients progressing to surgery through the pre-surgical assessment pathway as data was collected, an accurate response rate could not be determined. The nature of qualitative research means that sample sizes are smaller than quantitative studies [11] as the aim of qualitative research is to observe, understand, and explore a phenomena inductively, paying attention to the meaning and actions of participants, as opposed to entering a study with a pre-determined hypothesis and generating large quantities of numerical data [12]. A qualitative approach is therefore helpful in illuminating and understanding individual and collective patient experiences, which can assist in further developing support for individuals who undergo bariatric surgery.

First Phase—Interviews

Twelve participants (11 female, 1 male) consented to be interviewed (see Table 1). All participants had undergone bypass operations, with Roux-n-Y procedures (n = 7), one anastomosis gastric bypass (n = 4, and a revisional sleeve gastrectomy to Roux-en-gastric bypass). Participants’ ages ranged from 45 to 63 years (mean age 56 years) and the time since surgery ranged from 6 to 24 months (mean time 13 months) at time of interview. The pre-operative weight of participants ranged from 102 to 154 kg (mean pre-operative weight 124 kg) with weight loss since surgery ranging from 12 to 70 kg (mean weight loss 42 kg).

Table 1 Participant demographics (phase 1—interviews)
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The interviews took place in a location of participants’ choice, including place of work, hospital, and their homes. Each participant gave written consent; the interview was audio-recorded and transcribed verbatim. The researcher also took written notes during the interview, to note areas of interest to be explored further, and to clarify any ambiguity to ensure that interpretation of data was veracious to the participants’ experience and to minimise researcher bias. Transcripts were compared with earlier transcripts in a process known as constant comparative analysis, allowing researchers to identify concepts of interest. The concepts were discussed with the research team and a core set of emergent themes was identified and agreed (see Table 2) which informed the construction of the general survey questions, for phase 2.

Table 2 Themes constructed from interviews
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Second Phase

A total of 28 (22 females, 6 males) completed the survey (on-line or print) (see Table 3). The types of procedures performed were Roux-n-Y Gastric bypass 64% (n = 18), mean pre-surgical weight was 128 kg. The most commonly reported health conditions were type 2 diabetes (n = 8), pain (n = 6), and hypertension (n = 6). Improvements to health conditions were reported by 71% (n = 20) of participants, with 7% (n = 2) reporting it was too early to notice a change, 3% (n = 1) had a chronic disease flare-up post-surgery and 18% (n = 5) did not respond (see Table 3).

Table 3 Participant demographics—phase II (surveys)
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Most participants were aware they were going to see a pharmacist as part of pre-surgical assessment. Patients attended the appointment alone or with someone else and spent between 10 and 30 min with the pharmacist. The participant-reported experiences of the pharmacist appointment are shown in Table 4.

Table 4 Pharmacist appointment
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The pre- and post-surgical changes to medications are outlined in Table 5, with the majority showing a reduction in medications. Although phase 1 identified a dichotomy between prescription medications and nutrient supplementation in the context of taking pills daily, the majority of respondents in phase 2 did not perceive vitamins and minerals as ‘medication’.

Table 5 Pre- and post-operative medications and medical equipment
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The final phase of the survey asked participants to reflect on the role of the pharmacist (see Table 6). Over three quarters felt that the pharmacist input was valuable or extremely valuable, with high levels of confidence in taking medication post-surgically. Over half (n = 16) stated the service could be improved with additional appointments with the pharmacist after surgery.

