Patient-reported outcome measures in follow-up care after bariatric surgery

Background: Bariatric Surgery (BS) is acknowledged as an effective long-term treatment for patients with obesity. Even though most patients experience significant improvements in comorbidities and health-related quality of life (HRQOL), some patients do not experience improvement and some even experience a deterioration of HRQOL or mental health after surgery. This knowledge has been implemented in several guidelines for follow-up care after BS that emphasise the importance of focusing on HRQOL and mental health. However, there is a lack of concrete recommendations for how healthcare professionals can include HRQOL and mental health assessments in their daily practice. Aim: The aim of this research was to implement a patient-reported outcome monitoring with a clinical feedback system (PRO/CFS) in BS follow-up care. The specific aims were to assess the effectiveness of PRO/CFS on HRQOL through a review of systematic reviews (Study 1), to provide a detailed description of the PRO/CFS implemented in the bariatric surgery outpatient clinic and plans for evaluating the feasibility of this PRO/CFS (Study 2), to assess the patients’ overall treatment satisfaction five years after surgery (Study 3) and to assess whether a digital questionnaire developed for use in mental health services (the Norse Feedback (NF)) was valid for a population of patients undergoing BS (Study 4). Results: A PRO/CFS was implemented in the BS outpatient clinic at Helse Førde Hospital Trust on 1 February 2018. In study 1, five systematic reviews exploring the effectiveness of the PRO/CFS on HRQOL in patients in mental health treatment and in cancer care were included. The synthesis demonstrated inconsistent findings, however effectiveness of a PRO/CFS was found in patients undergoing mental health treatment and for symptom burden in patients with cancer. A key finding was the variability in how the concept of the PRO/CFS was understood in the individual trials included in the systematic reviews. In study 2, a detailed description was provided of the PRO/CFS implemented in two BS outpatient clinics. Furthermore, this paper provided a study protocol for planned quantitative and qualitative inquiries of patients’ and healthcare professionals’ experiences with the PRO/CFS in the clinical consultations. In study 3, higher body-mass index, reduced mental component of HRQOL and reduced obesity-specific HRQOL were associated with reporting to be dissatisfied or unsure about the overall treatment outcomes. In study 4, 12 out of 19 scales in the NF demonstrated satisfactory psychometric properties, but with large floor effects in several of the scales. In addition, 19 out of 21 scales in the NF showed moderate to small correlation with the Obesity-related Problems scale. The overall finding was that the NF is a promising tool in a PRO/CFS, but that the questionnaire needs to be adapted to the population of patients undergoing BS. Conclusion: Through the studies included in this thesis, the importance of including aspects such as HRQOL, mental health and treatment satisfaction in the clinical consultations after BS is emphasised. A digital PRO/CFS seems to be a feasible tool for including such assessments in follow-up care