Physician Burnout, Engagement and Career Satisfaction in a Large Academic Medical Practice.

OBJECTIVE: To determine (1) if engagement among physicians impacted plans to stay in current role and job satisfaction, (2) what factors impact engagement and burnout, and (3) the relationship between engagement and burnout. Burnout has been described as a syndrome characterized by depersonalization, emotional exhaustion, and a sense of low personal accomplishment resulting in decreased effectiveness at work. Engagement may be regarded as the antonym to burnout and has been described as a connection to one's work characterized by dedication, vigor, and absorption. DESIGN: We extracted data from an academic practice-wide survey conducted at two time-points and evaluated physician burnout and engagement. We used the Maslach Burnout Inventory and the Utrecht Work Engagement Scale to evaluate the association between burnout and engagement and the impact of engagement on mitigating the effect of burnout in a large physician academic faculty practice. SETTING: Large academic practice PARTICIPANTS: Academic physicians METHODS: The authors conducted a hospital-wide physician practice survey in 2014 and 2017 assessing physician burnout and engagement. RESULTS: Of eligible physicians (n=1882), 92.0% completed a survey. High levels of engagement and burnout were shown in 59.5% and 45.6%, respectively. Compared to physicians with high levels of engagement and low levels of burnout, physicians with low engagement and low burnout were less satisfied with their career (OR=0.20, 95% CI=0.11-0.35) and less likely to stay in their current role (OR=0.52, 95% CI= 0.37-0.73). Among physicians with high levels of burnout, highly engaged physicians were more satisfied (OR=0.21; 95% CI=0.12-0.36 vs OR=0.08; 95% CI=0.05-0.12) and more likely to stay in their career (OR=0.34; 95% CI=0.25-0.45 vs OR=0.27; 95% CI=0.21-0.34) than non-engaged physicians. CONCLUSION: Engaged physicians have higher career satisfaction. There are many actionable ways to improve engagement.

Baby Boomers and Beds: a Demographic Challenge for the Ages.

The United States is facing a significant demographic transition, with about 10,000 baby boomers turning age 65 each day. At the same time, the nation is experiencing a similarly striking transition in hospital capacity, as the supply of hospital beds has declined in recent decades. The juxtaposition of population aging and hospital capacity portends a potentially widening divergence between supply and demand for hospital care. We provide a closer look at current hospital capacity and a rethinking of the future role of hospital beds in meeting the needs of an aging population.

What Do High-Risk Patients Value? Perspectives on a Care Management Program.

BACKGROUND: There is growing interest in coordinating care for high-risk patients through care management programs despite inconsistent results on cost reduction. Early evidence suggests patient-centered benefits, but we know little about how participants engage with the programs and what aspects they value. OBJECTIVE: To explore care management program participants' awareness and perceived utility of program offerings. DESIGN: Cross-sectional telephone survey administered December 2015-January 2016. PARTICIPANTS: Patients enrolled in a Boston-area primary care-based care management program. MAIN MEASURES: Our main outcome was the number of topics in which patients reported having "very helpful" interactions with their care team in the past year. We analyzed awareness of one's care manager as an intermediate outcome, and then as a primary predictor of the main outcome, along with patient demographics, years in the program, attitudes, and worries as secondary predictors. KEY RESULTS: The survey response rate was 45.8% (n = 1220); non-respondents were similar to respondents. More respondents reported worrying about family (72.8%) or financial issues (52.5%) than about their own health (41.6%). Seventy-four percent reported care manager awareness, particularly women (OR 1.33, 95% CI 1.01-1.77) and those with more years in the program (OR 1.16, 95% CI 1.03-1.30). While interaction rates ranged from 19.8% to 72.4% across topics, 81.3% rated at least one interaction as very helpful. Those who were aware of their care manager reported very helpful interactions on more topics (OR 2.77, 95% CI 2.15-3.56), as did women (OR 1.25, 95% CI 1.00-1.55), younger respondents (OR 0.98 for older age, 95% CI 0.97-0.99), and those with higher risk scores (OR 1.04, 95% CI 1.02-1.06), preference for deferring treatment decisions to doctors (OR 2.00, 95% CI 1.60-2.50), and reported control over their health (OR 1.67, 95% CI 1.33-2.10). CONCLUSIONS: High-risk patients reported helpful interactions with their care team around medical and social determinants of health, particularly those who knew their care manager. Promoting care manager awareness may help participants make better use of the program.

