Exploring Social Support Dynamics After Bariatric Surgery: Insights From Patients and Providers.

INTRODUCTION: Weight loss after bariatric surgery is impacted by several factors, and social support is one of them. Our objective was to characterize patient and provider perceptions about social support after bariatric surgery. METHODS: We reported a secondary analysis of qualitative data acquired from semi-structured interviews conducted from January-November 2020 with bariatric surgery patients and providers. Participants included primary care providers, health psychologists, registered dietitians, bariatric surgeons, and patients with at least 1 y of follow-up after their bariatric procedure. Interview guides were designed using a hybrid of Andersen's Behavioral Model of Health Services and Torain's Framework for Surgical Disparities. Using directed content analysis, study team members generated codes, which were categorized into themes about social support pertaining to dietary habits, physical activity, and follow-up care. RESULTS: Forty-five participants were interviewed, including 24 patients (83% female; 79% White; mean age 50.6 ± 10.7 y) and 21 providers (six primary care providers, four health psychologists, five registered dieticians, and six bariatric surgeons). We identified four themes relating to social support affecting weight loss after surgery: (1) family involvement in helping patients adjust to the bariatric diet, (2) engagement in activities with partners/friends, (3) help with transportation to appointments, and (4) life stressors experienced by patients within their social relationships. CONCLUSIONS: Continued assessment of interpersonal factors after bariatric surgery is essential for weight loss maintenance. Providers can contribute by reinforcing the facilitators of social support and making referrals that may help patients overcome barriers to social support for sustained weight loss after surgery.

A Qualitative Study of Barriers to Anal Cancer Screenings in US Veterans Living with HIV.

People living with human immunodeficiency virus (HIV) are at high risk for anal cancer. Anal cancer screenings are recommended annually for US veterans with HIV. Screenings can identify treatable precursor lesions and prevent cancer development. In a previous study, we found screening rate to be only 15%. Semistructured interviews were conducted with Veterans Affairs (VA) providers who treat veterans living with HIV. Participants described their experiences with anal cancer screenings. Researchers developed a codebook based on Theoretical Domains Framework (TDF) and coded data using thematic analysis to identify barriers to anal cancer screenings. Twenty-three interviews were conducted with VA providers representing 10 regions. Barriers identified corresponded with five targetable TDF domains: Knowledge, Skills, Environmental Context/Resources, Professional Roles/Identities, and Social Influence. Many providers lacked knowledge of screening protocols. Knowledgeable providers often lacked needed resources, including swabs, clinic space, reliable pathology, access to high-resolution anoscopy, or leadership support to implement a screening program. Providers mentioned competing priorities in the care of veterans with HIV infection and lack of skilled/trained personnel to perform the tests. It was often unclear which provider specialty should "own" screening responsibilities. Additional factors included patient discomfort with screening exams. Anal cancer screening protocols are recommended but not widely adopted in VA. There is a critical need to address barriers to anal cancer screenings in veterans. The TDF domains identified align with five intervention domains to target, including education, training, resource/environment, delineation of provider roles, and improved counseling efforts. Targeting these barriers may help improve the uptake of anal cancer screenings within VA.

Patient and Provider Perceptions About Communication After Bariatric Surgery: A Qualitative Analysis.

INTRODUCTION: Communication between patients and providers can strongly influence patient behavior after surgery. The objective of this study was to assess patient and provider perceptions of how communication affected weight-related behaviors after bariatric surgery. MATERIALS AND METHODS: Semistructured interviews with bariatric surgery patients and providers were conducted from April-November 2020. Patients who had Medicaid within 3 y of surgery were defined as socioeconomically disadvantaged. Interview guides were derived from Andersen's Behavioral Model of Health Services and Torain's Framework for Surgical Disparities. Participants described postoperative experiences regarding diet, physical activity, and follow-up care. A codebook was developed deductively based on the two theories. Directed content analysis identified themes pertaining to patient-provider communication. RESULTS: Forty-five participants were interviewed, including 24 patients (83% female; 79% White), six primary care providers, four health psychologists, five registered dietitians, and six bariatric surgeons. Four themes regarding communication emerged: (1) Patients experiencing weight regain did not want to follow-up with providers to discuss their weight; (2) Patients from socioeconomically disadvantaged backgrounds had less trust and required more rapport-building from providers to enhance trust; (3) Patients felt that providers did not get to know them personally, which was perceived as a lack of personalized communication; and (4) Providers often changed their language to be simpler, so patients could understand them. CONCLUSIONS: Patient-provider communication after bariatric surgery is essential, but perceptions about the elements of communication differ between patients and providers. Reassuring patients who have attained less weight loss than expected and establishing trust with socioeconomically vulnerable patients could strengthen care after bariatric surgery.

