Using a single item to measure burnout in primary care staff: a psychometric evaluation.

BACKGROUND: Burnout affects nearly half of all U.S. nurses and physicians, and has been linked to poor outcomes such as worse patient safety. The most common measure of burnout is the well-validated Maslach Burnout Inventory (MBI). However, the MBI is proprietary and carries licensing fees, posing challenges to routine or repeated assessment. OBJECTIVE: To compare a non-proprietary, single-item burnout measure to a single item from the MBI Emotional Exhaustion (MBI:EE) subscale that has been validated as a standalone burnout measure. DESIGN: Cross-sectional online survey. PARTICIPANTS: A sample of primary care providers (PCPs), registered nurses, clinical associates (e.g., licensed practical nurses (LPNs), medical technicians), and administrative clerks in the Veterans Health Administration surveyed in 2012. MAIN METHODS: We compared a validated one-item version of the MBI:EE and a non-proprietary single-item burnout measure used in the Physician Work Life Study. We calculated kappa statistics, sensitivity and specificity, positive predictive (PPV) and negative predictive values (NPV), and area under the receiver operator curve (AUC). We conducted analyses stratified by occupation to determine the stability of the correlation between the two measures. KEY RESULTS: We analyzed responses from 5,404 participants, including 1,769 providers and 1,380 registered nurses. The prevalence of burnout was 36.7% as measured on the single MBI:EE item and 38.5% as measured on the non-proprietary single-item measure. Relative to the MBI:EE, the non-proprietary single-item measure had a correlation of 0.79, sensitivity of 83.2%, specificity of 87.4%, and AUC of 0.93 (se = 0.004). Results were similar when stratified by respondent occupation. CONCLUSIONS: A non-proprietary single-item measure served as a reliable substitute for the MBI:EE across occupations. Because it is non-proprietary and easy to interpret, it has logistical advantages over the one-item MBI.

Optimism and depression: a new look at social support as a mediator among women at risk for breast cancer.

OBJECTIVE: Breast cancer risk is a chronic stressor associated with depression. Optimism is associated with lower levels of depression among breast cancer survivors. However, to our knowledge, no studies have explored the relationship between optimism and depression among women at risk for breast cancer. We hypothesized that women at risk for breast cancer who have higher levels of optimism would report lower levels of depression and that social support would mediate this relationship. METHOD: Participants (N = 199) with elevated distress were recruited from the community and completed self-report measures of depression, optimism, and social support. Participants were grouped based on their family history of breast cancer. Path analysis was used to examine the cross-sectional relationship between optimism, social support, and depressive symptoms in each group. RESULTS: Results indicated that the variance in depressive symptoms was partially explained through direct paths from optimism and social support among women with a family history of breast cancer. The indirect path from optimism to depressive symptoms via social support was significant (ß = -.053; 90% CI = -.099 to -.011, p = .037) in this group. However, among individuals without a family history of breast cancer, the indirect path from optimism to depressive symptoms via social support was not significant. CONCLUSIONS: These results suggest that social support partially mediates the relationship between optimism and depression among women at risk for breast cancer. Social support may be an important intervention target to reduce depression among women at risk for breast cancer.

Cognitive Behavioral Stress Management for Healthy Women at Risk for Breast Cancer: a Novel Application of a Proven Intervention.

BACKGROUND: Women at risk for breast cancer report elevated psychological distress, which has been adversely associated with cancer-relevant behaviors and biology. PURPOSE: The present study sought to examine the effects of a 10-week cognitive behavioral stress management (CBSM) group intervention on distress among women with a family history of breast cancer. METHODS: Participants were randomly assigned to CBSM (N = 82) or a wait-list comparison group (N = 76). Baseline to postintervention effects of CBSM on depressive symptoms and perceived stress were examined using hierarchical regression. RESULTS: CBSM participants reported significantly lower posttreatment depressive symptoms (ß = -0.17, p < 0.05) and perceived stress (ß = -0.23, p < 0.05) than wait-list comparison participants. Additionally, greater relaxation practice predicted lower distress. CONCLUSIONS: Group-based CBSM intervention is feasible and can reduce psychological distress among women with a family history of breast cancer. The present findings represent an encouraging avenue for the future application of CBSM. ( Clinicaltrials.gov number NCT00121160).

