Physician burnout and wellbeing are an ongoing concern. Limited research has reported on the impact of the COVID 19 pandemic on burnout over time among U.S. physicians.
We surveyed U.S. frontline ...physicians at two time points (wave one in May-June 2020 and wave two in Dec 2020-Jan 2021) using a validated burnout measure. The survey was emailed to a national stratified random sample of family physicians, internists, hospitalists, intensivists, emergency medicine physicians, and infectious disease physicians. Burnout was assessed with the Professional Fulfillment Index Burnout Composite scale (PFI-BC). Responses were weighted to account for sample design and non-response bias. Random effects and quantile regression analyses were used to estimate change in conditional mean and median PFI-BC scores, adjusting for physician, geographic, and pandemic covariates.
In the random effects regression, conditional mean burnout scores increased in the second wave among all respondents (difference 0.15 (CI: 0.24, 0.57)) and among respondents to both waves (balanced panel) (difference 0.21 (CI: - 0.42, 0.84)). Conditional burnout scores increased in wave 2 among all specialties except for Emergency medicine, with the largest increases among Hospitalists, 0.28 points (CI: - 0.19,0.76) among all respondents and 0.36 (CI: - 0.39,1.11) in the balanced panel, and primary care physicians, 0.21 (CI: - 0.23,0.66) among all respondents and 0.31 (CI: - 0.38,1.00) in the balanced panel. The conditional mean PFI-BC score among hospitalists increased from 1.10 (CI: 0.73,1.46) to 1.38 (CI: 1.02,1.74) in wave 2 in all respondents and from 1.49 (CI: 0.69,2.29) to 1.85 (CI: 1.24,2.46) in the balanced panel, near or above the 1.4 threshold indicating burnout. Findings from quantile regression were consistent with those from random effects.
Rates of physician burnout during the first year of the pandemic increased over time among four of five frontline specialties, with greatest increases among hospitalist and primary care respondents. Our findings, while not statistically significant, were consistent with worsening burnout; both the random effects and quantile regressions produced similar point estimates. Impacts of the ongoing pandemic on physician burnout warrant further research.
Celotno besedilo
Dostopno za:
CEKLJ, DOBA, IZUM, KILJ, NUK, PILJ, PNG, SAZU, SIK, UILJ, UKNU, UL, UM, UPUK
Many family physicians are familiar with the U.S. Preventive Services Task Force (USPSTF) evidence-based recommendations for clinical preventive services. However, they may not be aware of the ...Community Preventive Services Task Force (CPSTF), which differs from USPSTF in its focus on population health. Family physicians know that health is improved by interventions outside the examination room that impact social, behavioral, environmental, and community factors. CPSTF evaluates evidence and recommends effective interventions to improve health in the community, home, school, work, and health care settings. Systematic evidence reviews form the basis for these recommendations, which target upstream structural, economic, and social factors that affect health outcomes.
Patients with suspected nephrolithiasis were randomly assigned to ultrasonography performed by an emergency physician or a radiologist or to CT for initial study. Ultrasonography was associated with ...a lower cumulative radiation dose, with no significant difference in complications.
