RESUMEN
BACKGROUND: Patient enrollment levels at Veterans Health Administration (VHA) facilities change based on Veteran demand for care, potentially affecting demands on staff. Effects on burnout in the primary care workforce associated with increases or decreases in enrollment are unknown. OBJECTIVE: Estimate associations between patient enrollment and burnout. DESIGN: In this serial cross-sectional study, VHA patient enrollment and workforce data from 2014 to 2018 were linked to burnout estimates for 138 VHA facilities. The VHA's annual All Employee Survey provided burnout estimates. PARTICIPANTS: A total of 82,421 responses to the 2014-2018 All Employee Surveys by primary care providers (PCPs), including physicians, nurse practitioners, and physician assistants; nurses; clinical associates; and administrative clerks were included. Respondents identified as patient-aligned care team members. MAIN MEASURES: Independent variables were (1) the ratio of enrollment to PCPs at VHA facilities and (2) the year-over-year change in enrollment per PCP. Burnout was measured as the annual proportion of staff at VHA facilities who reported emotional exhaustion and/or depersonalization. Each primary care role was analyzed independently. KEY RESULTS: Overall enrollment decreased from 1553 enrollees per PCP in 2014 to 1442 enrollees per PCP in 2018 across VHA facilities. Forty-three facilities experienced increased enrollment (mean of 1524 enrollees/PCP in 2014 to 1668 in 2018) and 95 facilities experienced decreased enrollment (mean of 1566 enrollees/PCP in 2014 to 1339 in 2018). Burnout decreased for all primary care roles. PCP burnout was highest, decreasing from a facility-level mean of 51.7% in 2014 to 43.8% in 2018. Enrollment was not significantly associated with burnout for any role except nurses, for whom a 1% year-over-year increase in enrollment was associated with a 0.2 percentage point increase in burnout (95% CI: 0.1 to 0.3). CONCLUSIONS: Studies assessing changes in organizational-level predictors are rare in burnout research. Patient enrollment predicted burnout only among nurses in primary care.
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Agotamiento Profesional , Veteranos , Humanos , Estados Unidos/epidemiología , Atención Primaria de Salud , Salud de los Veteranos , Estudios Transversales , Agotamiento Profesional/epidemiología , Agotamiento Profesional/psicología , United States Department of Veterans AffairsRESUMEN
Objective: Assess factors contributing to variation in the use of new and evolving diagnostic and interventional procedures for percutaneous coronary intervention (PCI). Background: Evidence-based practices for PCI have the potential to improve outcomes but are variably adopted. Finding possible drivers of PCI procedure-use variability is key for efforts aimed at establishing more uniform practice. Methods: Veterans Affairs Clinical Assessment, Reporting, and Tracking Program data were used to estimate a proportion of variation attributable to hospital-, operator-, and patient-level factors across (a) radial arterial access, (b) intravascular imaging/optical coherence tomography, and (c) atherectomy for PCI. We used random-effects models with hospital, operator, and patient random effects. Overlap between levels generated cumulative variability estimates greater than 100%. Results: A total of 445 operators performed 95,391 PCI procedures across 73 hospitals from 2011 to 2018. The rates of all procedures increased over this time. 24.45% of variability in the use of radial access was attributable to the hospital, 53.04% to the operator, and 57.83% to patient-level characteristics. 9.06% of the variability in intravascular imaging use was attributable to the hospital, 43.92% to the operator, and 21.20% to the patient. Lastly, 20.16% of the variability in use of atherectomy was attributed to the hospital, 34.63% to the operator, and 57.50% to the patient. Conclusions: The use of radial access, intracoronary imaging, and atherectomy is influenced by patient, operator, and hospital factors, but patient and operator-level effects predominate. Efforts to increase the use of evidence-based practices for PCI should consider interventions at these levels.
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Intervención Coronaria Percutánea , Humanos , Intervención Coronaria Percutánea/métodos , Tomografía de Coherencia Óptica , Arterias , Factores de Tiempo , Resultado del TratamientoRESUMEN
BACKGROUND: Full practice authority (FPA) improves clinical autonomy for nurse practitioners (NPs). Autonomy may reduce burnout. PURPOSE: Estimate the effect of changing from reduced or restricted practice authority to FPA on NP burnout. METHODS: In this quasi-experimental study, we compared NP burnout before (2016) and after (2018) a Veterans Health Administration (VHA) regulation authorized NP FPA. Burnout proportions were estimated for VHA facilities by aggregating responses to the VHA's All Employee Survey from 1,352 primary care NPs. DISCUSSION: Seventy-seven percent of facilities changed to FPA postregulation. Burnout was six points lower among NPs in facilities that changed to FPA compared to facilities that had FPA prior to the regulation; however, this association was not statistically significant. CONCLUSION: NPs are increasingly working under independent practice. While changing to FPA did not reduce NP burnout, this association may vary by health care setting or when burnout is measured for individuals or teams.
