Evaluating a potential role for community pharmacists in post‐bariatric patient nutritional support

Physiological changes to the body from bariatric surgery necessitate lifelong vitamin and mineral supplementation to prevent potential nutritional deficiencies. Presently, there is no consensus on appropriate long‐term follow‐up in community settings for people who have undergone bariatric surgery. Current UK guidelines recommend annual monitoring of nutritional status, but little else. Semi‐structured interviews were carried out with members of a high volume bariatric surgical unit and community pharmacists working in a variety of settings and locations. Data were collected between June and August 2018 and analysed using a thematic analytic framework. Twenty‐five participants were recruited. Bariatric staff (n = 9) reported negligible interaction with community pharmacists but felt establishing communication and developing a potential pathway to collaborate, would provide additional support and potentially improved levels of patient compliance. Community pharmacists (n = 16) reported poor knowledge of bariatric surgery, indicating they were unable to routinely identify people who had bariatric surgery, but understood issues with absorption of vitamins. There is evident potential to involve community pharmacists in post‐bariatric patient care pathways. Pharmacists possess knowledge of absorption and metabolism of supplements which could be used to actively support people who have had bariatric surgery in their changed physiological status. Education ought to focus on the functional impact of bariatric surgical procedures and interventions and the consequent nutritional recommendations required. Communication between bariatric units and community pharmacies is needed to construct a clear and formalized infrastructure of support, with remuneration for pharmacy specialist expertise agreed to ensure both financial viability and sustainability.


