Reducing burnout and enhancing work engagement among clinicians: The Minnesota experience.

BACKGROUND: The Minnesota Hospital Association (MHA) recognized the impact that burnout and disengagement had on the clinician population. A clinician task force developed a conceptual framework, followed by annual surveys and a series of interventions. Features of the job demands-resources model were used as the conceptual underpinning to this analysis. PURPOSE: The aim of this study was to assess the applicability of a clinician-driven conceptual model in understanding burnout and work engagement in the state of Minnesota. METHODOLOGY: Four thousand nine hundred ninety clinicians from 94 MHA member hospitals/systems responded to a 2018 survey using a brief instrument adapted, in part, from previously validated measures. RESULTS: As hypothesized, job demands were strongly related to burnout, whereas resources were most related to work engagement. Variables from the MHA model explained 40% of variability in burnout and 24% of variability in work engagement. Variables related to burnout with the highest beta weights included having sufficient time for work (-0.266), values alignment with leaders (-0.176), and teamwork efficiency (-0.123), all ps < .001. Variables most associated with engagement included values alignment (0.196), feeling appreciated (0.163), and autonomy (0.093), ps < .001. CONCLUSION: Findings support the basic premises of the proposed conceptual model. Remediable work-life conditions, such as having sufficient time to do the job, values alignment with leadership, teamwork efficiency, feeling appreciated, and clinician autonomy, manifested the strongest associations with burnout and work engagement. PRACTICE IMPLICATIONS: Interventions reducing job demands and strengthening resources such as values alignment, teamwork efficiency, and clinician autonomy are seen as having the greatest potential efficacy.

The clinical utility of vocal dosimetry for assessing voice rest.

OBJECTIVES/HYPOTHESIS: Voice rest is frequently recommended following surgical disruption of vocal fold epithelium, but patients report variable adherence to voice rest recommendations. The objective of this study was to assess the clinical utility of an ambulatory vocal dosimeter for measuring adherence to voice rest recommendations. STUDY DESIGN: Outcomes research. METHODS: Part 1: To determine the utility of the dosimeter in nonclinical use, the relationship between self-reported voice use and dosimeter measurements was examined in normal subjects (n = 11) who prospectively logged voice use while wearing the dosimeter. Part 2: To determine clinical utility of the dosimeter, patients undergoing vocal fold surgery for which postoperative voice rest was recommended (n = 11) wore a dosimeter for 2 days prior to and 2 days after surgery. Phonation percent and sound level were compared at baseline and during voice rest. RESULTS: The dosimeter performed as hypothesized with both normal subjects and patients. A moderate correlation (r = 0.62) was noted between self-reported voice use and dosimeter measurements in normal subjects. In patients on voice rest, a statistically and clinically significant decrease was observed in measured voice use, both in phonation time (P = .002) and intensity of phonation (P = .004). CONCLUSIONS: Ambulatory vocal dosimetry may have clinical utility for assessing adherence to voice rest recommendations. This information will be useful for the design of future studies on voice rest.

Psychosocial distress in patients presenting with voice concerns.

OBJECTIVES: To assess the prevalence of psychosocial distress (depression, anxiety, somatization, and perceived stress) in a consecutive sample of patients presenting with voice concerns and to qualitatively analyze patient comments on challenges associated with voice problems. STUDY DESIGN: Cross-sectional study. METHODS: New patients presenting to a multidisciplinary voice clinic with voice concerns were invited to participate. Respondents (n = 197) completed the Brief Symptom Inventory 18-item scale, the 4-item Perceived Stress Scale, and the Voice Handicap Index 10-item scale. Qualitative analysis was performed of responses to an open-ended question about challenges associated with a voice problem. RESULTS: Approximately one-third (32%) of the patients met the strict case criteria for depression, anxiety, and/or somatic concerns based on the Brief Symptom Inventory 18-item scale. Most patients had no prior diagnosis of depression or anxiety, and the degree of distress was not predicted by the type of voice-related diagnosis. Perceived stress was higher among female patients (P = 0.02). As expected, scores on the Voice Handicap Index 10-item scale were indicative of concurrent voice-related handicap (mean, 19.5; standard deviation, 9.4). In qualitative analysis of responses regarding challenges associated with a voice problem, 19 themes were identified (eg, threat to occupational functioning). CONCLUSIONS: These findings identify a high prevalence of multiple types of distress among patients with voice disorders, presenting an opportunity to provide more comprehensive care to this patient population.