Factors Associated With Socioeconomic Disparities in Breast Reconstruction: Perspectives of Wisconsin Surgeons.

INTRODUCTION: The objective is to expand our understanding of the factors associated with receipt of breast reconstruction for socioeconomically disadvantaged women within Wisconsin. METHODS: A purposeful sample of general/breast and plastic surgeons were identified. One-on-one interviews were conducted, audio-recorded, and transcribed in full (n = 15). Conventional content analysis was performed to identify themes. RESULTS: Both general/breast and plastic surgeons perceived that general/breast surgeons served as gatekeepers to which patients are offered a referral for reconstruction. Given the additional recovery time, frequent clinic visits, and potential for complications associated with reconstruction, general/breast surgeons perceived that not all women prioritize it. Surgeons perceived this to be especially true for socioeconomically disadvantaged women. Surgeons identified time off work, travel for visits, and out-of-pocket costs as specific challenges to reconstruction experienced by socioeconomically disadvantaged women. Surgeons perceived that early education, incorporating financial considerations into discussions, and reducing travel burden may help to improve access to reconstruction. CONCLUSION: Wisconsin surgeons described factors they perceived contributed to lower rates of reconstruction for socioeconomically disadvantaged women and described ways to increase reconstruction access.

The invisible work of transfer centre nurses: A qualitative study of strategies to overcome communication challenges.

AIMS: To explore the role of transfer centre nurses and how they facilitate communication between referring and accepting providers during calls about interhospital transfers, including their strategies to overcome communication challenges. DESIGN: A qualitative interview study. METHODS: We conducted semi-structured interviews with 17 transfer centre nurses at one tertiary medical centre from March to August 2019, asking participants to describe their work. We performed content analysis, applying codes based on the Relational Coordination Framework and generating emergent codes, then organized codes in higher-order concepts. We followed the COREQ checklist. RESULTS: Transfer centre nurses employed multiple strategies to mitigate communication challenges. When referring providers had misconceptions about the transfer centre nurse's role and the accepting hospital's processes, the nurses informed referring providers why sharing information with them was necessary. If providers expressed frustrations or lacked understanding about their counterpart's caseload, the nurses managed providers' emotions by letting them "vent," explaining the other provider's situational context and describing the hospital's capabilities. Some nurses also mediated conflict and sought to break the tension if providers debated about the best course of action. When providers struggled to share complete and accurate information, the nurses hunted down details and 'filled in the blanks'. CONCLUSION: Transfer centre nurses perform invisible work throughout the lifespan of interhospital transfers. Nurses' expert knowledge of the transfer process and hospitals' capabilities can enhance provider communication. Meanwhile, providers' lack of knowledge of the nurse's role can impede respectful and efficient transfer conversations. Interventions to support and optimize the transfer centre nurses' critical work are needed. IMPACT: This study describes how transfer centre nurses facilitate communication and overcome challenges during calls about interhospital transfers. An intervention that supports this critical work has the potential to benefit nurses, providers and patients by ensuring accurate and complete information exchange in an effective, efficient manner that respects all parties. PATIENT OR PUBLIC CONTRIBUTION: This study was designed to capture the perspectives and experiences of transfer centre nurses themselves through interviews. Therefore, it was not conducted using input or suggestions from the public or the patient population served by the organization.

Impact of COVID-19 on the Postoperative Bariatric Surgery Patient Experience.