Summary
Physiological changes to the body from bariatric surgery necessitate lifelong vitamin and mineral supplementation to prevent potential nutritional deficiencies. Presently, there is no consensus on appropriate long-term follow-up in community settings for people who have undergone bariatric surgery. Current UK guidelines recommend annual monitoring of nutritional status, but little else. Semi-structured interviews were carried out with members of a high volume bariatric surgical unit and community pharmacists working in a variety of settings and locations. Data were collected between June and August 2018 and analysed using a thematic analytic framework.
Twenty-five participants were recruited. Bariatric staff (n = 9) reported negligible interaction with community pharmacists but felt establishing communication and developing a potential pathway to collaborate, would provide additional support and potentially improved levels of patient compliance. Community pharmacists (n = 16) reported poor knowledge of bariatric surgery, indicating they were unable to routinely identify people who had bariatric surgery, but understood issues with absorption of vitamins. There is evident potential to involve community pharmacists in post-bariatric patient care pathways. Pharmacists possess knowledge of absorption and metabolism of supplements which could be used to actively support people who have had bariatric surgery in their changed physiological status. Education ought to focus on the functional impact of bariatric surgical procedures and interventions and the consequent nutritional recommendations required. Communication between bariatric units and community pharmacies is needed to construct a clear and formalized infrastructure of support, with remuneration for pharmacy specialist expertise agreed to ensure both financial viability and sustainability. The restrictive and malabsorptive effects of bariatric surgical procedures require lifelong vitamin and mineral supplementation to avoid nutrient deficiencies, which can lead to long term pathological change. 1 Post-surgically, people who have had a bariatric procedure are cared for by the surgical multi-disciplinary bariatric team for a period of 2 years, before being discharged into general practice for long-term follow-up and care. Current guidelines from the National Institute for Health and Care Excellence recommend the need for "at least annual monitoring of nutritional status and appropriate vitamin supplementation according to identifiable need. This is an integral part of post-surgical care in the context of a shared care model of chronic disease management". 2 However, no evidence based consensus currently exists as to what this post-surgical follow-up ought to entail.
There are published recommendations for both acute and community settings offering guidance, 1,3-6 but there is also a degree of ambiguity regarding with whom responsibility for the long-term follow-up of patients' individual nutritional status lies, with limited references to the involvement of community pharmacy. Effective communication and co-ordination between bariatric surgical units and community settings is pivotal in ensuring pathways are developed and sustained, to provide optimal, ongoing care for bariatric surgical patients who are transitioning through changes in attitude and behaviour towards both their short and long term nutritional needs. 7 Prior to surgery, nutrition and supplementation is discussed with the patient via members of the bariatric multidisciplinary team, including dietitians and a specialist pharmacist in our bariatric surgical unit.
The pharmacist undertakes a medication review, which a personalized set of guidelines and key recommendations for both medicines use and adjunct nutritional supplementation following surgery. A copy of this documentation is provided to the patient, sent to the GP and also filed in the patient's hospital notes.
Whilst the ongoing need for vitamin and mineral supplementation is reinforced in follow-up appointments in Secondary Care, audits in our bariatric surgical unit reveal there are high rates of patient nonattendance. Additionally, there is no information on the uptake of published guidance about the long term management of bariatric surgical patients in the community and, but it is not clearly defined as to what the role of community pharmacy within this monitoring ought to include.
Evidence shows that many patients decline to attend follow-up appointments following surgery, 8-10 nutrient deficiencies are common 11 and compliance with vitamin and mineral supplements is poor 12 for many reasons, including the size of pills or capsules 13 and their perceived and actual side effects. 14 Feedback from patients at our support group and previous research has shown that patients felt they needed support around nutritional considerations in the longer term. 15 Public Health England has highlighted the evident need for greater research into understanding the role of community pharmacists, acknowledging the importance of community pharmacies to local health needs, since they are often the first point of contact for the general public and can offer individualized advice and focused interventions to promote and support the long term health and wellbeing of the population. 16 There are nearly 12 000 community pharmacies in England. 17 Community pharmacies are perceived by the general public as being easily accessible, conveniently located. 89% of the population of England are within a 20-minutes walk of their nearest pharmacy, where they are perceived as being flexible, providing trustworthy advice and as a consequence are often the initial point of contact for people with health concerns (1.6 million health encounters per day), with over 90% of community pharmacies having a designated consultation area in which to provide confidential advice and support to patients. 18 In addition to community pharmacies, NHS England launched a pilot study in 2015 to support pharmacists working within general practice in the United Kingdom, with pharmacists working collaboratively in more patient-centric roles, using and applying their knowledge of medicines management and taking responsibility for patients with long term conditions and the routine execution of clinical medications use reviews (MURs). 16 Currently, community pharmacists do not have a definitive role in post-bariatric surgical support but undoubtedly have the generic skills and degree of accessibility to the general public, which ensures their functional capacity to potentially support these patients long-term.
The aim of this study was to explore a potential role for community pharmacists in the provision of post-bariatric surgical nutrient support.

What is already known about this subject
• The long-term monitoring and support of people undergoing bariatric surgery is crucial to the potential for successful post-operative outcomes and an improved quality of life.
• There is currently limited guidance as to what ought to be included and what is feasible in the context of followup in community-based settings.
• Bariatric surgery fundamentally alters the physiology of the body, meaning lifelong vitamin supplementation is needed.

What this study adds
• A potential role for community pharmacists in bariatric surgical care is explored.
• The availability and accessibility in community contexts provides an opportunity to directly improve long term patient compliance with recommended levels of vitamin supplementation.

