Summary Background Physician burnout has reached epidemic levels, as documented in national studies of both physicians in training and practising physicians. The consequences are negative effects on ...patient care, professionalism, physicians' own care and safety, and the viability of health-care systems. A more complete understanding than at present of the quality and outcomes of the literature on approaches to prevent and reduce burnout is necessary. Methods In this systematic review and meta-analysis, we searched MEDLINE, Embase, PsycINFO, Scopus, Web of Science, and the Education Resources Information Center from inception to Jan 15, 2016, for studies of interventions to prevent and reduce physician burnout, including single-arm pre-post comparison studies. We required studies to provide physician-specific burnout data using burnout measures with validity support from commonly accepted sources of evidence. We excluded studies of medical students and non-physician health-care providers. We considered potential eligibility of the abstracts and extracted data from eligible studies using a standardised form. Outcomes were changes in overall burnout, emotional exhaustion score (and high emotional exhaustion), and depersonalisation score (and high depersonalisation). We used random-effects models to calculate pooled mean difference estimates for changes in each outcome. Findings We identified 2617 articles, of which 15 randomised trials including 716 physicians and 37 cohort studies including 2914 physicians met inclusion criteria. Overall burnout decreased from 54% to 44% (difference 10% 95% CI 5–14; p<0·0001; I2 =15%; 14 studies), emotional exhaustion score decreased from 23·82 points to 21·17 points (2·65 points 1·67–3·64; p<0·0001; I2 =82%; 40 studies), and depersonalisation score decreased from 9·05 to 8·41 (0·64 points 0·15–1·14; p=0·01; I2 =58%; 36 studies). High emotional exhaustion decreased from 38% to 24% (14% 11–18; p<0·0001; I2 =0%; 21 studies) and high depersonalisation decreased from 38% to 34% (4% 0–8; p=0·04; I2 =0%; 16 studies). Interpretation The literature indicates that both individual-focused and structural or organisational strategies can result in clinically meaningful reductions in burnout among physicians. Further research is needed to establish which interventions are most effective in specific populations, as well as how individual and organisational solutions might be combined to deliver even greater improvements in physician wellbeing than those achieved with individual solutions. Funding Arnold P Gold Foundation Research Institute.
Poor mental health places a burden on individuals and populations. Resilient persons are able to adapt to life's challenges and maintain high quality of life and function. Finding effective ...strategies to bolster resilience in individuals and populations is of interest to many stakeholders.
To synthesize the evidence for resiliency training programs in improving mental health and capacity in 1) diverse adult populations and 2) persons with chronic diseases.
Electronic databases, clinical trial registries, and bibliographies. We also contacted study authors and field experts.
Randomized trials assessing the efficacy of any program intended to enhance resilience in adults and published after 1990. No restrictions were made based on outcome measured or comparator used.
Reviewers worked independently and in duplicate to extract study characteristics and data. These were confirmed with authors. We conducted a random effects meta-analysis on available data and tested for interaction in planned subgroups.
The standardized mean difference (SMD) effect of resiliency training programs on 1) resilience/hardiness, 2) quality of life/well-being, 3) self-efficacy/activation, 4) depression, 5) stress, and 6) anxiety.
We found 25 small trials at moderate to high risk of bias. Interventions varied in format and theoretical approach. Random effects meta-analysis showed a moderate effect of generalized stress-directed programs on enhancing resilience pooled SMD 0.37 (95% CI 0.18, 0.57) p = .0002; I2 = 41% within 3 months of follow up. Improvement in other outcomes was favorable to the interventions and reached statistical significance after removing two studies at high risk of bias. Trauma-induced stress-directed programs significantly improved stress -0.53 (-1.04, -0.03) p = .03; I2 = 73% and depression -0.51 (-0.92, -0.10) p = .04; I2 = 61%.
We found evidence warranting low confidence that resiliency training programs have a small to moderate effect at improving resilience and other mental health outcomes. Further study is needed to better define the resilience construct and to design interventions specific to it.
PROSPERO #CRD42014007185.
The relationship between delayed gastric emptying and upper GI symptoms (UGI Sx) is controversial.
To assess association between gastric emptying and UGI Sx, independent of treatment.
