How do patients describe their experiences of a pre-operative health optimisation scheme?

Problem

Pre-operative Health Optimisation (POHO) is the delaying of elective surgery to provide time for patients to make positive health behaviour change. Typically, this focuses on smoking cessation and weight management. Its advocates argue it reduces perioperative risk and may promote longer term change at a teachable moment. Despite criticism, mandatory POHO programmes have been introduced in several CCGs. We aimed to understand patients’ experience of one mandatory POHO scheme which introduces a delay to the elective surgery referral pathway for patients to stop smoking or lose weight.

Approach

We conducted a qualitative study involving people who had been referred by their GPs to a mandatory POHO scheme in South Yorkshire. The scheme introduced a delay in the referral pathway for smokers and people with obesity. Patients referred to the POHO scheme by 10 GP practices were invited to take part in the study by mailed invitation. Additional participants were recruited through weight-loss schemes involved in the POHO programme.

Data was collected from face to face interviews and transcribed for analysis. We used a thematic approach to analysis and developed themes iteratively over interviews and re-readings of transcripts. We used an interpretive phenomenological approach in analysing patients’ accounts. This recognised the subjectivity of both participant and interviewer. Finally, we considered accounts as examples of “resistance narratives”.

Findings

We invited 150 patients over 3 rounds but only 9 agreed to be interviewed. Participants came from diverse socioeconomic backgrounds and had engaged with the programme to varying extents. We identified four main themes

Perceived benefit for some

Four of the patients we interviewed had managed to lose some weight during their POHO period. Two felt the programme was instrumental in this. The remainder saw no benefit from delaying surgery.

First impressions matter

None of the interviewees reported a positive introduction to the POHO programme by their GP. Some used their GP’s ambivalence to support their position of non-engagement.

Asked the impossible

Interviewees saw weight loss and smoking cessation as countering each other and unrealistic at the same time. They felt this showed policymakers hadn’t considered the reality for patients in this situation.

What’s the link?

While interviewees recognised a number of health benefits from weight loss and smoking cessation, getting fit before surgery wasn’t one of them. Some argued that delaying surgery to improve health was unfair and stigmatising, particularly as those with other behaviours were not targeted.

Consequences

Patients described several negative experiences of mandatory pre-operative health optimisation. On the one hand these represent points to address in improving delivery of POHO. On the other they represent narratives of resistance by which patients contest the unilateral imposition of POHO. Both these perspectives are relevant for commissioners and providers of POHO schemes.