Abstract Objective This study reports all-payer amputation rates using state-based administrative claims data for high-risk patients with lower extremity (LE) ulcers and concomitant peripheral artery ...disease (PAD), diabetes mellitus (DM), or combination PAD/DM. In addition, we characterize patient factors that affect amputation-free survival. We also attempted to create a measure of a patient's ability to manage chronic diseases or to access appropriate outpatient care for ulcer management by accounting for hospital and emergency department (ED) visits in the preceding 60 days to determine how this also affects amputation-free survival. Methods Patients admitted to nonfederal hospitals, seen in an ED, or treated in an eligible ambulatory surgery center within California from 2005 through 2013 with an International Classification of Diseases, Ninth Revision, Clinical Modification diagnosis code for a disease-specific LE ulcer were identified in the California Office of Statewide Health Planning and Development database. All subsequent hospital, ED, and ambulatory surgery center visits and procedures are captured to identify whether a patient underwent major amputation. Yearly amputation rates were determined to analyze trends. Amputation-free survival for the PAD, DM, and PAD/DM groups was determined. Cox modeling was used to evaluate the effect of patient characteristics. Results There were 219,547 patients identified with an incident LE ulcer throughout the state. Of these, 131,731 were DM associated, 36,193 were PAD associated, and 51,623 were associated with both PAD and DM. From 2005 to 2013, the number of patients with LE ulcers who required inpatient admission, presented to the ED, or had outpatient procedures was stable. However, there was a statistically significant increase in overall disease-associated amputation rates from 5.1 in 2005 to 13.5 in 2013 ( P < .001). Patients with PAD/DM had the greatest increase in amputation rates from 10 per 100 patients with LE ulcers in 2005 to 28 per 100 patients in 2013 ( P < .001). Despite that patients with PAD/DM were 8 years younger than patients with PAD only, they had similar amputation-free survival. Within all age groups, men had worse amputation-free survival than women did. Race did not predict amputation-free survival, but having multiple prior ED or hospital admissions was a significant predictor of worse amputation-free survival. Conclusions Potentially preventable amputations associated with high-risk diseases are increasing among patients who require inpatient hospital admission, present to the ED, or require outpatient interventional treatment. This trend is most notable among patients with a combination of PAD and DM. Patients with repeated hospitalizations before admission for the LE ulcer had the highest risk of amputation.
In most patients with NSCLC, the disease is diagnosed in an advanced stage, the prognosis is poor, and survival is typically measured in months. Standard therapeutic treatment regimens for patients ...with stage IV NSCLC typically include chemotherapy and palliative radiation. Despite newer regimens that may include molecularly targeted therapy and immunotherapy, the overall 5-year survival for stage IV disease remains low at 4% to 6%. Although therapeutic surgery is performed in a minority of cases, accumulating data suggest that thoracic surgery may play several beneficial roles for these patients.
In this narrative review, we summarize the literature on surgical intervention in the multimodality management of stage IV NSCLC, focusing on the potential evidence for and against therapeutic or curative intent procedures to affect outcomes for patients with oligometastatic disease and pleural metastasis.
In selected patients, surgical resection can result in a 5-year survival rate of 30% to 50%, but this is heavily influenced by the presence of mediastinal nodal disease, which should be evaluated before therapeutic surgical procedures are undertaken. Additionally, diagnostic or palliative surgical procedures can play an important role in the personalized management of stage IV disease. These data suggest that for carefully selected patients with advanced stage NSCLC, surgical intervention can be an important component of combined modality treatment.
Given the advances in molecular targeted therapy and immunotherapy, further studies should focus on the possible use of surgery as a strategy of therapeutic “consolidation” for appropriately selected patients with stage IV NSCLC who are receiving combined modality care.
When used judiciously, cesarean sections can save lives; but in the United States, prior research indicates that cesarean birth rates have risen beyond the threshold to help women and infants and ...become a contributor to increased maternal mortality and rising healthcare costs. Healthy People 2020 has set the goal for nulliparous, term, singleton, vertex (NTSV) cesarean birth rate at no more than 23.9% of births. Currently, cesarean rates vary from 6% to 69% in US hospitals, unexplained by clinical or demographic factors. This wide variation in cesarean use is also seen among individual providers of intrapartum care. Previous research of birth attitudes found providers of intrapartum care hold widely differing views, which may be a key underlying factor influencing practice variation; however, further study is needed to determine if differences in attitudes are associated with differences in clinical outcomes. The purpose of this study was to estimate the association between individual provider attitudes towards birth and their low-risk primary cesarean rate.
Four hundred providers were drawn from a stratified random sample of all California providers of intrapartum care in 2013 and surveyed for their attitudes towards various aspects of labor and birth. Providers' NTSV cesarean birth rates were obtained for 2013 and 2014. Covariates included gender, years of experience, practice location, and primary hospital's NTSV cesarean rate. We used adjusted multivariate Poisson regression to compare cesarean rates and linear regression to compare attitude scores of providers meeting versus not meeting the Healthy People 2020 (HP2020) goal.