Elements of team-based care in a patient-centered medical home are associated with lower burnout among VA primary care employees.

BACKGROUND: A high proportion of the US primary care workforce reports burnout, which is associated with negative consequences for clinicians and patients. Many protective factors from burnout are characteristics of patient-centered medical home (PCMH) models, though even positive organizational transformation is often stressful. The existing literature on the effects of PCMH on burnout is limited, with most findings based on small-scale demonstration projects with data collected only among physicians, and the results are mixed. OBJECTIVE: To determine if components of PCMH related to team-based care were associated with lower burnout among primary care team members participating in a national medical home transformation, the VA Patient Aligned Care Team (PACT). DESIGN: Web-based, cross-sectional survey and administrative data from May 2012. PARTICIPANTS: A total of 4,539 VA primary care personnel from 588 VA primary care clinics. MAIN MEASURES: The dependent variable was burnout, and the independent variables were measures of team-based care: team functioning, time spent in huddles, team staffing, delegation of clinical responsibilities, working to top of competency, and collective self-efficacy. We also included administrative measures of workload and patient comorbidity. KEY RESULTS: Overall, 39 % of respondents reported burnout. Participatory decision making (OR 0.65, 95 % CI 0.57, 0.74) and having a fully staffed PACT (OR 0.79, 95 % CI 0.68, 0.93) were associated with lower burnout, while being assigned to a PACT (OR 1.46, 95 % CI 1.11, 1.93), spending time on work someone with less training could do (OR 1.29, 95 % CI 1.07, 1.57) and a stressful, fast-moving work environment (OR 4.33, 95 % CI 3.78, 4.96) were associated with higher burnout. Longer tenure and occupation were also correlated with burnout. CONCLUSIONS: Lower burnout may be achieved by medical home models that are appropriately staffed, emphasize participatory decision making, and increase the proportion of time team members spend working to the top of their competency level.

Veterinarians' Self-Reported Behaviors and Attitudes toward Spectrum of Care Practices.

Access to veterinary care for animal owners is an important part of keeping animals healthy and keeping pets and people together whenever that is appropriate. Insufficient financial and other resources to allocate to veterinary care are major barriers for pet owners to receiving preventative, sick, and emergency services. The veterinary community has begun to incorporate offering a range of diagnostic and treatment options more intentionally in response to clients' inability to pay and to a lesser extent to mitigate other barriers to care. Many veterinarians are nonetheless oriented toward providing specialized and more sophisticated care based on their training. This study sought to identify the self-reported behaviors, knowledge, attitudes, and beliefs of veterinarians about offering a spectrum of care options (SoC) to clients. The finding that many reported offering SoC is encouraging. However, veterinarians who report comfort and confidence in a variety of aspects of clinical care were most likely to offer SoC. Practitioners in the field for 20 or more years were less likely to offer SoC to clients with financial limitations. Rural veterinarians were more likely to offer SoC to any client compared to urban veterinarians. These results provide a point of reference and potential focus for veterinarians who are not currently offering SoC as well as an exploration of veterinarians' reported knowledge, behaviors, attitudes, perceptions, and concerns about SoC.

The effect of pre-transplant distress on immune reconstitution among adult autologous hematopoietic cell transplantation patients.