OBJECTIVE: To characterize patient and provider perceptions of the impact of coronavirus disease 2019 (COVID-19) on weight loss following bariatric surgery. BACKGROUND: COVID-19 has disrupted routines and healthcare throughout the United States, but its impact on bariatric surgery patients' postoperative experience is unknown. METHODS: Semistructured interviews with bariatric surgery patients, primary care providers, and health psychologists were conducted from April to November 2020. As part of a secondary analysis, patients and providers described how the COVID-19 pandemic affected the postoperative experience within 3 domains: dietary habits, physical activity, and follow-up care. Interview guides were created from 2 conceptual models: Torain's Surgical Disparities Model and Andersen's Behavioral Model of Health Services Use. Study team members derived codes, which were grouped into themes using conventional content analysis. RESULTS: Thirty-four participants were interviewed: 24 patients (12 Roux-en-Y gastric bypass and 12 sleeve gastrectomy), 6 primary care providers, and 4 health psychologists. Patients were predominately female (83%) and White (79%). Providers were predominately female (90%) and White (100%). COVID-19 affected the postoperative bariatric surgery patient experience via 3 mechanisms: (1) it disrupted dietary and physical activity routines due to facility closures and fear of COVID-19 exposure; (2) it required patients to transition their follow-up care to telemedicine delivery; and (3) it increased stress due to financial and psychosocial challenges. CONCLUSIONS: COVID-19 has exacerbated patient vulnerability. The pandemic is not over, thus bariatric surgery patients need ongoing support to access mental health professionals, develop new physical activity routines, and counteract increased food insecurity.

Socioeconomic disparities and bariatric surgery outcomes: A qualitative analysis.

BACKGROUND: Disparities in socioeconomic status (SES) have been associated with less weight loss after bariatric surgery. The objective of this study was to identify socioeconomic barriers to weight loss after bariatric surgery. METHODS: We performed semi-structured interviews with bariatric surgery patients and providers from April-November 2020. Participants were asked to describe their post-operative experiences regarding dietary habits, physical activity, and follow-up care. Interview data were coded using Directed Content Analysis based on domains in Andersen's Behavioral Model of Health Services Use and Torain's Surgical Disparities Model. RESULTS: 24 patients (median of 4.1 years post-operatively; mean age 50.6 ± 10.7 years; 12 bypass and 12 sleeve; 83% female) and 21 providers (6 bariatric surgeons, 5 registered dietitians, 4 health psychologists, and 6 primary care providers) were interviewed. Barriers to weight loss included: 1) challenging employment situations; 2) limited income; 3) unreliable transportation; 4) unsafe/inconvenient neighborhoods; and 5) limited health literacy. CONCLUSIONS: Interventions targeting socioeconomic barriers to weight loss are needed to support patients, particularly those who are socioeconomically disadvantaged.

Communication During Interhospital Transfers of Emergency General Surgery Patients: A Qualitative Study of Challenges and Opportunities.

OBJECTIVES: Transferred emergency general surgery (EGS) patients experience worse outcomes than directly admitted patients. Improving communication during transfers may improve patient care. We sought to understand the nature of and challenges to communication between referring (RP) and accepting (AP) providers transferring EGS patients from the transfer center nurse's (TCN) perspective. METHODS: Guided by the Relational Coordination Framework, we interviewed 17 TCNs at an academic medical center regarding (in)efficient and (in)effective communication between RPs and APs. In-person interviews were recorded, transcribed, and managed in NVivo. Four researchers developed a codebook, cocoded transcripts, and met regularly to build consensus and discuss emergent themes. We used data matrices to perform constant comparisons and arrive at higher-level concepts. RESULTS: Challenges to ideal communication centered on the appropriateness and completeness of information, efficiency of the conversation, and degree of consensus. Transfer center nurses described that RPs provided incomplete information because of a lack of necessary infrastructure, personnel, or technical knowledge; competing clinical demands; or a fear of the transfer request being rejected. Inefficient communication resulted from RPs being unfamiliar with the information APs expected and the lack of a structured process to share information. Communication also failed when providers disagreed about the necessity of the transfer. Accepting providers diffused tension and facilitated communication by embracing the role of a "coach," negotiating "wait-and-see" agreements, and providing explanations of why transfers were unnecessary. CONCLUSIONS: Transfer center nurses described numerous challenges to provider communication. Opportunities for improvement include sharing appropriate and complete information, ensuring efficient communication, and reaching consensus about the course of action.