Table 6 Post-surgical reflections on the role of the pharmacist (phase 2)
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Participants were asked how the pharmacist service could be developed further with in vivo quotes suggested as recommendations:

‘I recommend that all patients are told to buy a pill organiser before surgery’

‘Having a pharmacist available for patients who are discharged on a weekend’

‘A more detailed leaflet which describes all the vitamins and what to take and when’

‘It was all explained very well to me, but listening to the other patients on the ward after surgery I feel that some people just don’t listen carefully to the pharmacist, who explained everything to me without being patronising’

‘It would be great to have an on-line Question and Answer session so that if your General Practitioner leaves you hanging, as mine did, you can get answers to your questions without needing a hospital appointment’

‘More information on being aware of how hard it is to take tablets after surgery’

‘I firmly believe that the pharmacists’ involvement in bariatric surgery is crucial. Patients such as myself need a lot of support pre- and post-operatively, and the information regarding medication and how/when to take them and why they are being taken is important to keeping us patients healthy and consistent in our progress’

Discussion

Many participants felt they had become experts in their medicines management and acted as an intermediary between the bariatric unit and the primary care team responsible for their long-term care and follow-up, reporting that general practitioners were often not aware of the need to both alter medication regimes, or the necessity of lifelong vitamin supplementation.

The act of taking pills was important for participants. For those on multiple medications for comorbidities, a reduction in the number of pills taken each day signified a positive improvement in their post-surgical lives. However, the need for additional pills in the form of vitamins and temporary (6 month) medications added a layer of complexity to the adjustment after surgery in terms of expectations. Participants felt that although medications were ‘bad’ and vitamins were ‘good’ in terms of complying with post-surgical advice and being healthy, the act of taking pills itself was difficult. Additionally, there were reported side effects of vitamins and supplements (e.g. constipation with ferrous fumarate), and timing of vitamins to avoid interactions with medications was difficult to deal with and affected compliance. For some participants, it was difficult to separate pills in terms of medication and vitamins, for others, the dichotomy between good (vitamins) and bad (medications), despite the number of tablets taken increased after surgery, was not as much of an issue and was accepted as part of the post-surgical lifestyle. It was noted in Table 5 that there were inconsistencies in the patient-reported medicines after surgery, in that some patients did not mention the post-operative medications, or did not mention vitamins.

The discussion with the pharmacist was also thought to be an important step in self-care and empowerment following surgery. Patients reported downloading medication reminder apps on their mobile phones, carrying their medication list with them, and having pills in certain locations (home, work, handbags) to be accessible during the day and improve compliance.

Participants also reported using the information gained from the pharmacist to initiate discussions with others involved in their care, notably their general practitioners. Some participants reported using the information sheet supplied by the pharmacist in pre-surgical assessment as a tool to initiate discussion with their GPs around what was needed after surgery.

Conclusions

Overall, the pharmacist role in the pre-surgical assessment was largely perceived by all participants as positive. The findings are limited to a small sample size of patients in one bariatric surgical unit in the UK and may not be generalizable to other bariatric surgical populations. Additionally, it is noted that it was more difficult to recruit participants to take part in the surveys. It is accepted that there is a high rate of patients who do not attend for follow-up appointments after surgery, so they may also not wish to take part in research; therefore, it cannot be excluded that the participants recruited for this study may not reflect the opinions of the total patient population within our service. Owing to the underpinning interpretivist framework which focuses on participants’ experiences using self-reported information, many participants were not able to give specific information about the doses they were on and often expressed changes colloquially, e.g. ‘two tablets instead of four’, making it difficult to provide statistically valid information; however, the aim of the study was to understand the patient-reported impact of the role of the pharmacist and not provide a quantitative measurement of compliance.

The themes of self-care and patient empowerment can be framed under an overall concept of gaining control, which has been identified as important within the bariatric surgical population. Pre-surgically, many people feel out of control, and afterwards regain a sense of control over their lives [13, 14].

The pharmacist is a valued resource by patients as part of their pre-surgical assessment, but consideration should be given to further appointments post-surgically to address medication issues following weight loss and changes to health status, to reinforce the importance of life-long vitamin supplementation and management of potential side effects. Currently, the pharmacist role is limited to pre-surgical assessment, but there is potential for pharmacists to become more involved in the management of patients following surgery, particularly in the management of long-term chronic diseases [15]. Further research into the role of pharmacist as an integral part of the MDT in bariatric patient care is recommended, along with ascertaining education and training for this specialist role in practice.