Integrated health article

On-line bariatric surgery information session as effective as in-personinformation session

Lisa Eaton, M.S.*, Christine Walsh, R.N., M.B.A., Thomas Magnuson, M.D.,Michael Schweitzer, M.D., Anne Lidor, M.D., M.P.H., Hien Nguyen, M.D.,

Kimberley Steele, M.D.Department of Surgery, Johns Hopkins Bayview Medical Center, Baltimore, Maryland

Received May 6, 2011; accepted October 19, 2011

Abstract Background: All patients at our academic medical center complete a mandatory bariatric surgeryinformation session before scheduling their first clinic visit. The patients could attend an in-personinformation session or view a prerecorded information session through our Web site. The studyaimed to compare the information retention after both delivery methods using an institutional reviewboard-approved test in an academic medical center in the United States.Methods: From February 2010 through March 2011, 338 tests were voluntarily completed by newpreoperative bariatric patients at their clinic visit. The patients provided basic demographic infor-mation, co-morbid medical conditions, and identified which bariatric procedures they were inter-ested in. The test assessed the retention of information delivered during the information session,including knowledge of the risks and benefits of bariatric surgery, the surgical options available atour center, and the steps commonly required for insurance approval. The patients and surgeons werekept unaware of the results.Results: Of the patients, 54% attended the on-line information session; 80% of these participantswere women, and their mean body mass index was 48.09 kg/m2. The remaining 46% attended thein-person information session, and 83% of these participants were women and their mean body massindex was 49.08 kg/m2. The average test score was 85.69% for the on-line group and 80.32% forthe in-person group. The difference in test scores for the on-line and in-person groups wasstatistically significant (P � .003).Conclusion: Internet-based training is rapidly becoming a key educational tool. Our results suggestthat on-line training has the potential to be as effective as traditional in-person training in educatingpatients about bariatric surgery. Bariatric surgery centers might consider incorporating on-linetraining into their educational programs as a convenient and potentially effective way to educatepatients. (Surg Obes Relat Dis 2012;8:225–229.) © 2012 American Society for Metabolic andBariatric Surgery. All rights reserved.

Surgery for Obesity and Related Diseases 8 (2012) 225–229

Keywords: Bariatric surgery; Education; Information session; Internet; On-line

In the United States, 79% of all adults use the Internet[1]. The Pew Research Center found that 80% of adultInternet users in the United States search on-line for healthinformation, and that, of those users, the groups most likely

*Correspondence: Lisa Eaton, M.S., Department of Surgery, Johns Hop-kins Bayview Medical Center, 4940 Eastern Avenue, Baltimore, MD 21224.

E-mail: lisa.eaton@jhmi.edu.

1550-7289/12/$ – see front matter © 2012 American Society for Metabolic anddoi:10.1016/j.soard.2011.10.015

to search for health information include women, whites, andadults aged 18–49 years [1]. The demographics of thisgroup overlap with the bariatric surgery population. Pratt etal. [2] found that the typical bariatric surgery patient at anAmerican Society for Metabolic and Bariatric Surgery Cen-ter of Excellence is a 43-year-old white woman.

With so many potential bariatric surgery patients seeking

health information on-line, integrating information about

Bariatric Surgery. All rights reserved.

wotaaE

226 L. Eaton et al. / Surgery for Obesity and Related Diseases 8 (2012) 225–229

bariatric surgery into a Web-based delivery system is smartfrom a customer service standpoint and as a method toremain competitive and relevant to the customer. It couldalso be an excellent educational resource for these patients.

Patient education is important in helping patients makeinformed decisions about bariatric surgery and for creatingappropriate expectations about life after surgery. Jones et al.[3] found that an educational program before knee arthros-copy reduced length of stay from 7 to 5 days. A diabeteseducation program at Saint Joseph’s Hospital in Atlanta,Georgia, helped patients reduce their hemoglobin A1c lev-els [4].