Two hundred nine total participants (obstetricians, family physicians, and midwives) completed surveys, of which 109 perform cesareans. Providers' NTSV cesarean rate was significantly associated with their composite attitudes score IRR for each one-point increase 1.21 (95% CI 1.002-1.45). Physicians meeting the HP2020 goal held attitudes which were significantly more favorable towards vaginal birth: mean 2.70 (95% CI 2.58-2.83) versus 2.91 (95% CI 2.82-3.00), p < 0.01.
Provider attitudinal differences are associated with NTSV cesarean rates. Those meeting the HP2020 goal hold attitudes more favorable towards vaginal birth. These findings may present a modifiable target for quality improvement initiatives to decrease low risk primary cesareans.
Frequent users of emergency departments (ED) account for 21-28% of all ED visits nationwide. The objective of our study was to identify characteristics unique to patients with psychiatric illness who ...are frequent ED users for mental health care. Understanding unique features of this population could lead to better care and lower healthcare costs.
This retrospective analysis of adult ED visits for mental healthcare from all acute care hospitals in California from 2009-2014 used patient-level data from California's Office of Statewide Health Planning and Development. We calculated patient demographic and visit characteristics for patients with a primary diagnosis of a mental health disorder as a percentage of total adult ED visits. Frequent ED users were defined as patients with more than four visits in a 12-month period. We calculated adjusted rate ratios (aRR) to assess the association between classification as an ED frequent user and patient age, sex, payer, homelessness, and substance use disorder.
In the study period, 846,867 ED visits for mental healthcare occurred including 238,892 (28.2%) visits by frequent users. Patients with a primary mental health diagnosis and a co-occurring substance use diagnosis in the prior 12 months (77% vs. 37%, aRR 4.02, 95% confidence interval CI 3.92-4.12), homelessness (2.9% vs 1.1%, odds ratio 1.35, 95% CI 1.27-1.43) were more likely to be frequent users. Those covered by Medicare (aRR 3.37, 95% CI 3.20-3.55) or the state's Medicaid program Medi-Cal (aRR 3.10, 95% CI 2.94-3.25) were also more likely to be frequent users compared with those with private insurance coverage.
Patients with substance use disorders, homelessness and public healthcare coverage are more likely to be frequent users of EDs for mental illness. Substance use and housing needs are important factors to address in this population.
Abstract Background A concern before 2020, physician burnout worsened during the COVID-19 pandemic. Little empirical data are available on pandemic workplace support interventions or their influence ...on burnout. We surveyed a national sample of frontline physicians on burnout and workplace support during the pandemic. Methods We surveyed a stratified random sample of 12,833 US physicians most likely to care for adult COVID-19 patients from the comprehensive AMA Physician Professional Data ™ file. The sample included 6722 primary care physicians (3331 family physicians, 3391 internists), 880 hospitalists, 1783 critical care physicians (894 critical care physicians, 889 pulmonary intensivists), 2548 emergency medicine physicians, and 900 infectious disease physicians. The emailed survey elicited physicians’ perceptions of organizational interventions to provide workplace support and/or to address burnout. Burnout was assessed with the Professional Fulfillment Index Burnout Composite scale (PFI-BC). Proportional specialty representation and response bias were addressed by survey weighting. Logistic regression assessed the association of physician characteristics and workplace interventions with burnout. Results After weighting, respondents were representative of the total sample. Overall physician burnout was 45.4%, significantly higher than in our previous survey. Open-ended responses mentioned that staffing shortages (physician, nursing, and other staff) combined with the increased volume, complexity, and acuity of patients during the pandemic increased job demands. The most frequent workplace support interventions were direct pandemic control measures (increased access to personal protective equipment, 70.0%); improved telehealth functionality (43.4%); and individual resiliency tools (yoga, meditation, 30.7%). Respondents placed highest priority on workplace interventions to increase financial support and increase nursing and clinician staffing. Factors significantly associated with lower odds of burnout were practicing critical care (compared with emergency medicine) OR 0.33 (95% CI 0.12 – 0.93), improved telehealth functionality OR 0.47 (95% CI 0.23 – 0.97) and being in practice for 11 years or longer OR 0.44 (95% CI 0.19–0.99). Conclusions Burnout across frontline specialties increased during the pandemic. Physician respondents focused on inadequate staffing in the context of caring for more and sicker patients, combined with the lack of administrative efforts to mitigate problems. Burnout mitigation requires system-level interventions beyond individual-focused stress reduction programs to improve staffing, increase compensation, and build effective teams.
