Impact of Bariatric Pre-Operative Education on Patient Knowledge and Satisfaction with Overall Hospital Experience

Abstract

Obesity is a major health problem in the United States and is associated with morbidity and mortality. According to the Centers for Disease Control and Prevention (CDC), 63 % of adult Americans have a Body Mass Index (BMI) in excess of 25.0 kg/m² and are considered overweight. Treatment of obesity includes diet, behavior modification, exercise, and medication therapy. However, for many people surgery is considered the most effective intervention. According to the American Society of Bariatric Surgery, about 500,000 weight reduction operations are performed annually in the United States. Bariatric surgery involves creating a stomach pouch or rerouting the small intestine; this could result in a 60–70% reduction in weight. According to a University Health Consortium benchmarking study from 2005, patient education is vital for a successful outcome for bariatric patients. Patients who pursue bariatric surgery often get information from various places, including the Internet, where the accuracy of the information is uncertain. It is our belief that structured pre-operative education classes provide a more reliable source of information for patients. The purpose of this study was to evaluate the effectiveness of structured pre-operative classes offered to bariatric patients and their families and to determine how these classes impact patients' knowledge level of the hospital experience and satisfaction with their inpatient stay. Patients attending the structured pre-op class got 85 percent of the questions on our survey correct. They also rated their satisfaction with how well they were prepared for their hospital stay very high—92 percent. Their overall satisfaction score was 88 percent.

Introduction

In the past decade, the prevalence of obesity has increased dramatically. This is especially true in the United States, where obesity is now the second most common cause of death, accounting for 300,000 deaths annually.¹ It also has a tremendous impact financially, costing $238 billion annually.² Obesity is defined as a Body Mass Index (BMI) of greater than 30 kg/m². Bariatric surgery is considered the only viable option for some patients after multiple attempts at other weight loss measures such as behavior modification, diet, and change in lifestyle. According to the American Society of Bariatric Surgery, about 500,000 operations are performed annually in the United States.

Patients who seek weight loss surgery have to cope with long-term changes in lifestyle, eating habits, and body image. The ability to cope with these changes to a great extent depends on how well the patients are prepared before surgery. Various educational sources are available for patients undergoing surgery; however, not all are reliable.

Structured pre-operative classes, scheduled through the Patient Learning Center, have been crucial in preparing patients for surgery and post-operative care at the University of Minnesota Medical Center, Fairview. The Patient Learning Center is designed to provide patients and family members with a lablike environment for learning and reviewing information, and for practicing and demonstrating needed skills. It is open seven days a week and is staffed by registered nurses.

The purpose of this study was to evaluate the effectiveness of structured pre-operative classes offered to bariatric patients and their families and to determine how these classes impact the patients' knowledge level of the hospital experience and satisfaction with their inpatient stay. Two hypotheses were explored in this study:

Patients who attend the structured pre-operative class will be knowledgeable about preparation for surgery and immediate post-operative care.

Patients who attend the structured pre-operative class will be satisfied with their inpatient stay.

Literature Review

Obesity is a major health problem in the United States that continues to grow. In 2002, the U.S. Surgeon General's Report indicated that 61% of American adults are overweight (BMI > 25) and 27% are obese (BMI > 30).³ As mentioned, obesity is now the second most common cause of death in the United States, accounting for 300,000 deaths annually, or approximately 14% of all deaths.¹ The financial cost of care associated with obesity in the United States is estimated to be $238 billion annually.²

Most patients undergoing bariatric surgery have comorbidities related to their obesity. Schauer (2001) identified 6.8 comorbidities per person.⁴ These include degenerative joint disease (64%), hypercholesterolemia (62%), hypertension (52%), gastroesophageal reflux disease (51%), depression (41%), hypertriglyceridemia (39%), sleep apnea (36%), fatty liver disease (28%), urinary stress incontinence (24%), type 2 diabetes (22%), cholelithiasis (17%), and asthma (16%). It is also interesting to note that the lifetime prevalence of depression in those seeking bariatric surgery is 19% to 51%.^5,6

Those who seek bariatric surgery have usually gone through multiple attempts to lose weight by changing their diet, increasing their activity level, or trying medical management without long lasting impact. Thus, bariatric surgery becomes the last source of hope for healthy living for this patient population. Because there are several surgical options available and the information is often complex, most patients want as much assistance as possible to help guide them in making their decision.