It seems that the delivery method of the educationalintervention can make a difference for patients. An ortho-pedic study by Cornoiu et al. [5] found that patients whoviewed a computer-based multimedia presentation scoredbetter on a questionnaire about knee arthroscopy surgerythan patients who were given the same information verballyor through a pamphlet. Lo et al. [6] randomized patients

ith colon cancer to either a multimedia education programr a brochure about stoma care. They found that patients inhe multimedia group demonstrated greater knowledgebout stomas and better self-care than the brochure groupfter their intervention. A study in The Netherlands bydward et al. [7] found that compared with patients who

read a brochure, those who reviewed a multimedia Web sitewith information about anesthesia performed better on aquestionnaire about anesthesia than patients who read abrochure.

At our academic medical center, both the on-line andin-person information sessions share a core presentation;however, owing to the delivery methods, differences be-tween the 2 information sessions are unavoidable, as de-scribed in the study methods.

The aim of the present study was to determine whetheran on-line information session has similar retention of spe-cific “need to remember” elements as identified by ourmultidisciplinary team compared with the standard in-per-son information session.

Methods

Background—information sessions

In 2008, we made an information session the mandatoryfirst step for new patients at our bariatric center. The pa-tients must attend an information session and complete ahealth history packet before they can be scheduled for aconsultation with one of our bariatric surgeons. The goal ofthe information session is to inform patients about the basicsof bariatric surgery and to establish a basic knowledge levelfor our patients. We do not administer a pretest to assess thepatient’s knowledge of bariatric surgery before their partic-

ipation in an information session.

We host several in-person sessions each month at ourcampus and at satellite locations. After we made the infor-mation session mandatory, we quickly implemented an on-line information session to accommodate patients for whomthe in-person session was inconvenient.

At both the in-person and the on-line information ses-sion, patients hear a presentation about the bariatric surgeryprocedures offered by our center, the risks and benefits ofbariatric surgery, our program requirements, and the stepsnecessary to navigate the insurance approval process.

The core script for both sessions was designed by ourpractice. To encourage on-line patients to view the presen-tation in its entirety, we decided on the important “need toremember” elements and incorporated them into a gradedquiz administered at the end of the on-line session. Patientsare given a username and password to access the quizduring the presentation. The patients need to score a �75%on the quiz and can view the presentations multiple times.

No quiz is given at the in-person information session. Atthe in-person session, in addition to the core presentation,the patients have the opportunity to ask questions, hear otherpatients’ questions, and hear a previous patient speak abouttheir experience with bariatric surgery.

Participants

The participants in the assessment were new, first-timebariatric surgery patients at our clinic locations. All patientsprovided written informed consent for their treatment; how-ever, the study itself was an anonymous assessment forwhich our institutional review board granted a consentwaiver. The participants were instructed that if they chose toparticipate, they should complete the survey and deposit itin a marked collection box at the clinic desk before meetingwith their surgeon.

The participants were asked to provide their gender, age,height, and weight. They were also asked to identifywhether they had attended an on-line or in-person informa-tion session, indicate whether they had diabetes, sleep ap-nea, hypertension, gastroesophageal reflux disease, or heartdisease, and indicate whether they were interested in gastricbypass, laparoscopic adjustable gastric banding, sleeve gas-trectomy, or biliopancreatic diversion with duodenal switch,or if they were unsure of which procedure they wouldchoose. The respondents were able to give multiple re-sponses for co-morbidities and possible bariatric proce-dures.

In our analysis, we did not include assessments withinsufficient data to calculate the body mass index (n � 8),assessments from people who attended both an on-lineand an in-person session (n � 16), assessments frompeople who did not specify which session they had at-tended (n � 20), or assessments from those who reporteda height and weight that corresponded to a body mass

index �35 kg/m2 (n � 4).

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227On-line Bariatric Surgery Information Session / Surgery for Obesity and Related Diseases 8 (2012) 225–229

A total of 338 assessments were eligible for analysis. Themean patient age was 41 � 11 years; 81% were womenn � 274), and their body mass index ranged from 35 to 74g/m2 (median 46.83, mean 48.55).

Assessment

The assessment had 20 questions. The total possiblescore range was 0–100 points, with greater total scoresindicating increased information retention. The questionspertained to candidate selection (2 questions), the effect ofobesity and bariatric surgery on co-morbid conditions (3questions), insurance and bariatric center requirements (4questions), the risks to and responsibilities of the patientafter surgery (5 questions), and knowledge of surgical pro-cedures (6 questions).