Comparison of newborn screening protocols for congenital adrenal hyperplasia in preterm infants.

OBJECTIVE: To compare 2 screening protocols performed concurrently in Minnesota: (1) liquid chromatography tandem mass spectrometry steroid profiling as a second-tier test on positive fluoroimmunoassay (FIA) results; and (2) low-birthweight 3-screen protocol (FIA tests at <48 hours, 2 weeks, 4 weeks) on all infants <1800 g, regardless of result. STUDY DESIGN: Population-based study of all <1800 g infants (n = 8739) born in Minnesota from 2004-2010 comparing newborn screening performance metrics of 2-tier (FIA + liquid chromatography tandem mass spectrometry) protocol (2004-2010) vs 1-tier (FIA) low-birthweight 3-screen protocol (2006-2010). False positive (FP) rates were calculated per infant's final confirmatory result. Protocol results used in different time periods (2004-2005 vs 2006-2010) were compared by 2-sample tests of proportions; results of both protocols for 2006-2010 were compared by McNemar test. RESULTS: First-tier testing of final dried blood spot result (n = 6625) of the low-birthweight 3-screen protocol during 2006-2010 reduced the FP rate more than 5-fold (P < .0001) compared with 2-tier testing of a single dried blood spot (n = 2114) from 2004-2005. In comparing results (n = 6625) of both protocols from 2006-2010, first-tier testing of final dried blood spot accounted for 23% of FPs; second-tier testing of the first dried blood spot accounted for 77%, yielding significantly more FP results (McNemar test, P < .0001). CONCLUSION: Timing of dried blood spot collection rather than assay used played a more important role in reducing FP results of congenital adrenal hyperplasia newborn screening in low birthweight infants.

Comparison of one-tier and two-tier newborn screening metrics for congenital adrenal hyperplasia.

BACKGROUND: Newborn screening (NBS) for the classic forms of congenital adrenal hyperplasia (CAH) is mandated in all states in the United States. Compared with other NBS disorders, the false-positive rate (FPR) of CAH screening remains high and has not been significantly improved by adjusting 17α-hydroxyprogesterone cutoff values for birth weight and/or gestational age. Minnesota was the first state to initiate, and only 1 of 4 states currently performing, second-tier steroid profiling for CAH. False-negative rates (FNRs) for CAH are not well known. METHODS: This is a population-based study of all Minnesota infants (769,834) born 1999-2009, grouped by screening protocol (one-tier with repeat screen, January 1999 to May 2004; two-tier with second-tier steroid profiling, June 2004 to December 2009). FPR, FNR, and positive predictive value (PPV) were calculated per infant, rather than per sample, and compared between protocols. RESULTS: Overall, 15 false-negatives (4 salt-wasting, 11 simple-virilizing) and 45 true-positives were identified from 1999 to 2009. With two-tier screening, FNR was 32%, FPR increased to 0.065%, and PPV decreased to 8%, but these changes were not statistically significant. Second-tier steroid profiling obviated repeat screens of borderline results (355 per year average). CONCLUSIONS: In comparing the 2 screening protocols, the FPR of CAH NBS remains high, the PPV remains low, and false-negatives occur more frequently than has been reported. Physicians should be cautioned that a negative NBS does not necessarily rule out classic CAH; therefore, any patient for whom there is clinical concern for CAH should receive immediate diagnostic testing.