Celotno besedilo
Dostopno za:
CEKLJ, DOBA, IZUM, KILJ, NUK, PILJ, PNG, SAZU, SIK, UILJ, UKNU, UL, UM, UPUK
Few autism spectrum disorder (ASD) studies have estimated non-medical costs for treatment or addressed possible differences in provision of services across gender, race-ethnic, age or demographic or ...expenditure categories, especially among adults.
The California Department of Developmental Services (CDDS) provides services to residents with developmental disabilities. CDDS provided aggregate data on primarily non-medical spending for fiscal year 2012-2013 for persons with ASD with or without intellectual disability (ID) (main sample, n = 42,274), and two sub-samples: ASD only (n = 30,164), and ASD+ID (n = 12,110). Demographic variables included sex, age and race-ethnicity. Spending categories included Employment Support, Community Care Facilities, Day Care, Transportation, and in-home and out-of-home Respite.
Per-person spending for males and females were approximately the same: $10,488 and $10,791 for males and females for ages 3-17 and $26,491 and $26,627 for ages 18+. Among race/ethnicity categories, the ranking from highest to lowest among ages 3-17 was white non-Hispanics ($11,480), Asian non-Hispanics ($11,036), "Others" ($11,031), Hispanics ($9,571), and African-American non-Hispanics ($9,482). For ages 18+, the ranking was whites ($31,008), African-Americans ($26,831), "Others" ($25,395), Asians ($22,993), and Hispanics ($18,083). The ASD+ID sub-sample exerted disproportionate influence on findings from the main sample for persons 18+. Combining all ages, the top two expenditure categories for per-person spending were Community Care Facilities ($43,867) and Day Care ($11,244). For most adult age groups, the percentage of recipients participating were highest for Day Care (44.9% - 62.4%) and Transportation (38.6% - 50.9%). Per-person spending for Day Care, Transportation, and Employment Support was relatively low for children but relatively high for adults.
White non-Hispanics received the highest per-person spending and Hispanics among the least. Amounts within spending categories varied considerably across age groups. Our estimates may be useful as baseline measures for stakeholders preparing for increasing ASD prevalence, especially among adults.
Celotno besedilo
Dostopno za:
DOBA, IZUM, KILJ, NUK, PILJ, PNG, SAZU, SIK, UILJ, UKNU, UL, UM, UPUK
School health systems are increasingly investing in telemedicine platforms to address acute and chronic illnesses. Asthma, the most common chronic illness in childhood, is of particular interest ...given its high burden on school absenteeism.
Conduct a systematic review evaluating impact of school-based telemedicine programs on improving asthma-related outcomes.
PubMed, Cochrane CENTRAL, CINAHL, ERIC, PsycINFO, Embase, and Google Scholar.
Original research, including quasi-experimental studies, without restriction on the type of telemedicine.
School-aged pediatric patients with asthma and their families.
School-based telemedicine.
Two authors independently screened each abstract, conducted full-text review, assessed study quality, and extracted information. A third author resolved disagreements.
Of 371 articles identified, 7 were included for the review. Outcomes of interest were asthma symptom-free days, asthma symptom frequency, quality of life, health care utilization, school absences, and spirometry. Four of 7 studies reported significant increases in symptom-free days and/or decrease in symptom frequency. Five of 6 reported increases in at least one quality-of-life metric, 2 of 7 reported a decrease in at least 1 health care utilization metric, 1 of 3 showed reductions in school absences, and 1 of 2 reported improvements in spirometry measures.
Variability in intervention designs and outcome measures make comparisons and quantitative analyses across studies difficult. Only 2 of 7 studies were randomized controlled trials.
High-quality evidence supporting the use of school-based telemedicine programs to improve patient outcomes is limited. While available evidence suggests benefit, only 2 comparative trials were identified, and the contribution of telemedicine to these studies’ results is unclear.
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