The assessment questions were determined from the corecontent presented in both the on-line and in-person infor-mation sessions. They were identified by our multidisci-plinary team as the information we would most like patientsto retain. The validity and reliability of the test as an as-sessment tool was not established.

Statistical analysis

Analysis was performed using the Statistics Open ForAll software, version 1.0.4 (available on-line). The valueswere compared using t tests and chi-square analysis, asappropriate.

Results

Demographic and weight characteristics

The mean age of the on-line group was 39.54 � 10.91years. The mean age of the in-person group was 42.75 �11.03 years (P � .008). The mean body mass index of theon-line group was 48.09 � 8.48 kg/m2. The mean bodymass index of the in-person group was 49.08 � 7.51 kg/m2;he difference was not statistically significant. The on-lineroup was 80% women. The in-person group was 83%omen (the difference was not statistically significant).

o-morbid conditions

The patients were asked to identify whether they had

Table 1Co-morbid conditions by information session group

Condition In-person (%) On-line (%) P value

Diabetes 36.31 20.44 .001Sleep apnea 38.85 37.57 .808Hypertension 51.59 38.67 .017GERD 17.20 28.18 .017Heart disease 7.64 6.08 .569

GERD � gastroesophageal reflux disease.

iabetes, sleep apnea, hypertension, gastroesophageal reflux

isease, or heart disease (Table 1). The on-line group re-orted a greater incidence of gastroesophageal reflux dis-ase (P � .017). The in-person group reported a greaterncidence of diabetes (P � .001) and hypertension (P �

.017). No difference was found in the incidence of sleepapnea or heart disease.

Desired procedures

Both groups expressed the most interest in gastric bypass(Table 2). Laparoscopic adjustable gastric banding was thesecond-most desired procedure, with the on-line partici-pants expressing a greater level of interest (P � .001). Nodifference was found in the rates of those who were inter-ested in gastric bypass, sleeve gastrectomy, or biliopancre-atic diversion with duodenal switch, or in the rate of thosewho stated they were unsure about which procedure theywould choose.

Overall assessment score

The average test score for the on-line group was 85.69 �13.99, significantly better than the average test score for thein-person group, 80.32 � 19.30 (P � .003).

Specific questions

Of the 20 questions in the assessment, statistically sig-nificant differences were found in the number of correctresponses to 8 questions using the chi-square test. For all 8questions with a statistically significant difference, the on-line group had a greater percentage of respondents whoanswered correctly.

The in-person group was less educated about the effectsof obesity and bariatric surgery on co-morbid conditions;had less knowledge about what is actually performed duringbariatric surgery procedures; and were less informed aboutthe requirements of insurance companies and our bariatriccenter. Of the 8 questions that had a significant difference inthe number of correct answers for in-person versus on-lineparticipants, the knowledge gap for 4 questions was ofparticular concern.

Table 2Desired procedures by information session group

Procedure In-Person(%)

On-line(%)

Pvalue

Gastric bypass 61.78 51.93 .068Adjustable gastric banding 20.38 39.78 �.001Sleeve gastrectomy 19.11 16.57 .543Biliopancreatic diversion

with duodenal switch.64 .55 .920

Unsure 9.55 12.15 .445

228 L. Eaton et al. / Surgery for Obesity and Related Diseases 8 (2012) 225–229

Q5—Some bariatric procedures will permanentlychange a patient’s anatomy (options: true, false; desiredresponse: true)It is interesting that gastric bypass was the most-desiredprocedure among the in-person group (61.78%) and thatonly 75.16% of the in-person group answered it correctlycompared with 86.74% correct in the on-line group(P � .006). Of the on-line group, 51.93% expressed aninterest in gastric bypass. A review of the Bariatric Out-comes Longitudinal Database showed that 54.68% ofbariatric procedures performed in the United States aregastric bypass [8]. All patients, regardless of the desiredprocedure, should have a basic awareness of what occursduring commonly performed bariatric procedures tomake an informed decision about their procedure ofchoice.