We performed a ...systematic review and meta-analysis of the literature from 2007 to 2017, review of references and additional papers identified by content expert. We included studies evaluating the association between gastric emptying and nausea, vomiting, early satiety/postprandial fullness, abdominal pain and bloating. Covariate analyses included optimal gastric emptying test method, gastric emptying type (breath test or scintigraphy) and patient category. Meta-regression compared the differences based on type of gastric emptying tests.
Systematic review included 92 gastric emptying studies (26 breath test, 62 scintigraphy, 1 ultrasound and 3 wireless motility capsule); 25 of these studies provided quantitative data for meta-analysis (15 scintigraphy studies enrolling 4056 participants and 10 breath test studies enrolling 2231 participants). Meta-regression demonstrated a significant difference between optimal and suboptimal gastric emptying test methods when comparing delayed gastric emptying with nausea and vomiting. On evaluating studies using optimal gastric emptying test methodology, there were significant associations between gastric emptying and nausea (OR 1.6, 95% CI 1.4 to 1.8), vomiting (OR 2.0, 95% CI 1.6 to 2.7), abdominal pain (OR 1.5, 95% CI 1.0 to 2.2
and early satiety/fullness (OR 1.8, 95% CI 1.2 to 2.6) for patients with UGI Sx; gastric emptying and early satiety/fullness in patients with diabetes; gastric emptying and nausea in patients with gastroparesis.
The systematic review and meta-analysis supports an association between optimally measured delayed gastric emptying and UGI Sx.
Studies have reported a lack of association between improvements in gastric emptying (GE) and upper gastrointestinal (UGI) symptoms with promotility drugs. However, GE test methods were suboptimal in ...some studies. We assessed improvements in GE and UGI symptoms in patients given promotility agents in studies with optimal or moderate test methods (scintigraphy or breath test, solid meal, >2 hours duration) compared to studies with suboptimal GE test methods.
With an expert librarian, we completed an extensive search of publications in the Ovid MEDLINE (1946 to present), EMBASE (1988 to January 2018), and EBM Reviews Cochrane Central Register of Controlled Trials, without restrictions on language or year. Two independent reviewers evaluated the following inclusion criteria: randomized, blinded, parallel, or crossover trials of 5HT4 agonists, D2 receptor antagonist, or ghrelin agonists; trials that measured change in GE (T1/2) or composite UGI symptoms; trials of patients with functional dyspepsia and gastroparesis; and trials of GE test methods. Standardized mean differences (units expressed as SD) were used to standardize symptom assessments that were not uniform across studies. Random effects model was used to analyze data and meta-regression was used to evaluate the association between change in GE and UGI symptoms.
Of 899 studies considered, 22 studies assessed change in GE; 23 evaluated UGI symptoms; and 14 evaluated GE and UGI symptoms. Promotility agents significantly accelerated GE (T1/2) in all studies (mean reduction in T1/2, 16.3 minutes; 95% confidence interval, –22.1 to –10.6 minutes) and in studies that used optimal GE test methods (mean reduction in T1/2, 23.6 minutes; 95% confidence interval, –32.3 to –14.9 minutes). Promotility agents also significantly reduced UGI symptoms (mean reduction, 0.25 SD; 95% confidence interval, –0.37 to –0.13 SD). Meta-regression found no significant association between change in GE and UGI symptoms. However, when only studies with optimal GE test methods were evaluated, there was a significant positive association between improvement in GE and UGI symptoms (P = .02).
In a meta-analysis of published trials, we found promotility agents to significantly accelerate GE (when optimal test methods were used) and to produce significant improvements in UGI symptoms.
Background: Although technology-enhanced simulation is increasingly used in health professions education, features of effective simulation-based instructional design remain uncertain.
Aims: Evaluate ...the effectiveness of instructional design features through a systematic review of studies comparing different simulation-based interventions.
Methods: We systematically searched MEDLINE, EMBASE, CINAHL, ERIC, PsycINFO, Scopus, key journals, and previous review bibliographies through May 2011. We included original research studies that compared one simulation intervention with another and involved health professions learners. Working in duplicate, we evaluated study quality and abstracted information on learners, outcomes, and instructional design features. We pooled results using random effects meta-analysis.