| MATERIALS AND METHODS
A qualitative methodological approach underpinned the study. The inductive approach of qualitative methods are most appropriate where there is a distinct paucity of information on specific subjective issues for investigation, 19 permitting exploration and consequently a critical understanding of issues to be gained. 20 Data were analysed using a thematic analytic framework, informed by the guidance of Braun and Clarke 21 and Robson 22 (see Table 1). Thematic analysis seeks to uncover patterns or themes which emerge from the data related to the research question. Themes allow exploration of the parts of the phenomenon, which give a greater understanding of the whole. 23 The identified themes serve as the basis for analysis, which inform a rich, detailed and complex account of the situation under investigation. 23 Thematic analysis is flexible in that it can be adapted to suit a range of theoretical and philosophical approaches. 21 For this study, a social constructivist philosophical perspective informed the analysis.
This perspective that reality is constructed through interactions with others and is influenced and shaped by life experiences, social and cultural norms and values. 24 We assert that obesity, through its classification as a disease by the American Medical Association 25 is an illness and it is important to understand the social construction of obesity as an illness as this may potentially influence policy on treatments and allocation of resources. Conrad and Barker 25 offer three areas for exploration within a social constructivist framework: 1. Many illnesses are particularly embedded with cultural meaning, which may not be related to the condition, which directs how society responds to the people suffering from that condition. 25 Currently, society perceives obesity as a deviant condition, with culpability attributed to the individual 26 and treatments such as bariatric surgery, have negative connotations, for example, a method of cheating or wasting health resources. 27 2. Most illnesses are socially constructed at the experiential level, framed on how people understand and deal with the illness on a day to day basis.
Medical knowledge about illness and disease is not necessarily given by nature but is constructed and developed by claims-makers and interested parties. 25 In order to more fully understand the way in which the participants' made meaning of their professional roles, the approaches to patient support and the resultant meanings and actions, it was important to acknowledge the multiple realities and interpretations of the participants.
Active delineation between what socially constructed knowledge is and what knowledge actually constitutes is also a paramount consideration, since it impacts on the capacity that bariatric surgical teams and community pharmacists have to react to it in practice. 28 Critical reflection and the capacity for reflexivity in the context of decision-making now characterizes the majority of medical and allied health and social care professions. 29 This has entrenched the notion of an ethical stance as an integral part of professional practice. It stems from the notion that accountability in terms of "being" in the world belies the contextual and situational basis of how we might begin "know" in practice. This methodological approach ensured knowing was authentic and contextually valid.
Two cohorts of participants were approached to become participants in the study. First, a range of staff working within the Bariatric Surgical Unit were asked to consider taking part in the study. Second, community pharmacies within the general locality of the hospital and wider areas from which patients had been referred to the hospital were approached. All participants in the study were approached in writing and were informed of the aims of the study and that participation was both voluntary and anonymous.
Participants who consented to take part had the option to be interviewed face to face or by telephone. Purposive sampling was employed to ensure that a representative sample of the bariatric multidisciplinary team was apparent, to capture the wide range of contextual situations and settings in which community pharmacists practice and to reflect the wide geographical spread of the patient population.
Written consent was obtained from each participant and all were assigned an anonymous code to ensure the confidentiality of all data collected. The researchers ensured that prior to interview, each participant was aware of the aims of the study and were comfortable taking part. No participant declined to take part or dropped out.
Data were collected through semi-structured interviews, face to face (n = 14) and by telephone (n = 11) and were facilitated via the use of a topic guide (see Table 2) which was pilot tested with a representative sample prior to seeking ethical approval. Interviews were carried out by two experienced researchers, both female. One was a clinical academic researcher working between academia and the NHS (YG), the other was an academic pharmacist (CES). According to the preferences of the participants, face to face interviews were carried out in a private area in the participants' place of work and involved only the participant and researcher. All participants were aware of the researchers' academic and clinical backgrounds and a rapport was established with each participant prior to commencing the interviews.

T A B L E 1
Thematic analytic framework Step Definition Actions Bariatric surgical staff were asked to discuss any interactions with community pharmacists, their experiences of patient compliance with nutrient supplementation and to explore how they felt community pharmacies might potentially be utilized in the provision of bariatric patient care. The community pharmacist cohort were asked to discuss any involvement with bariatric surgical teams, their knowledge of bariatric surgical procedures, their involvement with bariatric patients, which services were currently delivered in the context of their roles and finally whether they perceived that involvement with bariatric patient support was an area worthy of further exploration.
All interviews were audio-recorded and transcribed verbatim.
Interviews lasted between 30 and 45 minutes. Both researchers took additional notes during and after the interviews. Participants were interviewed once and any areas of ambiguity were clarified after data was transcribed. Data saturation in each group was agreed with the research team before ceasing recruitment. Data were analysed by YG, CES, CH, LP, KM and LCD through a constant comparative framework in order to specifically understand individual participants' perspectives, to identify common themes 19 constructed from the data and to maintain reflexivity to identify and acknowledge any inherent bias 30 from the interviewers. The coding process was completed manually.
Recruitment took place between June and August 2018.
Ethical approval for the research was granted by the National Health Service and the University of Sunderland, with written, informed consent obtained from all participants.

