Guest Editorial: Understanding the Patient Experience, Patient Satisfaction, and the Obese Person with a Wound

Health care organizations across the globe are seeking ways to improve the patient experience. This is particularly important in the United States because reimbursement is tied to this initiative. In the bariatric world, achieving a meaningful patient experience is especially challenging because of well-documented issues associated with direct and indirect care from a patient/resident or provider perspective. When considering all patients, whether bariatric or nonbariatric, well thought-out care that enhances the patient experience can be challenging, but it is essential to fiscal viability related to economic incentives.

The Agency for Healthcare Research and Quality  (AHRQ) describes the patient experience as interactions between patients and workers (staff members, professionals, or providers) that occur within the health care system; this includes providers and workers who have direct or indirect contact with the patient. As an element of health care quality, the patient experience includes those aspects of health care delivery that patients value. In the wound or ostomy care setting, this could include access to timely appointments, complete follow-up instructions for care, or dignified, sensitive care.

Understanding the bariatric care experience is essential in integrating patient-centered wound or ostomy care. By exploring elements of the patients’ perspective, professionals can better understand the extent to which patients are receiving care that is respectful of and responsive to their individual preferences, needs, and values. Evaluating the patient experience along with other components such as effectiveness and safety of care is essential to providing a complete picture of bariatric care. This is especially necessary when considering the patient who is obese and has a wound or ostomy.

Patient and worker satisfaction are central to health care delivery and have been for at least the past 3 decades. However, in today’s environment it is important to differentiate between patient experience and patient satisfaction. The patient experience is patient-driven and reflects something the patient believes should happen or how often it should happen. Patient satisfaction, on the other hand, is about whether a patient’s expectations about a health encounter were met. Two (2) people who receive the exact same care but who have different expectations for how that care is supposed to be delivered can give different satisfaction ratings because of their different expectation.¹

Issues of patient satisfaction and the patient experience are important from both an economic and a humanistic perspective. From an economic perspective, determining costs associated with obesity has been elusive because of processes used for data collection and reporting. For instance, data widely used today and distributed by the Centers for Disease Control and Prevention include that the estimated annual medical cost of obesity in the US was $147 billion in 2008 and that the medical costs for people who have obesity were $1429 higher than those of normal weight.² These 2008 data are reported in articles published as recently as 2016.³

Recent data collected and reported by specific cities or states seems to be more timely and suggest a dramatic increase in cost. For example, according to a 2017 report⁴ based on the Gallup-Healthways Well-Being Index that featured the state of Tennessee, 2016 health care costs associated with obesity in Memphis alone were $538 million and represented more than half the budget of the city’s public school system. For the state of Tennessee, the annual excess health costs of obesity were $2.29 billion, equivalent to >6% of the entire state budget.⁴ In West Virginia, a state with a high prevalence of individuals with obesity, preventable direct medical costs of obesity range from $1.4 billion to $1.8 billion per year, with an additional $5 billion in indirect costs, such as lost productivity. Patients with obesity submit up to 7 times the number of medical claims compared with patients whose weight is in the healthy range.⁵

Most skin and wound experts agree that wound prevention and treatment are more complex when addressing the specific needs of the person who has excess body weight or weight maldistribution. Outcomes may be delayed or not as forthcoming as expected. This delay often interferes with a positive patient experience because patients generally value wound healing that is provided in a timely and pain-free manner that supports principles of dignity and respect.

Barriers to wound healing in the presence of excess adiposity are numerous. Pierpont et al⁶ suggest factors such as anatomic properties and poor vascularity of adipose tissue may impact the wound formation and healing processes. Further, vascular insufficiency that leads to decreased oxygen tension may decrease collagen synthesis, the capacity to fight infection, and the ability to support mechanisms of the healing cascade. Pokorny⁷ explains that wound healing generally is an orderly process involving inflammation, proliferation, epithelialization, and remodeling; decreased collagen deposition is thought to have an effect on the structural changes of the tissue during the proliferation stage, which delays the natural healing process.⁶ Others⁸ believe wound formation and delayed healing are more closely linked with well-documented hazards of immobility. Hospitalized patients who are obese may have limited mobility due to several factors such as their excess weight, environmental space limitations, and workers’ fear of occupational injury associated with standard mobility activities, each of which can lead to immobility and thus risks for skin injury.^9,10

Key considerations for understanding the bariatric patient care experience include¹¹:

• Rates of obesity are increasing among patients and clients in all practice settings and specialties;
• Physiologic changes and comorbid conditions associated with adiposity impact wound healing;
• Care of the bariatric patient with a wound is more complex and requires vigilance;
• Dignity, sensitivity, and respect humanize the bariatric patient experience; and
• Preplanning for care in all settings is essential.

In this issue of OWM, Beitz describes that dignity and sensitivity are at the heart of patient care outcomes. Dr. Beitz takes readers on a journey that explores the meaning of sensitivity, not as an addition to the patient care experience, but as the patient experience.¹² Hales et al¹³ present methods to simulate the bariatric experience for workers. Many individuals and facilities worldwide have invested in bariatric body suits as an adjunct to their bariatric sensitivity training. The authors describe a way to introduce workers who otherwise would not have the experience of using a standard-sized restroom or clinic waiting area to navigating related scenarios as an individual who is obese. Study participants wore the body suit onto public transportation to simulate the challenges some patients experience as part of the trip to a clinic. Each participant expressed an all-new understanding for the challenges associated with excess weight or weight maldistribution. However, the authors caution that although the bariatric body suit can be helpful to begin patient mobility training and enhance knowledge of respiratory and skin consequences to obesity and more, to date a process for such training has not been designed and/or tested.

No stranger to providing information on obesity and bariatric care, OWM has published more than 2 dozen articles over the past 20 years that include research on these topics. For this issue, we have assembled a compendium¹⁴ of these publications so readers can utilize relevant findings in practice.

Understanding the challenges associated with obesity can come only from those who are obese. However, as wound care experts, many opportunities exist to set the stage for a better patient experience,¹² such as exploring differences that contribute to wound formation and delays in healing.¹¹ Additionally, recognizing specific challenges an individual with a nontraditional body size faces in public settings can begin the process toward reasonable accommodation.¹³ To that end, substantial evidence points to a positive association between various aspects of the patient experience and other indicators such as better clinical outcomes, improved patient safety practices, and lower utilization of unnecessary health care services.

As wound care experts become increasingly involved with patients who are obese, it will become more and more important to intersect patient experience measures with wound care quality measures to create an overall picture of performance.