The Cost of Quality: An Academic Health Center's Annual Costs for Its Quality and Patient Safety Infrastructure.

BACKGROUND: In the United States, regulatory bodies, state licensing boards, hospital accreditation organizations, and medical specialty boards have increased their demands for data, public reporting, and improvement. Survey research suggests that as much as $15 billion is spent on reporting quality measures, but those costs, as well as those associated with improvement, have not been sufficiently characterized. A study was conducted to examine, in detail, the costs incurred by one health care organization-an academic health center (AHC) with employed physicians-in responding to quality and safety requirements. METHODS: To identify annual costs associated with an AHC's quality and safety infrastructure, a conceptual model was developed for organizing costs into four domains-Measurement and Reporting, Safety, Quality Improvement, and Training and Communication. In an inventory approach, a purpose-specific instrument was used to aggregate and sort costs; clinicians and administrators were asked to identify all domain activities and the associated full-time equivalents and other direct costs (labor and nonlabor) allocated to each activity. RESULTS: For this AHC, nearly $30 million of direct costs-more than 1.1% of net patient service revenue-were incurred to maintain the quality infrastructure. Approximately 81.6% of the costs were associated with mandates by regulators, accreditors, and payers-49.8% of which supported required public reporting. CONCLUSION: Indisputable good for patients and providers has resulted from organizational investments in quality and safety. But policy makers must be cognizant of potential trade-offs and explicitly recognize the incremental costs of additional measurement, improvement, and mandated reporting in their decision making.

Utilization Management of High-Cost Imaging in an Outpatient Setting in a Large Stable Patient and Provider Cohort over 7 Years.

Purpose To quantify the effect of a comprehensive, long-term, provider-led utilization management (UM) program on high-cost imaging (computed tomography, magnetic resonance imaging, nuclear imaging, and positron emission tomography) performed on an outpatient basis. Materials and Methods This retrospective, 7-year cohort study included all patients regularly seen by primary care physicians (PCPs) at an urban academic medical center. The main outcome was the number of outpatient high-cost imaging examinations per patient per year ordered by the patient's PCP or by any specialist. The authors determined the probability of a patient undergoing any high-cost imaging procedure during a study year and the number of examinations per patient per year (intensity) in patients who underwent high-cost imaging. Risk-adjusted hierarchical models were used to directly quantify the physician component of variation in probability and intensity of high-cost imaging use, and clinicians were provided with regular comparative feedback on the basis of the results. Observed trends in high-cost imaging use and provider variation were compared with the same measures for outpatient laboratory studies because laboratory use was not subject to UM during this period. Finally, per-member per-year high-cost imaging use data were compared with statewide high-cost imaging use data from a major private payer on the basis of the same claim set. Results The patient cohort steadily increased in size from 88 959 in 2007 to 109 823 in 2013. Overall high-cost imaging utilization went from 0.43 examinations per year in 2007 to 0.34 examinations per year in 2013, a decrease of 21.33% (P < .0001). At the same time, similarly adjusted routine laboratory study utilization decreased by less than half that rate (9.4%, P < .0001). On the basis of unadjusted data, outpatient high-cost imaging utilization in this cohort decreased 28%, compared with a 20% decrease in statewide utilization (P = .0023). Conclusion Analysis of high-cost imaging utilization in a stable cohort of patients cared for by PCPs during a 7-year period showed that comprehensive UM can produce a significant and sustained reduction in risk-adjusted per-patient year outpatient high-cost imaging volume. © RSNA, 2017.

Using a Self-Reported Global Health Measure to Identify Patients at High Risk for Future Healthcare Utilization.