There are a wide variety of educational resources available to patients, including media, research journals, and the Internet. The Internet is one of the most widely used resources for getting information quickly. Some individuals rely on various websites without considering the validity of the information posted. Nichols and Oermann (2005) evaluated 40 websites using Google and Yahoo as the primary search engines. They found that “conflict of interest” (evidence of commercial promotion) was evident in the majority (77.5%) of websites, that 62.5% of the sites were biased, and that only 37.5% of the sites had been recently updated and had current information.⁷

The evidence of the benefits for providing patients with pre-operative information spans 50 years.⁸ Hayward's (1975) classic work showed that patients who had been given pre-operative information required less analgesia and recovered faster than those who had not.⁹ This was supported by other investigators.^10,11 In a study of the effect of pre-operative information on post-operative anxiety, Callaghan and colleagues (1998) reported no decrease in demand for analgesia, but noted that patients who had received pre-operative information experienced less anxiety and an increased level of satisfaction with their hospital stay.¹² In a study of ICU patients, the investigators found that 92% felt a pre-operative tour of the unit was beneficial in alleviating anxiety.¹³

A study conducted on satisfaction levels for same-day surgery patients indicated that patient satisfaction and clinical outcomes were related to patients receiving specific information about possible complications that was tailored to their individual situation.¹⁴ Bernier (2003) found that the most favorable patient outcomes occurred when nursing care included pre-operative teaching and acknowledged individual situations.¹⁵

Lookinland and Pool (1998) conducted a study that compared the effect of pre-operative structured education with unstructured education provided after admission. They found that patients who received pre-operative structured education had improved clinical outcomes, were more satisfied, and were more likely to meet the targeted discharge dates. Further, they also experienced a faster recovery rate. One of their findings was that pre-operative information is a cost-effective way to support the educational needs of patients. When information transmission is successful, patients will arrive on time, understand the plan of care, and have knowledge and skills that will promote their recovery and satisfaction.¹⁶

Although there have been studies investigating the impact of education on post-operative patient satisfaction, no such study has been conducted with bariatric patients. The purpose of this study is to determine the impact of structured pre-operative patient education classes on knowledge level and satisfaction with the hospital stay for bariatric patients.

Materials and Methods

A prospective cohort design was used to evaluate the effectiveness of structured pre-operative bariatric education classes at the University of Minnesota Medical Center, Fairview. Outcome measures were knowledge of immediate post-operative care and satisfaction with the overall hospital experience. The study received approval from the University of Minnesota Medical Center, Fairview, the University of Minnesota Amplatz Children's Hospital, Nursing Research Council, and the University of Minnesota's Institutional Review Board.

Class content

The class covered the following content:

Pre-surgery appointments

Preparing for surgery—showering, bowel prep, pre-surgery diet instructions, medications, etc.

Coming to the hospital—what to bring, where to go, etc.

Post-op procedures

Pain management

Activities to prevent complications

Incision care

Nutrition

Lifestyle changes

Discharge instructions and follow-up—activities, appointments, home care, etc.

Patients were given written materials about their type of surgery, pre-op information cards with essential points to remember, and phone numbers of key resource people and services. A 10-minute video of a patient recovering from surgery on the bariatric patient care unit was shown. A tour of the surgical admission unit, patient care unit, and waiting room was included. Patients were encouraged to bring family members—and most chose to do so.

Instruments

All subjects were called and asked to complete a phone survey 2–4 days before surgery regarding their knowledge level. Study subjects were also asked to complete a survey at discharge regarding their satisfaction with the care they received.

Presurgery Knowledge Questionnaire: This questionnaire was administered to all participants 2–4 days before their bariatric surgery via a telephone interview that took less than 10 minutes to complete The items in this instrument are related to patients' expectation of recovery following surgery. (Appendix 1)

Postsurgery Satisfaction Survey: This questionnaire was administered to all participants close to their discharge and took less than 10 minutes to complete. This questionnaire has 11 items related to patients' level of satisfaction from their inpatient stay. (Appendix 2)

Face reliability and validity were established by having the questionnaires reviewed by clinical and research experts and by administering them to a few patients.

Sample

Patients were recruited for this study when they came to the Surgery Clinic for their pre-operative visit. A research assistant met with subjects and obtained informed consent. The sample consisted of 27 patients who were admitted for bariatric surgery to the University of Minnesota Medical Center, Fairview (university campus) between March 13, 2008, and August 29, 2008.

The inclusion criterion was all patients over 18 years of age admitted to the University of Minnesota Medical Center, Fairview for bariatric surgery. Exclusion criteria were as follows:

Patients who experienced post-operative complications that required transfer to the ICU or any unit other than the bariatric surgery unit

Patients who were having a revision of a previous gastric bypass surgery

Patients who did not have an inpatient hospital stay

The sample consisted of 4 men and 23 women, with ages ranging from 19 to 75. The largest age group was between 31 and 45 (12 people). Sixteen patients were married, and 10 were single, divorced, or widowed. Twenty patients were employed, and 6 were unemployed or retired. The length of stay ranged from 1 to 5 days, and the mean BMI was 45.99. Four patients had open procedures, and 23 were laparoscopic. The most common procedure (21 patients) was Roux-en-Y—see Table 1. Table 2 shows data on participants' comorbidities.

Table 1.