Q8—The purpose of bariatric surgery is to alleviate oreliminate obesity-related medical conditions (options:true; false; desired response: true)In our presentation, we state that the purpose of bariatricsurgery is to alleviate or eliminate obesity-related medicalconditions. The in-person group scored 87.90% correct, andthe on-line group scored 95.03% correct (P � .018). It isunclear whether the in-person group did not understand thatwe believe that is the goal for bariatric surgery, or if theyhad other goals they prioritized over alleviating their co-morbid conditions, leading them to answer this questionaccording to their own personal desires.

Q14—After surgery, patients might not lose all theirexcess body weight (options: true, false; desired re-sponse: true)Previous studies [9,10] have found that bariatric surgerypatients often have unrealistic expectations about theirweight loss. Of the in-person group, 82.17% respondedcorrectly to this question compared with 91.16% of theon-line group (P � .014). A pelvic surgery study by Kentonet al. [11] found that if patients did not believe they wereprepared before surgery, they were less likely to be satisfiedwith their outcomes after surgery. Thus, we want patients tohave realistic expectations for their weight loss aftersurgery.

Q20—Patients of the Center for Bariatric Surgery com-mit to following up with us for a minimum of 5 years(options: true, false; desired response: true)It is important that patients understand that bariatric surgeryis a lifelong commitment. The in-person response was77.71% correct compared with the on-line response of88.95% (P � .005).

These key concepts are repeated to the patients by themembers of our multidisciplinary team as they workthrough their preoperative requirements. Ideally, the on-line

and in-person groups would be compared with each other at

surgery or at some time after to reassess the retention ofcritical information.

Discussion

In our present study, we found significant differencesbetween the in-person and on-line groups in age, co-morbid conditions, desired procedures, and performanceon the assessment. Bariatric practices might wish to con-sider their patient population as composed of severaldemographic groups to address the educational prefer-ences of each group.

An on-line information session could be more attractiveto some patients for several reasons: an on-line informationsession can be delivered asynchronously and watched at anytime, from any location; younger patients with more Inter-net experience might be more familiar with the technologyand with completing the session on-line; and an on-linesession is sensitive to the needs of those with limited mo-bility and those outside of a practice’s usual geographicarea.

We know that most adult Internet users search forhealth information on-line [1]. Americans already rely onthe Internet for electronic mail, news, shopping, banking,and entertainment. Internet penetration can only be ex-pected to increase as the population becomes more com-fortable with it and on-line services expand. The PewInternet Research Project found that 95% of the Millen-nial generation, aged 18 –33 years, access the Internetand account for 35% of all adult Internet users [12]. Also,81% of the Millennial generation report broadband Inter-net access at home compared with 66% of all adults [12].Many of these adults will consider bariatric surgery atsome point in their lives, and they will go on-line to learnabout it.

Throughout the weight loss surgery journey, we be-lieve that education and compliance are critical to patientsuccess. Although the present study did show a signifi-cant value to on-line education, our study had somelimitations. We sampled a small number of patients whoselected themselves for participation in the assessment,and no pretest was given to assess the patients’ previousknowledge of bariatric surgery. Because of a desire topreserve patient anonymity, no definitive method wasavailable to determine how much time had elapsed fromthe patients’ participation in the information session andtheir first clinic visit and the completion of the assess-ment. We were unable to control for patients who mighthave viewed the on-line information session multipletimes, and the knowledge that a quiz would be given atthe end of the on-line information session could haveinfluenced their retention of the key “need to remember”elements. We did not ask patients about their socioeco-nomic or educational background, which might have had

an effect on participants’ acceptance of new technology

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229On-line Bariatric Surgery Information Session / Surgery for Obesity and Related Diseases 8 (2012) 225–229

and motivation for choosing one type of informationsession over another.

Conclusion

Additional research is needed to explore and control forthe differences that might exist between the participantsin the on-line and in-person information session groups, andthe influence of the two different information session deliv-ery methods on information retention.

Bariatric practices might wish to divide their patientpopulation into several demographic groups to address theeducation preferences of each. An on-line information ses-sion can be a method to successfully educate a group ofpotential bariatric surgery patients that has already beenseeking out health information on-line. It is important tocreate quality delivery methods to meet this need. Internet-based training is rapidly becoming a key educational tool,and bariatric surgery centers might consider incorporatingon-line systems into their educational programs as a conve-nient and potentially effective method to educate patientspreoperatively and postoperatively.