| RESULTS
A total of 25 participants were recruited to the study across both cohorts. In the bariatric surgical staff cohort, 9 participants were recruited to the study and consisted of the following healthcare professionals: dietitians (n = 2), specialist pharmacists (n = 2), physician (n = 1), surgeons (n = 2) and specialist nurses (n = 2). The second cohort were community pharmacists (n = 16), again purposively sampled to ensure that the wide range of settings in which community pharmacists practice were represented to capture all potential roles and to reflect the wide geographical spread of the patient population of the bariatric service (see Table 3). No participants dropped out of the study.

| Bariatric surgical staff
Bariatric staff (n = 9) reported negligible interaction with community pharmacists, but felt establishing communication and a potential pathway to embedding community pharmacists as part of patient care would provide additional support, resources and potentially improved patient compliance with nutrient supplementation.
Analysis of the data identified four core themes (see Table 4) which illuminated the perspectives of the bariatric surgical staff to provide an understanding of their interpretation of the role of community pharmacists and the potential to provide nutrient support for patients.

| Theme 1: Lack of patient engagement and compliance
The bariatric surgical staff participants reported that a lack of patient engagement and compliance with supplementation in the postsurgery phase of their care:

| Theme 3: Perceptions of limited intraprofessional communication between care settings
Participants revealed that intraprofessional communication between  Table 5). across healthcare teams, to inform potential of future service provision at local, national and global levels. As this was a pilot study, which aimed the perspectives of community pharmacists and aiming for an in-depth understanding of current knowledge and practice, we only focused on any relationships between them and bariatric surgical units; we did not seek the views of staff working in general practice such as GP's and Practice Nurses, nor did we interview any patients.

|
This will be undertaken in the next phase of our work.
Additionally, we acknowledge that there may be bias from the two researchers carrying out the interviews, given one worked part- Findings were discussed with both cohorts of participants and presented at a regional pharmacy collaborative. Feedback was overall positive, reflecting current practice and supportive of further work being undertaken to explore this area in more detail.
We recommend that a pilot project with a small group of pharmacies is carried out, working in collaboration with the bariatric surgical unit, utilizing the expertise of the specialist bariatric pharmacist and other members of the multidisciplinary team including dietitians to agree what support the community pharmacist could provide. This further study may potentially involve general practice and patient participants, to agree a pragmatic operational framework which could test the potential role and infrastructure of community pharmacy over a period of 6 months. We feel the optimum time to involve community pharmacies would be at the time of the pre-surgical assessment, when a patient could nominate a pharmacy, who would receive a copy of the medication review and be in a better position to offer support after surgery. As the pharmacist would have the information on the patient, it would lessen the burden on the patient to disclose and explain themselves. After such time, the project outcomes ought to be reviewed and evaluated to assess impact in clinical practice, patient and pharmacist acceptability and if successful, how to sustain this pathway long-term.

CONFLICT OF INTEREST
Kamal Mahawar is on the editorial board of Clinical Obesity, Yitka Graham received funding from Metagenics, and she is also a reviewer for Clinical Obesity. All other authors have no conflicts of interest to declare.

AUTHOR CONTRIBUTIONS
YG conceived the idea for the study, led on data collection and analysis and write up of the manuscript. CES collected data and contributed to analysis and write up. LP and CH contributed to data analysis and write up. CT and AF contributed to write up. KM assisted with study design, contributed to data analysis and write up. LCD contributed to study design, data analysis and writing up.