Lessons Learned: Recruiting Research Participants from an Underrepresented Patient Population at a Safety Net Hospital.

BACKGROUND: Recruiting participants to clinical research studies is challenging, especially when conducted in safety net settings. We sought to compare the efficacy of different recruitment strategies in an NIH-funded study assessing treatment burden in patients with multiple chronic conditions (MCCs). METHODS: Targeted mailing, in-person table-based recruitment ("tabling") in the waiting room, and telephone calling were used to enroll subjects into one of two studies of treatment burden: a survey study to validate a brief measure of treatment burden for quality assessment (study 1) or a qualitative study to develop a treatment burden clinical communication tool (study 2). RESULTS: Over 50% of subjects in each study were African American or African immigrants. In study 1, the enrollment goal of 200 was reached within 4 months. Tabling enrolled 78.5% of patients, while the remainder (21.5%) were enrolled from phone calls to eligible patients identified through the electronic medical record (EMR). In study 2, 340 eligible patients were identified through the EMR, and 7 (2.1%) were successfully enrolled via mailed invitations and responses. Retention rates (66% in study 1 and 71% in study 2) were reasonable in all groups. CONCLUSIONS: Study recruiting goals in our safety net population were rapidly reached using the tabling method, which had substantively higher enrollment rates than mailings or telephone calls based on EMR reports. Future trials could compare recruitment strategies across settings and clinical populations.

Factors associated with patient trust in their clinicians: Results from the Healthy Work Place Study.

BACKGROUND: Patient trust in their clinicians is an important aspect of health care quality, but little evidence exists on what contributes to patient trust. PURPOSE: The aim of this study was to determine workplace, clinician, and patient correlates of patient trust in their clinician. METHODOLOGY/APPROACH: The sample used baseline data from the Healthy Work Place trial, a randomized trial of 34 Midwest and East Coast primary care practices to explore factors associated with patient trust in their clinicians. A multivariate "best subset" regression modeling approach was used, starting with an item pool of 45 potential variables. Over 7 million models were tested, with a best subset of correlates determined using standard methods for scale optimization. Skewed variables were transformed to the fifth power using a Box-Cox algorithm. RESULTS: The final model of nine variables explained 38% of variance in patient trust at the patient level and 49% at the clinician level. Trust was related mainly to several aspects of care variables (including satisfaction with explanations, overall satisfaction with provider, and learning about their medical conditions and their clinician's personal manner), with lesser association with patient characteristics and clinician work conditions. CONCLUSION: Trust appears to be primarily related to what happens between clinicians and patients in the examination room. PRACTICE IMPLICATIONS: System changes such as patient-centered medical homes may have difficulty succeeding if the primacy of physician-patient interactions in inspiring patient trust and satisfaction is not recognized.

Where Trust Flourishes: Perceptions of Clinicians Who Trust Their Organizations and Are Trusted by Their Patients.

PURPOSE: Trust is an essential component of health care. Clinicians need to trust organizational leaders to provide a safe and effective work environment, and patients need to trust their clinicians to deliver high-quality care while addressing their health care needs. We sought to determine perceived characteristics of clinics by clinicians who trust their organizations and whose patients have trust in them. METHODS: We used baseline data from the Healthy Work Place trial, a randomized trial of interventions to improve work life in 34 Midwest and East Coast primary care clinics, to identify clinic characteristics associated with high clinician and patient trust. RESULTS: The study included 165 clinicians with 1,132 patients. High trust by clinicians with patients who trusted them was found for 34% of 162 clinicians with sufficient data for modeling. High clinician-high patient trust occurred when clinicians perceived their organizational cultures to have (1) an emphasis on quality (odds ratio [OR] 4.95; 95% CI, 2.02-12.15; P <.001), (2) an emphasis on communication and information (OR 3.21; 95% CI, 1.33-7.78; P = .01), (3) cohesiveness among clinicians (OR 2.29; 95% CI, 1.25-4.20; P = .008), and (4) values alignment between clinicians and leaders (OR 1.86; 95% CI, 1.23-2.81; P = .003). CONCLUSION: Addressing organizational culture might improve the trust of clinicians whose patients have high trust in them.

Low ICU burnout in a safety net hospital.

OBJECTIVE: Burnout tends to be high in Intensive Care Unit (ICU) settings. Stressors include serious patient illness, round-the-clock acute events, and end of life (non-beneficial) care. We report on an ICU with very low burnout scores. We sought to understand factors that might be responsible for these favorable outcomes. DESIGN: We compared ICU scores on burnout and its predictors with scores in non ICU providers, merging scores in four ICUs (burn, medical, surgical and pediatrics). Analyses included descriptive statistics, as well as general estimating equations to assess odds of burnout in ICU vs non ICU clinicians. SETTING: Annual wellness survey performed in October 2017 at Hennepin Healthcare System (HHS), an integrated system of care that includes an urban safety net hospital in Minneapolis, Minnesota. PARTICIPANTS: Six hundred seventy-nine providers (physicians and advanced practice providers). INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Annual surveys are performed using the validated Mini-Z 10 item wellness instrument. The Mini-Z assesses stress, satisfaction, and burnout, as well as known predictors including work control, chaos, teamwork, values alignment, and electronic medical record-related stress. Response rate in ICUs was 70% (64% elsewhere). Ten percent of ICU clinicians reported burnout, vs 37% of other providers (p = 0.015). ICUs were characterized as having lower chaos, less stress, and very high teamwork and values alignment between clinicians and leaders. Odds of burnout were four times lower in ICU clinicians (Odds Ratio 0.24, 95% CI 0.06, 0.96, p = 0.043). Of all HHS providers, those with values not aligned with leaders had 3.28 times the odds of burnout (CIs 1.92, 5.59, p < 0.001). CONCLUSIONS: Low burnout can be present in a busy, safety net ICU. Explicitly aligning values between clinicians and leaders may hold promise as a remediable worklife factor for producing these favorable results.