A Qualitative Study of the System-level Barriers to Bariatric Surgery Within the Veterans Health Administration.

OBJECTIVE: To characterize system-level barriers to bariatric surgery from the perspectives of Veterans with severe obesity and obesity care providers. SUMMARY OF BACKGROUND DATA: Bariatric surgery is the most effective weight loss option for Veterans with severe obesity, but fewer than 0.1% of Veterans with severe obesity undergo it. Addressing low utilization of bariatric surgery and weight management services is a priority for the veterans health administration. METHODS: We conducted semi-structured interviews with Veterans with severe obesity who were referred for or underwent bariatric surgery, and providers who delivered care to veterans with severe obesity, including bariatric surgeons, primary care providers, registered dietitians, and health psychologists. We asked study participants to describe their experiences with the bariatric surgery delivery process in the VA system. All interviews were audio-recorded and transcribed. Four coders iteratively developed a codebook and used conventional content analysis to identify relevant systems or "contextual" barriers within Andersen Behavioral Model of Health Services Use. RESULTS: Seventy-three semi-structured interviews with veterans (n = 33) and providers (n = 40) throughout the veterans health administration system were completed. More than three-fourths of Veterans were male, whereas nearly three-fourths of the providers were female. Eight themes were mapped onto Andersen model as barriers to bariatric surgery: poor care coordination, lack of bariatric surgery guidelines, limited primary care providers and referring provider knowledge about bariatric surgery, long travel distances, delayed referrals, limited access to healthy foods, difficulties meetings preoperative requirements, and lack of provider availability and/or time. CONCLUSIONS: Addressing system-level barriers by improving coordination of care and standardizing some aspects of bariatric surgery care may improve access to evidence-based severe obesity care within VA.

Individual-level barriers to bariatric surgery from patient and provider perspectives: A qualitative study.

BACKGROUND: Less than 1% adults in the United States who meet body mass index criteria undergo bariatric surgery. Our objective was to identify patient and provider perceptions of individual-level barriers to undergoing bariatric surgery. METHODS: Adults with severe obesity and obesity care providers described their experiences with the bariatric surgery care process in semi-structured interviews. Using conventional content analysis, individual-level barriers were identified within Andersen's Behavioral Model of Health Services Use. RESULTS: Of the 73 individuals interviewed, 36 (49%) were female, and 15 (21%) were non-white. Six individual-level barriers were identified: fear of surgery, fear of lifestyle change, perception that weight had not reached its "tipping point," concerns about dietary changes, lack of social support, and patient characteristics influencing referral. CONCLUSIONS: Patient and provider education should address patient fears of surgery and the belief that surgery is a "last resort." Bariatric surgery programs should strengthen social support networks for patients.

Protocol and short-term results for a feasibility randomized controlled trial of a video intervention for Veterans with obesity: The TOTAL (Teaching Obesity Treatment Options to Adult Learners) pilot study.