Myeloablative hematopoietic cell transplantation (HCT) is a common treatment for hematological malignancy. Delayed immune reconstitution following HCT is a major impediment to recovery with patients being most vulnerable during the first month after transplant. HCT is a highly stressful process. Because psychological distress has been associated with down regulation of immune function we examined the effect of pre-transplant distress on white blood cell (WBC) count among 70 adult autologous HCT patients during the first 3 weeks after transplant. The participants were on average 38 years old; 93% Caucasian, non-Hispanic and 55% male. Pre-transplant distress was measured 2-14 days before admission using the Cancer and Treatment Distress (CTXD) scale, and the Symptom Checklist-90-R (SCL-90-R) anxiety and depression subscales. WBC count was measured during initial immune recovery on days 5 through 22 post-transplant. Linear mixed model regression analyses controlling for gender and treatment-related variables revealed a significant effect of the mean pre-transplant SCL Anxiety-Depression score on WBC recovery. We found no significant effect of pre-transplant CTXD on WBC recovery. In general, higher levels of pre-treatment anxiety and depression were associated with slower WBC recovery. Psychological modulation of WBC recovery during HCT suggests a unique mechanism by which psychological distress can exert influence over the immune system. Given that WBC recovery is essential to survival for HCT patients, these data provide a rationale for treating anxiety and depression in HCT patients.

Owner-reported long-term outcomes, quality of life, and longevity after hospital discharge following surgical treatment of pyometra in bitches and queens.

OBJECTIVE: Investigate long-term complications, survival times, general health and quality of life (QoL) outcomes, and longevity in female dogs and cats (bitches and queens, respectively) following hospital discharge after ovariohysterectomy (OHE) for pyometra. ANIMALS: 306 pet-owner-completed surveys and corresponding medical records for 234 bitches and 72 queens treated with OHE for pyometra at the American Society for the Prevention of Cruelty to Animals Animal Hospital between January 1, 2017, and December 31, 2019. PROCEDURES: A telephone and online survey was conducted to gather data about pet owners' perception of pet health and QoL following OHE for pyometra, and potential associations between survey results and medical record data were evaluated. Median survival time at a given age at OHE for pyometra was calculated with the use of maximum likelihood estimation of a survival-time regression model. RESULTS: 72 of the 121 (60%) eligible owners of queens and 234 of the 390 (60%) eligible owners of bitches completed the survey. Most owners reported that at the time of the survey, their pet's health and QoL were better or the same as before pyometra. Reported health and QoL outcomes were similar for pets > 8 versus ≤ 8 years of age. CLINICAL RELEVANCE: Our findings indicated that bitches and queens undergoing OHE for pyometra at older ages and without other severe health issues can expect to live their full life span. Veterinarians in private practice could expect similar outcomes.

Incidence and Predictors of Canine Parvovirus Diagnoses in Puppies Relocated for Adoption.

Animal relocation programs seek to balance the animal population and resources between source and destination communities to promote positive outcomes, though little objective evidence has been reported on their physical and behavioral implications. The objective of the current report is to describe the incidence and predictors of canine parvovirus (CPV) diagnoses in 8- to 19-week-old puppies reported by destination shelters participating in a large scale, long-distance, structured animal relocation program. The incidence of post-transport CPV diagnoses in the study population of 4088 puppies was 2.3%. The number of pre-transport vaccinations, length of stay at the source shelter, and time between pre-transport vaccination and transport was not associated with the expected difference in count of post-transport CPV diagnoses (p > 0.05), and was lower in those 13-17 weeks of age (IRR = 0.08, 95% CI = 0.02-0.34, p = 0.001), 18-19 weeks of age (IRR = 0.11, 95% CI = 0.02-0.80, p = 0.029), transferred in to the source shelter (IRR = 0.31, 95% CI = 0.10-0.96, p = 0.043), and transported in the summer season (IRR = 0.07, 95% CI = 0.01-0.53, p = 0.010). When basic biosecurity practices and vaccination protocols were in place, post-transport CPV cases in puppies were few, suggesting that the timing of transport should take into account factors other than the number or timing of pre-transport vaccinations.

Pre-mortem risk factors for mortality in kittens less than 8 weeks old at a dedicated kitten nursery.