Demographics

Variables	No.	%
Age
19–30	5	18.5
31–45	12	44.4
45–60	6	22.2
60–75	4	14.8
Gender (m/f )	4/23	14.8/85.2
Marital status (married/single, divorced, or widowed)	16/10	59.3/37
Type of procedure (laparoscopic/open)	4/23	14.8/85.2
Surgical procedure
Roux-en-Y (RNY) laparoscopic	22	81.5
RNY open	4	14.8
Adjustable-band laparoscopic	1	3.7
Employment (working/unemployed or retired/missing)	20/6/1	76.9/22.2/3.7
Length of hospital stay (in days)	Mean = 2.52
	Median = 2.00
	Standard deviation = 1.014
Body Mass Index (BMI)	Mean = 45.99
	Median = 42.00
	Standard deviation = 9.96

Table 2.

Comorbidities

Variables	No.	%
Diabetes	12	44.4
Heart disease	9	33.3
Depression	16	59.3
Sleep apnea	10	37.0
Other	14	51.9

Results

Knowledge

Out of 27 participants, 24 (88%) received a score of six or more out of eight possible correct answers. One patient who received a low score had a 3-month delay from the time of the class to the actual surgery date. It was interesting to note that out of 27 patients, only 3 said they were not satisfied with their hospital experience. Two of those patients received a score of less than five out of eight possible correct answers on the knowledge questionnaire. The third patient with a low satisfaction score noted in the comments section several questions regarding diabetes care.

Satisfaction

Using Spearman's correlations, data were analyzed examining the predictors of satisfaction level. Gender and marital status were the only variables significantly associated with satisfaction. Subjects who were married and male reported more satisfaction with inpatient stay. Rate of satisfaction for those subjects was significant—92 percent said they were well prepared for their hospital stay and 88 percent said they were very satisfied with their hospital stay. See Table 3.

Table 3.

Spearman's Rho Correlation Coefficient Related to Satisfaction (n = 25)

Variable	Rho (ρ)
BMI	.123 (.557)
Gender	−.537 (.006)**
Age	−.107 (.610)
Marital status	−.452 (.023)*
Diabetes	.129 (.538)
Heart disease	.059 (.778)
Depression	−.359 (.078)
Sleep apnea	.218 (.296)
Total comorbidities	.057 (.787)
Knowledge score	−.090 (.669)
Number of information sources	−.034 (.873)
Accompany	.077 (.714)

Correlation is significant at the 0.01 level (2-tailed).

Correlation is significant at the 0.05 level (2-tailed).

Discussion

The impetus for this study came from the staff nurses on the bariatric inpatient care unit. They noticed that some patients seemed to know what to expect and were more accepting of hospital protocols. The staff then learned that some patients had chosen to attend the Patient Learning Center pre-op class. We designed the study to see if there was validity to the anecdotal stories we heard from these nurses. The data collected show that patients attending a structured pre-op class do receive high knowledge scores and have a high rate of satisfaction with their hospital experience.

Limitations

A major limitation of this study is small sample size, and thus results may not be generalizable to a larger population. Further, many patients are anxious right before a major surgery. This anxiety may have an impact on the ability of a patient to recall the information they learned about their upcoming surgery.

Another limitation is that the number of people who attended each group session varied between one patient and seven (plus additional family members) due to fluctuations in patient census and individual preferences. The differing composition may have influenced discussion during the session. There is no control over the questions patients ask during group sessions, so it is probable that some incidental learning will occur when additional information is given in response to questions.

There are many diverse factors that have an impact on satisfaction with the hospital stay. Having to share a room or not feeling well may have just as much to do with a person's satisfaction level as does a structured pre-operative class.

Conclusions

Results of this study suggest that the structured pre-op class was successful in providing patients with needed information. The majority of the patients who attended the classes received high scores on the knowledge questionnaire and had high levels of satisfaction with their hospital experience. The class was rated very highly by participants, and the comments reflected their appreciation for the program.

It is important for patients to receive accurate information prior to surgery. Many patients seek health information from the Internet as well as from family and friends. Thus, the information obtained may be inaccurate or biased. To be successful, it is crucial for patients to know how to properly prepare beforehand and to then care for themselves post-operatively. Offering a structured pre-op class containing accurate and up-to-date information provided by health care professionals makes a significant impact.

This study addressed important issues regarding the timing, structure, and effectiveness of pre-operative education for bariatric surgery patients. More and more people are having this surgery, so it is increasingly important to learn how to better meet the needs of this population.

Footnotes

Acknowledgments

The authors wish to thank research assistants Lisa Richter, BA; Angela Lundberg, BA; and Ursula Johnson, RN for their help collecting data for this study. Thanks go to the bariatric program staff for their support—Bridget Slusarek, RN; Kate Vierling, RN; Karla Stallings, RN; and Andrea Silverman, OTR, MA. This study was supported by a grant from Fairview Health Services Research Administration.

Disclosure Statement

No competing financial interests exist.

Appendix 1: Pre-Surgery Knowledge Questionnaire

Please answer the following questions by selecting the one most correct answer.

Appendix 2: Patient Satisfaction Discharge Evaluation

Date of surgery: _______________________________

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