INTRODUCTION: All three evidence-based treatment options for adults with severe obesity - behavioral weight management, weight management medications (WMM), and bariatric surgery - are underutilized in the Veterans Health Administration (VHA) system. Our objective in this study was to develop and pilot-test the TOTAL (Teaching Obesity Treatment Options to Adult Learners) intervention, which seeks to increase Veteran participation in obesity treatment. METHODS: In this single-site, parallel, pilot RCT, Veterans with severe obesity with an upcoming behavioral weight management visit were sent a recruitment letter after meeting inclusion/exclusion criteria via electronic health record screening. Eligible Veterans were randomized to TOTAL or usual care. TOTAL consisted of an 18-min video highlighting obesity health risks and treatment outcomes, eligibility criteria, and pros/cons of all three evidence-based obesity treatments. The primary outcomes were trial design feasibility (recruitment and retention rates) and acceptability to Veterans, which was assessed via semi-structured interviews with participants one week after randomization to TOTAL. Secondary outcomes included attitudes and self-efficacy to initiate treatment one week post-randomization and BMI change six months post-randomization (assessed via Cohen's d). RESULTS: Forty-two Veterans were randomized (recruitment rate = 47.2%), and 40/42 completed one-week assessments (retention rate = 95.2%). The mean participant age was 59.2 ± 11.9 years. Female and non-White participants comprised 14.3% and 11.9% of the cohort, respectively. Semi-structured interviews with all 20 participants who received TOTAL suggested that the delivery logistics and content of TOTAL were acceptable to Veterans. Attitudes toward behavioral weight management and bariatric surgery and weight loss improved in TOTAL vs. usual care patients (Cohen's d ranging from 0.3 to 0.6). CONCLUSIONS: TOTAL was feasible to implement, acceptable to Veterans, and has the potential to increase obesity treatment participation in VHA. An adequately powered RCT is warranted to assess its impact on population-level weight loss. TRIAL REGISTRATION: ClinicalTrials.gov NCT03856320.

Setting Up for Success: Strategies to Foster Surgeons' Pursuit of Basic Science Research.

BACKGROUND: Surgeons make important contributions to basic science research and are in a unique position to innovate scientifically. The number of surgeons pursuing basic science research has been declining over the past two decades. We sought to describe perceived barriers to surgeons' pursuit of basic science research and identify interventions that mitigate these obstacles. MATERIALS & METHODS: An online survey was sent to chairs of academic surgery departments and practicing surgeons involved in basic science research. A subset of these participants were interviewed about their experiences. Interviews were audio-recorded, transcribed, and uploaded to NVivo. Two coders developed a codebook using inductive content analysis to identify relevant themes. RESULTS: 97 people responded to the survey, 27 (29%) were department chairs. Major barriers to basic science research for all respondents were lack of funding, clinical duties and lack of dedicated time for research. Nine surgeons and three departmental chairs were subsequently interviewed. The importance of having clear research goals and timetables with specific plans for attaining funding were mentioned by all. Chairs described the usefulness of embedding early surgeon scientists in their scientific mentors' labs in a post-doctoral model. Additionally, departmental leaders must actively work to protect surgeon scientists from encroaching clinical and administrative demands. CONCLUSIONS: While barriers to surgeons' pursuit of basic science research exist, the surgeon scientist is a phenotype that can be fostered with the dedication and commitment of surgeons to continue to pursue science research and active support of departmental leadership.

Patient preferences for GI cancer surveillance and telemedical follow-up.

INTRODUCTION: Surveillance care including routine physical exams and testing following gastrointestinal (GI) cancer treatment can be fiscally and emotionally burdensome for patients. Emerging technology platforms may provide a resource-wise surveillance strategy. However, effective implementation of GI cancer surveillance is limited by a lack of patient level perspective regarding surveillance. This study aimed to describe patient attitudes toward GI cancer surveillance and which care modalities such as telemedicine and care team composition best meet the patient's needs for follow-up care. METHODS: Focused interviews were conducted with 15 GI cancer patients undergoing surveillance following curative-intent surgery. All interviews were audio recorded, transcribed verbatim, and uploaded to NVivo. Study personnel trained in qualitative methods consensus coded 10% of data inductively and iteratively developed a codebook and code descriptions. Using all transcripts, data matrices were developed to identify themes inherent in the transcripts. RESULTS: Qualitative analysis revealed three overarching themes. First, increasing ease of access to surveillance care through telemedicine follow-up services may interfere with patients' preferred follow-up routine, which is an in-office visit. Second, specialist providers were trusted by patients to deliver surveillance care more than primary care providers (PCPs). Thirdly, patients desired improved psychosocial health support during the surveillance period. CONCLUSION: These novel patient-level qualitative data demonstrate that replacing conventional in-office GI cancer surveillance care with telemedicine is not what many patients desire. These data also demonstrate that his cohort of patients prefer to see specialists for GI cancer surveillance care rather than PCPs. Future efforts to enhance surveillance should include increased psychosocial support. Telemedicine implementation should be personalized toward specific populations who may be interested in fewer in-office surveillance visits.