OBJECTIVES: Kittens have unique requirements for care in a shelter setting given their higher susceptibility to infectious disease and socialization needs. Significant time and resources are necessary to care for this vulnerable population and dedicated kitten nurseries are one way to meet the requirements of kittens too young for neutering and rehoming. However, young kittens remain at a higher risk of dying relative to adult cats, even in specialized settings. Efforts to investigate kitten mortality have focused on post-mortem findings and little is known about pre-mortem clinical signs that may be associated with death. The purpose of this study was to elucidate predictors of mortality in underage kittens. METHODS: The medical records of kittens aged <8 weeks reared in a kitten nursery in New York City during 2017 were examined. The data collected included signalment (estimated age and weight at intake, sex), physical findings (body condition score [BCS]), clinical signs (weight loss, anorexia, diarrhea, upper respiratory tract infection [URI]), diagnoses (panleukopenia, trauma), how early in the feline breeding season the kitten entered (April-November), and whether the kitten had died or was euthanized. The data were analyzed using Cox proportional hazard modeling with 1353 kittens to identify factors associated with any death or euthanasia. RESULTS: Elevated risk of dying was found for kittens in the lightest weight group (13 times greater), diagnosed with panleukopenia (13 times greater), exhibiting weight loss (>9 times greater), diagnosed with URI (almost four times greater), exhibiting anorexia (three times greater), identified with a low BCS at intake (two times greater) and experiencing diarrhea (almost two times greater). CONCLUSIONS AND RELEVANCE: These findings identify clinical signs and diagnoses that can serve as prognostic indicators for underage kitten survival in a shelter/rescue setting and can aid in enhancing protocols for monitoring, intervention and euthanasia decision-making.

Impact of the Timing of Spay-Neuter Related to Transport on Disease Rates in Relocated Dogs.

Companion animal relocation programs are an important method to address geographic and resource disparities in pet overpopulation through transport from areas with high homeless pet populations to areas with high adopter demand. Despite mitigation by following best practices, a potential risk of animal relocation is increased disease incidence related to infectious disease spread and the effects of stress during transport. Surgical sterilization may compound disease risk due to the impact of surgical stress on disease susceptibility and the potential for disease exposure from other patients. Our study aimed to provide information about disease and surgical complication incidence as relates to the timing of surgical sterilization in relocated dogs. A population of 431 dogs relocated to a shelter in Washington State was monitored for disease while at the destination shelter and immediately post-adoption. No increased disease incidence was identified for dogs altered within two weeks of transport at the destination shelter compared with those altered within two weeks prior to transport at the source shelter. Because of disparities addressed by relocation programs, surgical sterilization of relocated companion animals is typically best performed at the destination shelter. Our study indicates that disease incidence is not increased by spay-neuter at the destination shelter.

Are Underweight Shelter Dogs More Likely to Display Food Aggression toward Humans?

It is commonly believed that underweight or emaciated dogs are predisposed to food aggression toward humans. Each year, the American Society for the Prevention of Cruelty to Animals (ASPCA) receives hundreds of dogs from criminal cruelty cases. The dogs range from emaciated to overweight. We analyzed existing data from 900 such dogs to examine the relationship between body condition score and food and chew item aggression toward humans. Across all types of cruelty cases, 9.2% of dogs were aggressive over the food, chew, or both, which is a lower prevalence than that previously reported among shelter dogs. Dogs from cruelty cases originating in New York City were more likely to show aggression over food (z = 3.91, p < 0.001) and chew items (z = 2.61, p = 0.01) than dogs from large-scale cruelty cases, although it is unclear why. Female dogs were less likely to show food (z = -3.75, p < 0.001) and chew item (z = -2.25, p = 0.02) aggression compared to males. Underweight dogs were not more likely to display food aggression, but when they did, the aggression was no more severe than that of normal-weight dogs (Fisher's exact tests = 0.41 and 0.15 for the Food Bowl and Chew Item scenarios, respectively). Breed type was not a significant predictor of aggression. Canine food aggression does not appear to be an aberrant behavior caused by a history of food scarcity but may be related to biological factors such as sex. These findings could prove useful for animal behavior subject matter experts testifying in court or consulting on cruelty cases, as they could speak with scientific validity to the question of whether there is a link between previous food scarcity and the likelihood of food aggression in dogs.