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Enfermeras Practicantes , Autonomía Profesional , Humanos , Rol de la Enfermera , Agotamiento Psicológico , Atención Primaria de SaludRESUMEN
OBJECTIVE: Burnout, or job-related stress, affects more than half of all US physicians, with primary care physicians (PCPs) experiencing some of the highest rates in medicine. Our study analyzes national survey data to identify and prioritize workplace climate predictors of burnout among PCPs within a large integrated health system. DESIGN: Observational study of annual survey data from the Veterans Health Administration (VHA) All Employee Survey (AES) for 2013-2017. AES response rate ranged from 56 to 60% during the study period. Independent and dependent variables were measured from separate random samples. In total, 8,456 individual-level responses among PCPs at 110 VHA practice sites were aggregated at the facility level by reporting year. We used the semi-automated LASSO procedure to identify workplace climate measures that were more influential in predicting burnout and assessed relative importance using the Shapely value decomposition. PARTICIPANTS: VHA employees that self-identify as PCPs. MAIN MEASURES: Dependent variables included two dichotomous measures of burnout: emotional exhaustion and depersonalization. Independent measures included 30 survey measures related to dimensions of workplace climate (e.g., workload, leadership, satisfaction). RESULTS: We identified seven influential workplace climate predictors of emotional exhaustion and nine predictors of depersonalization. With few exceptions, higher agreement/satisfaction scores for predictors were associated with a lower likelihood of burnout. The majority of explained variation in emotional exhaustion was attributable to perceptions of workload (32.6%), organization satisfaction (28.2%), and organization support (19.4%). The majority of explained variation in depersonalization was attributable to workload (25.3%), organization satisfaction (22.9%), and connection to VHA mission (20.7%). CONCLUSION: Identifying the relative importance of workplace climate is important for the allocation of health organization resources to mitigate and prevent burnout within the PCP workplace. In a context of limited resources, efforts to reduce perceived workload and improve organization satisfaction may represent the biggest leverage points for health organizations to address physician burnout.
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Agotamiento Profesional , Médicos de Atención Primaria , Agotamiento Profesional/epidemiología , Estudios Transversales , Humanos , Satisfacción en el Trabajo , Encuestas y Cuestionarios , Carga de Trabajo , Lugar de TrabajoRESUMEN
BACKGROUND: Chronic obstructive pulmonary disease (COPD) is among the most common medical diagnoses among Veterans. More than 50% of Veterans diagnosed with mild-to-moderate COPD are prescribed inhaled corticosteroids despite recommendations for use restricted to patients with frequent exacerbations. OBJECTIVE: We explored primary care providers' experiences prescribing inhaled corticosteroids among patients with mild-to-moderate COPD as part of a quality improvement initiative. DESIGN: We used a sequential mixed-methods evaluation approach to understand factors influencing primary care providers' inhaled corticosteroid prescribing for patients with mild-to-moderate COPD. Participants were recruited to participate in qualitative interviews and structured surveys. PARTICIPANTS: We used a purposive sample of primary care providers from 13 primary care clinics affiliated with two urban Veteran Health Administration healthcare systems. MAIN MEASURES: Interviews were transcribed and analyzed using content analysis. Qualitative findings informed a subsequent survey. Surveys were administered through REDCap and analyzed descriptively. Key qualitative and quantitative findings were compared. KEY RESULTS: Participants reported they were unaware of current evidence and recommendations for prescribing inhaled corticosteroids; for example, 46% of providers reported they were unaware of risks of pneumonia. Providers reported they are generally unable to keep up with the current literature due to the broad scope of primary care practice. We also found primary care providers may be reluctant to change inherited prescriptions, even if they thought inhaled corticosteroid therapy might not be appropriate. CONCLUSIONS: Inhaled corticosteroid prescribing in this patient population is partly due to primary care providers' lack of knowledge about the potential harms and availability of alternative therapies. Our findings suggest that efforts to expand access by increasing the number of prescribing providers a patient potentially sees could make it more difficult to de-implement harmful prescriptions. Our findings also corroborate prior findings that awareness of current evidence-based guidelines is likely an important part of medical overuse.