BACKGROUND: Research studies have shown that patient-reported outcome measures (PROMs) that assess global health are helpful for predicting health care utilization, but less evidence exists that collection of PROMs in routine care can identify patients with high health care needs. OBJECTIVE: To investigate the association between the PROMIS Global Health (PGH) scores and subsequent health care utilization among patients in a large accountable care organization (ACO). DESIGN: Retrospective cohort study of individuals in the Partners HealthCare ACO who completed at least one PGH during a primary care visit. PARTICIPANTS: A total of 2639 individuals who completed at least one PGH and who also had 12 months of ACO membership and/or claims data prior to the PROM completion and at least one month of claims data post-PGH completion. MAIN MEASURES: The main outcomes were the rates of emergency department (ED) visits and hospitalizations by quartile of PGH physical and mental health scores. We also compared the predictive accuracy of administrative data models with and without the PGH scores to identify the highest utilizers. KEY RESULTS: The group with the worst (lowest) physical and mental health scores had significantly higher rates of hospitalization (RR 5.14, 95% CI 2.37, 11.15; and 2.27, 95% CI 1.06, 4.85, respectively) than those with higher scores. After adjustment for demographic and clinical factors, only the group with lower physical health scores had higher rates of hospitalization (RR 3.15, 95% CI 1.30, 7.90). The addition of the physical health subscore to administrative data increased the sensitivity to detect the top 5% of hospital utilizers compared with administrative data alone (44.0% vs. 36.0% respectively). CONCLUSIONS: Worse self-reported physical health, measured during routine primary care, is associated with significantly higher rates of hospitalization. It is not associated with increased rates of ED visits. Self-reported physical health modestly increases the sensitivity to detect the highest hospital utilizers.

The patient-centered medical home: a reality for HIV care in Nigeria.

OBJECTIVE: HIV care delivery in resource-limited settings (RLS) may serve as a paradigm for chronic disease care, but comprehensive measurement frameworks are lacking. Our objective was to adapt the patient-centered medical home (PCMH) framework for use in RLS, and evaluate the performance of HIV treatment programs within this framework. DESIGN AND SETTING: Cross-sectional survey administered within the AIDS Prevention Initiative in Nigeria (APIN) network. PARTICIPANTS: Medical directors at APIN clinics. MAIN OUTCOME MEASURES: We adapted the 2011 US National Committee on Quality Assurance's PCMH standard to develop a survey measuring five domains of HIV care: (i) enhancing access and continuity, (ii) identifying and managing patient populations, (iii) planning and managing care, (iv) promoting self-care and support and (v) measuring and improving performance. RESULTS: Thirty-three of 36 clinics completed the survey. Most were public (73%) and urban/semi-urban (64%); 52% had >500 patients in care. On a 0-100 scale, clinics scored highest in self-care and support, 91% (63-100%); managing patient populations, 80% (72-81%) and improving performance, 72% (44-78%). Clinics scored lowest with the most variability in planning/managing care, 65% (22-89%), and access and continuity, 61% (33-80%). Average score across all domains was 72% (58-81%). CONCLUSIONS: Our findings suggest that the modified PCMH tool is feasible, and likely has sufficient performance variation to discriminate among clinics. Consistent with extant literature, clinics showed greatest room for improvement on access and continuity, supporting the tool's face validity. The modified PCMH tool may provide a powerful framework for evaluating chronic HIV care in RLS.

A Scalable Program for Customized Patient Education Videos.

PROBLEM DEFINITION: Patients must make sense of increasingly complex information to navigate their health and the health care system, with limited opportunity to do so in clinical settings. Patient education videos may help to communicate key information, but they are often impersonal and cumbersome to produce or update with new evidence. To address these limitations, a program was developed to facilitate local video creation to deliver targeted information to patients. APPROACH: The Patient Education Video Program was created at a large urban academic medical center. The medical director and two project managers worked with clinicians and patients to create and disseminate short, single-topic videos organized by segments. The videos educated patients on clinical and service topics such as self-care for low back pain and postoperative protocols. Videos were filmed and modified on a user-friendly mobile device application, then prescribed by sharing a link to the online video platform. Video creators were engaged through a learning collaborative, a physician incentive program, and a residency elective in which trainees designed video-based care redesign projects. OUTCOMES: The program was introduced to practice sites across 26 departments. Some 269 videos received 19,713 unique views in a two-year period. In an operational survey, 1,034 (86.0%) of 1,203 viewer responses stated that a video helped them understand their health, medical condition, or treatment plan. KEY INSIGHTS: A program to facilitate video creation and dissemination is feasible. Clinicians were most receptive to creating and using videos that addressed direct clinical or operational needs.

Longer-term impact of cardiology e-consults.