The Impact of Excluding Food Guarding from a Standardized Behavioral Canine Assessment in Animal Shelters.

Many shelters euthanize or restrict adoptions for dogs that exhibit food guarding while in the animal shelter. However, previous research showed that only half the dogs exhibiting food guarding during an assessment food guard in the home. So, dogs are often misidentified as future food guarders during shelter assessments. We examined the impact of shelters omitting food guarding assessments. Nine shelters conducted a two-month baseline period of assessing for food guarding followed by a two-month investigative period during which they omitted the food guarding assessment. Dogs that guarded their food during a standardized assessment were less likely to be adopted, had a longer shelter stay, and were more likely to be euthanized. When the shelters stopped assessing for food guarding, there was no significant difference in the rate of returns of food guarding dogs, even though more dogs were adopted because fewer were identified with food guarding behavior. Additionally, the number of injuries to staff, volunteers, and adopters was low (104 incidents from a total of 14,180 dogs) and did not change when the food guarding assessment was omitted. These results support a recommendation that shelters discontinue the food guarding assessment.

Welfare Impacts of Spay/Neuter-Focused Outreach on Companion Animals in New York City Public Housing.

Spay/neuter (S/N) programs aim to reduce shelter intake and euthanasia. However, there is little published evidence of a causal effect between S/N programs and shelter intake or euthanasia. To uncover any ancillary effects of S/N, this study examined the impact of S/N door-to-door outreach on welfare-related outcomes and attitudes around S/N in underserved areas of New York City. There was no significant difference between a group receiving intensive outreach and a comparison group on whether they had rehomed a companion animal in the last year. There was a significantly higher level of saturation of S/N in the intensive-outreach area. A significantly higher percentage of those in the intensive-outreach group reported knowing at least 1 way to get help for their companion animals and that the caregiver-defined general well being of nonhuman animals in their neighborhood was better during the previous year. These data suggest that intensive S/N outreach has an impact on the level of saturation of S/N, the perceived efficacy of caregivers to find help if needed, and the perception that animal welfare is being improved.

Estimating the Availability of Potential Homes for Unwanted Horses in the United States.

There are approximately 200,000 unwanted horses annually in the United States. This study aimed to better understand the potential homes for horses that need to be re-homed. Using an independent survey company through an Omnibus telephone (land and cell) survey, we interviewed a nationally projectable sample of 3036 adults (using both landline and cellular phone numbers) to learn of their interest and capacity to adopt a horse. Potential adopters with interest in horses with medical and/or behavioral problems and self-assessed perceived capacity to adopt, constituted 0.92% of the total sample. Extrapolating the results of this survey using U.S. Census data, suggests there could be an estimated 1.25 million households who have both the self-reported and perceived resources and desire to house an unwanted horse. This number exceeds the estimated number of unwanted horses living each year in the United States. This study points to opportunities and need to increase communication and support between individuals and organizations that have unwanted horses to facilitate re-homing with people in their community willing to adopt them.

Temporal associations and prior-list intrusions in free recall.

When asked to recall the words from a just-presented target list, subjects occasionally recall words that were not on the list. These intrusions either appeared on earlier lists (prior-list intrusions, or PLIs) or had not appeared over the course of the experiment (extra-list intrusions). The authors examined the factors that elicit PLIs in free recall. A reanalysis of earlier studies revealed that PLIs tend to come from semantic associates as well as from recently studied lists, with the rate of PLIs decreasing sharply with list recency. The authors report 3 new experiments in which some items in a given list also appeared on earlier lists. Although repetition enhanced recall of list items, subjects were significantly more likely to make PLIs following the recall of repeated items, suggesting that temporal associations formed in earlier lists can induce recall errors. The authors interpret this finding as evidence for the interacting roles of associative and contextual retrieval processes in recall. Although contextual information helps to focus recall on words in the target list, it does not form an impermeable boundary between current- and prior-list experiences.

Intrusions in episodic recall: age differences in editing of overt responses.