Results: From a pool of 10 903 articles we identified 289 eligible studies enrolling 18 971 trainees, including 208 randomized trials. Inconsistency was usually large (I 2 > 50%). For skills outcomes, pooled effect sizes (positive numbers favoring the instructional design feature) were 0.68 for range of difficulty (20 studies; p < 0.001), 0.68 for repetitive practice (7 studies; p = 0.06), 0.66 for distributed practice (6 studies; p = 0.03), 0.65 for interactivity (89 studies; p < 0.001), 0.62 for multiple learning strategies (70 studies; p < 0.001), 0.52 for individualized learning (59 studies; p < 0.001), 0.45 for mastery learning (3 studies; p = 0.57), 0.44 for feedback (80 studies; p < 0.001), 0.34 for longer time (23 studies; p = 0.005), 0.20 for clinical variation (16 studies; p = 0.24), and −0.22 for group training (8 studies; p = 0.09).
Conclusions: These results confirm quantitatively the effectiveness of several instructional design features in simulation-based education.
To compare efficacy of pharmacotherapies for chronic idiopathic constipation (CIC) based on comparisons to placebo using Bayesian network meta-analysis.
We conducted searches (inception to May 2015) ...of MEDLINE, EMBASE, Scopus and Cochrane Central, as well as original data from authors or drug companies for the medications used for CIC.
Phase IIB and phase III randomised, placebo-controlled trials (RCT) of ≥4 weeks' treatment for CIC in adults with Rome II or III criteria for functional constipation; trials included at least one of four end points.
Two investigators independently evaluated all full-text articles that met inclusion criteria and extracted data for primary and secondary end points, risk of bias and quality of evidence.
Primary end points were ≥3 complete spontaneous bowel movements (CSBM)/week and increase over baseline by ≥1 CSBM/week. Secondary end points were change from baseline (Δ
) in the number of SBM/week and Δ
CSBM/week.
Twenty-one RCTs (9189 patients) met inclusion and end point criteria: 9 prucalopride, 3 lubiprostone, 3 linaclotide, 2 tegaserod, 1 each velusetrag, elobixibat, bisacodyl and sodium picosulphate (NaP). All prespecified end points were unavailable in four polyethylene glycol studies. Bisacodyl, NaP, prucalopride and velusetrag were superior to placebo for the ≥3 CSBM/week end point. No drug was superior at improving the primary end points on network meta-analysis. Bisacodyl appeared superior to the other drugs for the secondary end point, Δ
in number of SBM/week.
Current drugs for CIC show similar efficacy. Bisacodyl may be superior to prescription medications for Δ
in the number of SBM/week in CIC.
Emerging epidemiological evidence suggests that proton pump inhibitor (PPI) acid-suppression therapy is associated with an increased risk of Clostridium difficile infection (CDI).
Ovid MEDLINE, ...EMBASE, ISI Web of Science, and Scopus were searched from 1990 to January 2012 for analytical studies that reported an adjusted effect estimate of the association between PPI use and CDI. We performed random-effect meta-analyses. We used the GRADE framework to interpret the findings.
We identified 47 eligible citations (37 case-control and 14 cohort studies) with corresponding 51 effect estimates. The pooled OR was 1.65, 95% CI (1.47, 1.85), I(2) = 89.9%, with evidence of publication bias suggested by a contour funnel plot. A novel regression based method was used to adjust for publication bias and resulted in an adjusted pooled OR of 1.51 (95% CI, 1.26-1.83). In a speculative analysis that assumes that this association is based on causality, and based on published baseline CDI incidence, the risk of CDI would be very low in the general population taking PPIs with an estimated NNH of 3925 at 1 year.
In this rigorously conducted systemic review and meta-analysis, we found very low quality evidence (GRADE class) for an association between PPI use and CDI that does not support a cause-effect relationship.
To examine the evidence supporting the use of simulation-based assessments as surrogates for patient-related outcomes assessed in the workplace.
The authors systematically searched MEDLINE, EMBASE, ...Scopus, and key journals through February 26, 2013. They included original studies that assessed health professionals and trainees using simulation and then linked those scores with patient-related outcomes assessed in the workplace. Two reviewers independently extracted information on participants, tasks, validity evidence, study quality, patient-related and simulation-based outcomes, and magnitude of correlation. All correlations were pooled using random-effects meta-analysis.