AIMS: Cardiac e-consults may be an effective way to deliver value-oriented outpatient cardiology care in an accountable care organization. Initial results of cardiac e-consults have demonstrated high satisfaction among both patients and referring providers, no known adverse events, and low rates of diagnostic testing. Nevertheless, differences between e-consults and traditional consults, effects of e-consults on traditional consult volume, and whether patients seek traditional consults after e-consults are unknown. METHODS AND RESULTS: We established a cardiac e-consult program on January 13, 2014. We then conducted detailed medical record reviews of all patients with e-consults to detect any adverse clinical events and detect subsequent traditional visits to cardiologists. We also performed 2 comparisons. First, we compared age, gender, and referral reason for e-consults vs traditional consults. Second, we compared changes in volume of referrals to cardiology vs other medical specialties that did not have e-consults. From January 13 to December 31, 2014, 1,642 traditional referrals and 165 e-consults were requested. The proportion of e-consults of all evaluations requested over that period was 9.1%. Gender balance was similar among traditional consults and e-consults (44.8% male for e-consults vs 45.0% for traditional consults, P = .981). E-consult patients were younger than traditional consult patients (55.3 vs 60.4 years, P < .001). After the introduction of cardiac e-consults, the increase in traditional cardiac visit requests was less than the increase in traditional visit requests for control specialties (4.5% vs 10.1%, P < .001). For e-consults with at least 6 months of follow-up, 75.6% patients did not have any type of traditional cardiology visit during the follow-up period. CONCLUSION: E-consults are an effective and safe mechanism to enhance value in outpatient cardiology care, with low rates of bounceback to traditional consults. E-consults can account for nearly one-tenth of total outpatient consultation volume at 1 year within an accountable care organization and are associated with a reduction in traditional referrals to cardiologists.

Provider Feedback about Imaging Appropriateness by Using Scores from Order Entry Decision Support: Raw Rates Misclassify Outliers.

PURPOSE: To determine the relevant physician- and practice-related factors that jointly affect the rate of low-utility imaging examinations (score of 1-3 out of 9) ordered by means of an order entry system that provides normative appropriateness feedback. MATERIALS AND METHODS: This HIPAA-compliant study was approved by the institutional review board under an expedited protocol for analyzing anonymous aggregated administrative data. This is a retrospective study of approximately 250 000 consecutive scheduled outpatient advanced imaging examinations (computed tomography, magnetic resonance imaging, nuclear medicine) ordered by 164 primary care and 379 medical specialty physicians from 2008 to 2012. A hierarchical logistic regression model was used to identify multiple predictors of the probability that an examination received a low utility score. Physician- and practice-specific random effects were estimated to articulate (odds ratio) and quantify (intraclass correlation) interphysician variation. RESULTS: Fixed effects found to be statistically significant predictors of low-utility imaging included examination type, whether the examination was cancelled, status of the person entering the order, and the total number of examinations ordered by the clinician. Neither patient age nor sex had any effect, and there were no secular trends (year of study). The remaining amount of interphysician variation was moderate (intraclass correlation, 22%), whereas the variation between medical specialties and primary care practices was low (intraclass correlation, 5%). The estimated physician-specific effects had reliability of 70%, which makes them just suitable for identifying outliers. CONCLUSION: The authors found that 22% of the variation in the rate of low-utility examinations is attributable to ordering providers and 5% to their specialty or clinic.

Evaluating a Model to Predict Primary Care Physician-Defined Complexity in a Large Academic Primary Care Practice-Based Research Network.

