all factors, that are important for the other but also the distance

Note: The trends in the answers that are frequently repeated among the respondents are colored for better readability. The colors do not represent any specific ranking between the trends.

First, it should be noted that the respondents hardly have any experience with referring elderly patients or patients with co-morbidities for a bariatric surgery. Therefore, all the answers that they gave are hypothetical and not based on real situations. As can be seen in Table 18, three of the GPs could not recall any specific characteristic for this group of patients. The answers of Respondents 4, 8 and 11 give insights that the close proximity could be important for this group. Respondent 5, on the other side, explained that distance influences the hospital choice for elderly patients but not in the case of bariatric surgery. For such a complex operation, the complications are leading factors according the same GP. Respondents 1 and 7 put the focus on the availability of all disciplines, including a geriatric department in the hospital and previous experience of the patient with a particular hospital.

The obtained answers on this question are consistent with the literature. The preference for the close distance among elderly patients is revealed by Bussche et al., (2010). Previous experience with the hospital was defined important for all patients by Dixon et al., (2010 a & b) and Dijs- Elsinga et al., (2010). The suggestions that this patient group was more likely to be influenced by hospital facilities and parking place are in consistence with the findings of Dijs-Elsinga et al., (2010).

One interesting fact is that, according to the GPs, they hardly refer patients older than 50 years for bariatric surgery. Indeed, the GPs defined that the patients who they refer are mostly younger patients. Respondents 1, 5, 6 and 10 said that obese patients are mostly in the group 30-40 years old. Respondent 7 also shared that he only referred for bariatric surgery patients younger than 50

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years. Respondent 9, shared that he would not refer elderly patients and those with co- morbidities because of the higher risk. Furthermore, Respondent 8 shared that the elderly patients probably do not ask for this kind of surgery. On the other side, Respondent 10 had the opinion that the elderly patients do not have this disease. She related obesity and diabetic only with a younger age. In fact, that it also in accordance with the study of Paolino et al., (2015), that stated the obese patients are in their majority younger patients.

Considering all above, it can be concluded that it is most likely, the choice of bariatric surgery provider for elderly patients and patients with co-morbidities to be influenced by the same factors that influence these groups of patients in general: close distance, hospital facilities and parking place.

The answers lead to the conclusion that the elderly patients are probably limited in their choice due to the eligibility criteria and the GP’s concern to refer them.

Topic V, Question 5: If the provider implement telemonitoring for post-operative care would that highly influence the choice for the elderly patients and patients with co- morbidities?

Table 19 Results from Topic V, Question 5

Respondent Question 5

N Would implementing of telemonitoring influence the choice

Respondent 1 yes

Respondent 2 only if it is proven to work successfully

Respondent 3 not in their settings

Respondent 4 yes

Respondent 5 not in their settings

Respondent 6 yes

Respondent 7 yes

Respondent 8 no

Respondent 9 yes

Respondent 10 not sure

Respondent 11 yes

Note: The trends in the answers that are frequently repeated among the respondents are colored for better readability. The colors do not represent any specific ranking between the trends.

This question was added to the interview to gain insight whether the bariatric department may attract more patients if they implement telemonitoring in the follow-up care. There is literature evidence that telemonitoring can successfully be used for follow-up in long-term conditions and to reduce hospitalization in cases of diabetes and chronic health failure (McLean et al., 2013). These co-morbidities are related to obesity and the long-term follow-up can benefit from implementation of this technology, especially for the high-risk patients.

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The interview results have shown that GPs have different opinions whether the implementation of telemonitoring by the bariatric surgery provider would influence the choice of the patient. Three of them said that in their settings, where the providers are close by, that is not a big advantage. One of the GPs mentioned that, at this moment telemonitoring is not yet proven to work so well. When it is proven, he expects all hospitals to implement it, so it will again hardly influence the choice. On the other side, six of the physicians shared that the implementation of telemonitoring would influence the patients’ choice as well as her own choice.

Finally, it can be concluded that the GPs in general are positive regarding implementation of telemonitoring by bariatric surgery providers. However, there are indications that it may mostly attract patients from areas that do not have options for bariatric surgery close by.