BACKGROUND

The U.S. Surgeon General declared obesity a national epidemic1 and the prevalence of obesity has now reached nearly 40% of the adult population in the United States (U.S.).2 Given its significant burden along with increased risks for many clinical conditions, the importance of providing timely prevention care has been emphasized.1 However, obesity is a stigmatized condition, leading individuals with obesity to be more likely to experience weight-based discrimination when seeking care.3 Assessing patient experiences with received care among those with overweight or obesity could aid in training health care providers and targeting interventions to improve access to care among those at risk.

OBJECTIVE

To determine whether overall satisfaction with health care and perceived quality of interaction with one’s health care provider were associated with clinically defined body mass index (BMI) category.

METHODS AND FINDINGS

We conducted a retrospective cross-sectional study of Medical Expenditure Panel Survey (MEPS) data from 2011 to 2015. The MEPS is an annual nationally representative survey of the US civilian non-institutionalized population in the U.S. Our initial analytic sample included U.S. adults aged 18 years or older who completed the self-administered questionnaire (SAQ) (n = 90,070). SAQ includes questions from the Consumer Assessment of Healthcare Providers and Systems Survey (CHAPS®), which measures overall patient experience with health care. We excluded individuals who reported being underweight (BMI < 18.5; based on self-reported height and weight), diagnosed with cancer, or pregnant (n = 6839).

A multivariable logistic regression model was used to estimate the likelihood of reporting a top-box score for four measures of patient experience (Table 1): (1) perceived access to care (3 item summative scale), (2) perceived interaction quality with provider (4 item summative scale), (3) perceived need for health insurance (4 items summative scale), and (4) overall satisfaction with health care (1 item on a 10 point scale). These measures of patient experience/attitude domains were previously validated and the summative scale for each domain had adequate internal reliability (α values between 0.69–0.89).4 Each measure was scored based on the top-box approach, where the proportion of higher-level response was calculated (using “always” or scores of 9–10).4 A sensitivity analysis was performed by analyzing each measure as a continuous outcome.

Table 1 Adjusted Associations Between Body Mass Index Category and Perceived Patient Access to Care and Health Care Experience, Odds Ratio of Reporting Top-Box Scores (95% CI)
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In our sample of 83,231 U.S. adults, 32.6% had normal weight (BMI 18.5–24.9), 35.0% overweight (25–29.9), 27.2% obesity (30–39.9), and 5.2% had severe obesity (≥ 40). Table 1 shows the adjusted odds ratios for the association between BMI category and reporting a top-box score for the four patient experience domains. Compared with individuals with normal weight, we did not find any significant differences across BMI category. When patient experience outcomes were treated continuously, our finding for overall satisfaction was consistent, albeit there were small but statistically significant differences across other measures (Fig. 1).

Fig. 1
figure 1

Sensitivity analysis: adjusted comparison of mean score for patient experience with care by BMI category. Higher scores indicate a better perceived patient experience. Results are adjusted for age, sex, marital status, race/ethnicity, family income, and education attainment, census region, self-reported health status, number of comorbid conditions, health insurance, usual source of care, and survey year.

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DISCUSSION

BMI category was not associated with reporting a top-box score for perceived access to care, interaction quality with providers, perceived need for health insurance, or overall satisfaction with health care; however, we observed small but statistically significant differences in the conditional mean of patient experiences by BMI category such that a higher BMI category was generally associated with better perceptions of access to care and interaction quality with care providers. The top-box finding differs from previous findings suggesting that weight bias and stigma can impact quality of care and health outcomes for patients with obesity.3 However, a recent study suggests that variations in patient experience are largely driven by differences in socioeconomic characteristics or health status, independent of BMI.5 Our study adds to the literature by highlighting additional measures of perceived patient experience not associated with weight status.

There are several possible explanations for our findings. First and most simply, patients with obesity may not, in fact, have more negative experiences on average than their normal weight peers. This may be reflective of a change in training and perceptions that obesity is a disease and does not reflect a shortcoming of the patient. Alternatively, patients with a large body size may limit interactions with clinicians concerning their weight problems, resulting in minimal effect on ratings of health care received.6 Given the disparate findings of patient experience by weight status, there is a need for additional and ongoing assessment of patient experiences, including qualitative and quantitative research to understand both subjective and objective measures of care for patients with obesity.