Two experiments compared episodic word-list recall of young and older adults. In Experiment 1, using standard free-recall procedures, older adults recalled significantly fewer correct items and made significantly more intrusions (recall of items that had not appeared on the target list) than younger adults. In Experiment 2, we introduced a new method, called externalized free recall, in which participants were asked to recall any items that came to mind during the recall period but to indicate with an immediate key press those items they could identify as intrusions. Both age groups generated a large number of intrusions, but older adults were significantly less likely than young adults to identify these as nonlist items. Results suggest that an editing deficit may be a contributor to age differences in episodic recall and that externalized free recall may be a useful tool for testing computationally explicit models of episodic recall.

Risk Factors for Dog Relinquishment to a Los Angeles Municipal Animal Shelter.

Dog relinquishment is a large component of shelter intake in the United States. Research has shown traits of the dog are associated with relinquishment as well as general characteristics of those relinquishing. Low income is often cited as a risk factor for relinquishment. The majority of people with lower incomes, however, do not relinquish. A group of people accessing a shelter in a low socioeconomic region of Los Angeles to relinquish their dogs was surveyed. This study examined risk factors for relinquishment, controlling for household income, compared to a group utilizing low cost spay/neuter services. A total of 76.9% of those relinquishing noted cost as a reason for relinquishment. Of participants in the relinquishment group, 80.7% reported not being aware of any services available to them. Most notable in the findings was that the odds of relinquishment were generally higher as the amount of perceived stress in the home in the past three months increased. The majority of people in both groups reported being emotionally attached to the dog. In this sample from a South Los Angeles community, the majority of reasons for relinquishment were likely solvable with assistance. These findings highlight an opportunity to assess community needs and provide community specific alternatives to relinquishment.

Association of medical home team-based care functions and perceived improvements in patient-centered care at VHA primary care clinics.

INTRODUCTION: Team-based care is central to the patient-centered medical home (PCMH), but most PCMH evaluations measure team structure exclusively. We assessed team-based care in terms of team structure, process and effectiveness, and the association with improvements in teams׳ abilities to deliver patient-centered care. MATERIAL AND METHODS: We fielded a cross-sectional survey among 913 VA primary care clinics implementing a PCMH model in 2012. The dependent variable was clinic-level respondent-reported improvements in delivery of patient-centered care. Independent variables included three sets of measures: (1) team structure, (2) team process, and (3) team effectiveness. We adjusted for clinic workload and patient comorbidity. RESULTS: 4819 surveys were returned (25% estimated response rate). The highest ratings were for team structure (median of 89% of respondents being assigned to a teamlet, i.e., a PCP working with the same clinical associate, nurse care manager and clerk) and lowest for team process (median of 10% of respondents reporting the lowest level of stress/chaos). In multivariable regression, perceived improvements in patient-centered care were most strongly associated with participatory decision making (ß=32, P<0.0001) and history of change in the clinic (ß=18, P=0008) (both team processes). A stressful/chaotic clinic environment was associated with higher barriers to patient centered care (ß=0.16-0.34, P=<0.0001), and lower improvements in patient-centered care (ß=-0.19, P=0.001). CONCLUSIONS: Team process and effectiveness measures, often omitted from PCMH evaluations, had stronger associations with perceived improvements in patient-centered care than team structure measures. IMPLICATIONS: Team process and effectiveness measures may facilitate synthesis of evaluation findings and help identify positive outlier clinics.

Should Dogs and Cats be Given as Gifts?

Policies that state dogs and cats should not be adopted as gifts are prevalent at animal welfare organizations, despite the fact that this belief is unfounded. Denying adopters who intend to give the animals as gifts may unnecessarily impede the overarching goal of increasing the rate of live-releases of dogs and cats from our nations' shelter system. The results of this brief survey show that receiving a dog or cat as a gift was neither significantly associated with impact on self-perceived love/attachment, nor was it associated with whether or not respondents still had the dog or cat in the home. The results from this survey add to a growing body of literature that suggests there is no increased risk of relinquishment for dogs and cats received as a gift.