Of 11,628 potentially relevant articles, the 33 included studies enrolled 1,203 participants, including postgraduate physicians (n = 24 studies), practicing physicians (n = 8), medical students (n = 6), dentists (n = 2), and nurses (n = 1). The pooled correlation for provider behaviors was 0.51 (95% confidence interval CI, 0.38 to 0.62; n = 27 studies); for time behaviors, 0.44 (95% CI, 0.15 to 0.66; n = 7); and for patient outcomes, 0.24 (95% CI, -0.02 to 0.47; n = 5). Most reported validity evidence was favorable, though studies often included only correlational evidence. Validity evidence of internal structure (n = 13 studies), content (n = 12), response process (n = 2), and consequences (n = 1) were reported less often. Three tools showed large pooled correlations and favorable (albeit incomplete) validity evidence.
Simulation-based assessments often correlate positively with patient-related outcomes. Although these surrogates are imperfect, tools with established validity evidence may replace workplace-based assessments for evaluating select procedural skills.
The impact of subclinical hypothyroidism (SCH) and of levothyroxine replacement in pregnant women with SCH is unclear. The aims of this study were to assess (i) the impact of SCH during pregnancy on ...maternal and neonatal outcomes, and (ii) the effect of levothyroxine replacement therapy in these patients.
Ovid MEDLINE In-Process & Other Non-Indexed Citations, Ovid MEDLINE, the Cochrane Controlled Trials Register, Ovid EMBASE, Web of Science, and Scopus were searched from inception to January 2015. Randomized trials and cohort studies of pregnant women with SCH that examined adverse pregnancy and neonatal outcomes were included. Reviewers extracted data and assessed methodological quality in duplicate. Eighteen cohort studies at low-to-moderate risk of bias were included. Compared with euthyroid pregnant women, pregnant women with SCH were at higher risk for pregnancy loss (relative risk RR 2.01 confidence interval (CI) 1.66-2.44), placental abruption (RR 2.14 CI 1.23-3.70), premature rupture of membranes (RR 1.43 CI 1.04-1.95), and neonatal death (RR 2.58 CI 1.41-4.73). One study at high risk of bias compared pregnant women with SCH who received levothyroxine to those who did not and found no significant decrease in the rate of pregnancy loss, preterm delivery, gestational hypertension, low birth weight, or low Apgar score.
SCH during pregnancy is associated with multiple adverse maternal and neonatal outcomes. The value of levothyroxine therapy in preventing these adverse outcomes remains uncertain.
Obtaining informed consent is a cornerstone of biomedical research, yet participants comprehension of presented information is often low. The most effective interventions to improve understanding ...rates have not been identified.
To systematically analyze the random controlled trials testing interventions to research informed consent process. The primary outcome of interest was quantitative rates of participant understanding; secondary outcomes were rates of information retention, satisfaction, and accrual. Interventional categories included multimedia, enhanced consent documents, extended discussions, test/feedback quizzes, and miscellaneous methods.
The search spanned from database inception through September 2010. It was run on Ovid MEDLINE, Ovid EMBASE, Ovid CINAHL, Ovid PsycInfo and Cochrane CENTRAL, ISI Web of Science and Scopus. Five reviewers working independently and in duplicate screened full abstract text to determine eligibility. We included only RCTs. 39 out of 1523 articles fulfilled review criteria (2.6%), with a total of 54 interventions. A data extraction form was created in Distiller, an online reference management system, through an iterative process. One author collected data on study design, population, demographics, intervention, and analytical technique.
Meta-analysis was possible on 22 interventions: multimedia, enhanced form, and extended discussion categories; all 54 interventions were assessed by review. Meta-analysis of multimedia approaches was associated with a non-significant increase in understanding scores (SMD 0.30, 95% CI, -0.23 to 0.84); enhanced consent form, with significant increase (SMD 1.73, 95% CI, 0.99 to 2.47); and extended discussion, with significant increase (SMD 0.53, 95% CI, 0.21 to 0.84). By review, 31% of multimedia interventions showed significant improvement in understanding; 41% for enhanced consent form; 50% for extended discussion; 33% for test/feedback; and 29% for miscellaneous.Multiple sources of variation existed between included studies: control processes, the presence of a human proctor, real vs. simulated protocol, and assessment formats.
Enhanced consent forms and extended discussions were most effective in improving participant understanding. Interventions of all categories had no negative impact on participant satisfaction or study accrual. Identification of best practices for studies of informed consent interventions would aid future systematic comparisons.
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