BACKGROUND: Improving the ability to risk-stratify patients is critical for efficiently allocating resources within healthcare systems. OBJECTIVE: The purpose of this study was to evaluate a physician-defined complexity prediction model against outpatient Charlson score (OCS) and a commercial risk predictor (CRP). DESIGN: Using a cohort in which primary care physicians reviewed 4302 of their adult patients, we developed a predictive model for estimated physician-defined complexity (ePDC) and categorized our population using ePDC, OCS and CRP. PARTICIPANTS: 143,372 primary care patients in a practice-based research network participated in the study. MAIN MEASURES: For all patients categorized as complex in 2007 by one or more risk-stratification method, we calculated the percentage of total person time from 2008-2011 for which eligible cancer screening was incomplete, HbA1c was ≥ 9 %, and LDL was ≥ 130 mg/dl (in patients with cardiovascular disease). We also calculated the number of emergency department (ED) visits and hospital admissions per person year (ppy). KEY RESULTS: There was modest agreement among individuals classified as complex using ePDC compared with OCS (36.7 %) and CRP (39.6 %). Over 4 follow-up years, eligible ePDC-complex patients had higher proportions (p < 0.001) of time with: incomplete cervical (17.8 % vs. 13.3 % for OCS; 19.4 % vs. 11.2 % for CRP), breast (21.4 % vs. 14.9 % for OCS; 22.7 % vs. 15.0 % for CRP), and colon (25.9 % vs. 18.7 % for OCS; 27.0 % vs. 18.2 % for CRP) cancer screening; HbA1c ≥ 9 % (15.6 % vs. 8.1 % for OCS; 15.9 % vs. 6.9 % for CRP); and LDL ≥ 130 mg/dl (12.4 % vs. 7.9 % for OCS; 11.8 % vs 9.0 % for CRP). ePDC-complex patients had higher rates (p < 0.003) of: ED visits (0.21 vs. 0.11 ppy for OCS; 0.17 vs. 0.15 ppy for CRP), and admissions in patients 45-64 and ≥ 65 years old (0.11 vs. 0.10 ppy AND 0.24 vs. 0.21 ppy for OCS). CONCLUSION: Our measure for estimated physician-defined complexity compared favorably to commonly used risk-prediction approaches in identifying future suboptimal quality and utilization outcomes.

Images of imaging: how to process and display imaging utilization for large populations.

OBJECTIVE: We propose a method of processing and displaying imaging utilization data for large populations. CONCLUSION: The comprehensive and finely grained picture of imaging utilization yielded by our methods is a first step toward population-based imaging utilization management. We believe that our methods for the categorization and display of imaging utilization will prove to be widely useful.

Asynchronous vascular consultation via electronic methods: A feasibility pilot.

Management of chronic disease often requires multidisciplinary clinical efforts and specialist care. With the emergence of Accountable Care Organizations (ACOs), health care systems are incentivized to evaluate methods of information exchange between generalists and specialists in order to provide value while preserving quality. Our objective was to evaluate patient and referring provider satisfaction and outcomes of asynchronous electronic consultations in vascular care in a large tertiary academic medical center. Referring providers were offered a vascular 'e-consult' option through an electronic referral management system. We conducted chart review to understand the downstream effects and surveyed patients and referring providers to assess satisfaction. From 24 March 2014 to 1 March 2015, 54 e-consults were completed. Additional testing and recommendations were made in 49/54 (90.7%) e-consults, including lower-extremity venous duplex ultrasonography with reflux testing, duplex ultrasonography of the carotid artery, computed tomography, magnetic resonance imaging, non-invasive physiology arterial studies, laboratory tests, medications, compression stockings, and sequential lymphedema compression therapy. Referring providers were compliant with recommendations in 40/49 (81.6%) of e-consults. A total of 17/54 (31.5%) patients were surveyed with a median patient satisfaction score of 13.7/15 (91.3%) (SD ± 6.4). The program was associated with high referring provider satisfaction, with 87.0% finding the e-consult very helpful and 80.0% stating it averted the need for a traditional visit. Our experience suggests that e-consults are an effective way to provide vascular care in some patients and are associated with high patient and provider satisfaction. E-consults may therefore be an efficient method of care delivery for vascular patients within an ACO.

Caring for high-need, high-cost patients: what makes for a successful care management program?

Provider groups taking on risk for the overall costs of care in accountable care organizations are developing care management programs to improve care and thereby control costs. Many such programs target "high-need, high-cost" patients: those with multiple or complex conditions, often combined with behavioral health problems or socioeconomic challenges. In this study we compared the operational approaches of 18 successful complex care management programs in order to offer guidance to providers, payers, and policymakers on best practices for complex care management. We found that effective programs customize their approach to their local contexts and caseloads; use a combination of qualitative and quantitative methods to identify patients; consider care coordination one of their key roles; focus on building trusting relationships with patients as well as their primary care providers; match team composition and interventions to patient needs; offer specialized training for team members; and use technology to bolster their efforts.