References

[1] Fox S. Health Topics. Pew Internet Project, 2011. Available from:http://pewinternet.org/Reports/2011/HealthTopics.aspx. Accessed

as in-person inform

portant, if not more. This study shows that providing more

[2] Pratt GM, Learn CA, Hughes GD, Clark BL, Warthen M, Pories W.Demographics and outcomes at American Society for Metabolic andBariatric Surgery Centers of Excellence. Surg Endosc 2009;23:795–9.

[3] Jones S, Alnaib M, Kokkinakis M, Wilkinson M, Gibson A, Kader D.Pre-operative patient education reduces length of stay after knee jointarthroplasty. Ann R Coll Surg Engl 2011;93:71–5.

[4] Kiblinger L, Braza N. The impact of diabetes education on improvingpatient outcomes. Insulin 2007;2:24–30.

[5] Cornoiu A, Beischer AD, Donnan L, Graves S, de Steiger R. Multi-media patient education to assist the informed consent process forknee arthroscopy. ANZ J Surg 2011;81:176–80.

[6] Lo S-F, Wang Y-T, Wu L-Y, Hsu M-Y, Chang S-C, Hayter M.Multimedia education programme for patients with a stoma: effec-tiveness evaluation. J Adv Nurs 2011;67:68–76.

[7] Edward GM, Naald NV, Oort FJ, et al. Information gain in patientsusing a multimedia website with tailored information on anaesthesia.Br J Anaesth 2011;106:319–24.

[8] DeMaria EJ, Pate V, Warthen M, Winegar DA. Baseline data fromAmerican Society for Metabolic and Bariatric Surgery-designated Bari-atric Surgery Centers of Excellence using the Bariatric Outcomes Lon-gitudinal Database. Surg Obes Relat Dis 2010;6:347–55.

[9] Karmali S, Kadikoy H, Brandt ML, Sherman V. What is my goal?Expected weight loss and comorbidity outcomes among bariatricsurgery patients. Obes Surg 2011;21:595–603.

10] Heinberg LJ, Keating K, Simonelli L. Discrepancy between ideal andrealistic goal weights in three bariatric procedures: who is likely to beunrealistic? Obes Surg 2010;20:148–53.

11] Kenton K, Pham T, Mueller E, Brubaker L. Patient preparedness: animportant predictor of surgical outcome. Am J Obstet Gynecol 2007;197:e1–6.

12] Zickuhr K. Generations 2010. Pew Internet Project, 2010. Availablefrom:http://pewinternet.org/Reports/2010/Generations-2010.aspx.

April 6, 2011. Accessed May 2, 2011.

Editorial comment

Comment on: On-line bariatric surgery information session as effective

ation session

This is an interesting study, because many of us arealready using on-line education in preparing our patients forbariatric surgery. The comparison between on-line and in-person education reconfirms that patients who use the In-ternet before selecting a bariatric surgeon or procedure areoften more educated when they come into our individualpractices.

We have also incorporated on-line preoperative educa-tion in our practice and Web site.

We follow-up with a second, “in-person” educationclass, with quizzes given at both educational sessions. Wehave learned we cannot provide enough education to ourpreoperative patients. We consider these educational classesonly a small part of the informed consent process. WithInternet education, we can reach out to the severely obesepopulation who might find traveling difficult. We often donot scrutinize the educational level of our patients; however,communication and education postoperatively is just as im-

on-line education could also help with the more difficulttask of postoperative education and follow-up.

Patients who become familiar with on-line educationfrom their beginning with a practice might be more inclinedfurther on, after surgery, to continue with follow-up and“back on track” issues. If we can make education simplerfor our patients in the beginning, their comprehension andunderstanding of the need for compliancy and follow-upcould possibly be made easier in the future.

Disclosures

The authors have no commercial associations that mightbe a conflict of interest in relation to this article.

Barbara N. Metcalf, C.B.N.Pacific Laparoscopy

San Francisco, CA