Patient and provider perceptions on utilizing a mobile technology platform to improve surgical outcomes in the perioperative setting.

BACKGROUND AND OBJECTIVES: Patient engagement software is a ubiquitous and expensive commercially available tool designed to improve transitions of care. There are currently no high-quality patient and provider-level data about the usability of these products for surgical oncology patients. This study aims to better understand patient and provider attitudes and perceptions about the implementation of such technology. METHODS: Focused interviews were conducted following the demonstration of a provider-built mobile technology platform. Interviews were audio-recorded, transcribed, and analyzed. Data were consensus coded inductively and categorized into themes regarding patient and provider perspectives on the usability and implementation of MobiMD. RESULTS: Our interviews revealed four consistent themes: (1) patients feel there is a lack of reliable resources for patient education; (2) both patients and providers are supportive of using a mobile application; (3) providers perceive patient onboarding as an added burden on current workflows; and (4) after onboarding, providers express that such an application would optimize current workflows. CONCLUSIONS: Patients perceive a need for improved perioperative education. Providers and patients agree that a mobile technology platform would be an effective solution in addressing this need. Effective implementation of such an intervention may improve patient education and engagement, leading to improved patient outcomes.

Smoking and gastrointestinal cancer patients-is smoking cessation an attainable goal?

BACKGROUND AND OBJECTIVES: Negative consequences of tobacco use during cancer treatment are well-documented but more in-depth, patient-level data are needed to understand patient beliefs about continued smoking (vs cessation) during gastrointestinal (GI) cancer treatment. METHODS: We conducted semi-structured interviews with 10 patients who were active smokers being treated for GI cancers and 5 caregivers of such patients. All interviews were audio-recorded, transcribed verbatim, and uploaded to NVivo. We consensus coded data inductively using conventional content analysis and iteratively developed our codebook. We developed data matrices to categorize the themes regarding patient perspectives on smoking as well as presumed barriers to smoking cessation during active therapy. RESULTS: Our interviews revealed three consistent themes: (a) Smoking cessation is not necessarily desired by many patients who have received a cancer diagnosis; (b) Failure in past quit attempts may lead to feelings of hopeless about future attempts, especially during cancer treatment; (c) Patients perceived little to no access to smoking cessation treatment at the time of their cancer diagnosis. CONCLUSIONS: Well-designed systemic changes that promote the positive and efficacious effects of quitting smoking during cancer treatment, and that provide barrier-free access to such treatments may be helpful in promoting tobacco-free behavior during cancer treatment.

Motivations of Males with Severe Obesity, Who Pursue Medical Weight Management or Bariatric Surgery.

Background: Both medical weight management (MWM) and bariatric surgery are significantly underutilized by patients with severe obesity, particularly males. Less than 30% of participants in MWM programs are male, and only 20% of patients undergoing bariatric surgery are men. Objectives: To identify motivations of males who pursue either MWM or bariatric surgery. Setting: Interviews with males with severe obesity (body mass index ≥35 kg/m2), who participated in a Veteran Affairs weight loss program in the Midwest. Materials and Methods: Participants were asked to describe their experiences with MWM and bariatric surgery. Interviews were audio-recorded, transcribed, and uploaded to NVivo for data management and analysis. Five coders iteratively developed a codebook using inductive content analysis to identify relevant themes. We utilized theme matrices organized by type of motivation and treatment pathway to generate higher-level analysis and generate themes. Results: Twenty-five males participated. Participants were 58.7 (standard deviation 8.6) years old on average, and 24% were non-white. Motivations for pursuing MWM or surgery included a desire to improve physical or psychological health and to enhance quality of life. Patients seeking bariatric surgery were motivated by the fear of death and felt that they had exhausted all other weight loss options. MWM patients believed they had more time to pursue other weight loss options. Conclusion: The opportunity to improve health, optimize quality of life, and lengthen lifespan motivates males with severe obesity to pursue weight loss treatments. These factors should be considered when providers educate patients about obesity treatment options and outcomes.