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Enfermedad Pulmonar Obstructiva Crónica , Corticoesteroides , Personal de Salud , Humanos , Atención Primaria de Salud , Enfermedad Pulmonar Obstructiva Crónica/tratamiento farmacológico , Encuestas y CuestionariosRESUMEN
BACKGROUND: Available data suggest that same-day discharge (SDD) after elective percutaneous coronary intervention (PCI) is safe in select patients. Yet, little is known about contemporary adoption rates, safety, and costs in a universal health care system like the Veterans Affairs Health System. METHODS: Using data from the Veterans Affairs Clinical Assessment Reporting and Tracking Program linked with Health Economics Resource Center data, patients undergoing elective PCI for stable angina between October 1, 2007 and Sepetember 30, 2016, were stratified by SDD versus overnight stay. We examined trends of SDD, and using 2:1 propensity matching, we assessed 30-day rates of readmission, mortality, and total costs at 30â¯days. RESULTS: Of 21,261 PCIs from 67 sites, 728 were SDDs (3.9% of overall cohort). The rate of SDD increased from 1.6% in 2008 to 9.7% in 2016 (Pâ¯<â¯.001). SDD patients had lower rates of atrial fibrillation, peripheral arterial disease, and prior coronary artery bypass grafting and were treated at higher-volume centers. Thirty-day readmission and mortality did not differ significantly between the groups (readmission: 6.7% SDD vs 5.6% for overnight stay, Pâ¯=â¯.24; mortality: 0% vs. 0.07%, Pâ¯=â¯.99). The mean (SD) 30-day cost accrued by patients undergoing SDD was $23,656 ($15,480) versus $25,878 ($17,480) for an overnight stay. The accumulated median cost savings for SDD was $1503 (95% CI $738-$2,250). CONCLUSIONS: Veterans Affairs Health System has increasingly adopted SDD for elective PCI procedures, and this is associated with cost savings without an increase in readmission or mortality. Greater adoption has the potential to reduce costs without increasing adverse outcomes.
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Procedimientos Quirúrgicos Ambulatorios/estadística & datos numéricos , Angina Estable/cirugía , Procedimientos Quirúrgicos Electivos/estadística & datos numéricos , Alta del Paciente/estadística & datos numéricos , Intervención Coronaria Percutánea/estadística & datos numéricos , Anciano , Procedimientos Quirúrgicos Ambulatorios/economía , Procedimientos Quirúrgicos Ambulatorios/mortalidad , Ahorro de Costo , Procedimientos Quirúrgicos Electivos/economía , Procedimientos Quirúrgicos Electivos/mortalidad , Femenino , Hospitales de Alto Volumen/estadística & datos numéricos , Humanos , Tiempo de Internación/economía , Tiempo de Internación/estadística & datos numéricos , Masculino , Persona de Mediana Edad , Alta del Paciente/economía , Alta del Paciente/tendencias , Readmisión del Paciente/economía , Readmisión del Paciente/estadística & datos numéricos , Readmisión del Paciente/tendencias , Intervención Coronaria Percutánea/economía , Intervención Coronaria Percutánea/métodos , Intervención Coronaria Percutánea/mortalidad , Puntaje de Propensión , Factores de Tiempo , Estados Unidos , United States Department of Veterans AffairsRESUMEN
Objectives. To determine whether (1) participating in HealthLinks, and (2) adding wellness committees to HealthLinks increases worksites' evidence-based intervention (EBI) implementation.Methods. We developed HealthLinks to disseminate EBIs to small, low-wage worksites. From 2014 to 2017, we conducted a site-randomized trial in King County, Washington, with 68 small worksites (20-200 employees). We assigned worksites to 1 of 3 arms: HealthLinks, HealthLinks plus wellness committee (HealthLinks+), or delayed control. At baseline, 15 months, and 24 months, we assessed worksites' EBI implementation on a 0% to 100% scale and employees' perceived support for their health behaviors.Results. Postintervention EBI scores in both intervention arms (HealthLinks and HealthLinks+) were significantly higher than in the control arm at 15 months (51%, 51%, and 23%, respectively) and at 24 months (33%, 37%, and 24%, respectively; P < .001). Employees in the intervention arms perceived greater support for their health at 15 and 24 months than did employees in control worksites.Conclusions. HealthLinks is an effective strategy for disseminating EBIs to small worksites in low-wage industries.Public Health Implications. Future research should focus on scaling up HealthLinks, improving EBI maintenance, and measuring impact of these on health behavior.
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Conductas Relacionadas con la Salud , Promoción de la Salud/organización & administración , Servicios de Salud del Trabajador/organización & administración , Pequeña Empresa/organización & administración , Lugar de Trabajo/organización & administración , Adolescente , Adulto , Anciano , Medicina Basada en la Evidencia , Femenino , Promoción de la Salud/estadística & datos numéricos , Humanos , Masculino , Persona de Mediana Edad , Servicios de Salud del Trabajador/estadística & datos numéricos , Evaluación de Programas y Proyectos de Salud , Pequeña Empresa/estadística & datos numéricos , Washingtón , Lugar de Trabajo/estadística & datos numéricos , Adulto JovenRESUMEN
BACKGROUND: The Patient-centered Medical Home (PCMH) uses team-based care to improve patient outcomes, including satisfaction. The quality of patients' communication with their primary care providers (PCPs) is a key determinant of patient satisfaction. A shift to team-based care could disrupt the therapeutic relationship between patients and their PCPs and reduce patient satisfaction if communication and coordination among primary care team members is poor. Little is known about the relationship between intrateam communication within a PCMH and patient satisfaction with PCPs, and whether patient-provider communication might mediate this relationship. OBJECTIVES: To examine the relationship between intrateam communication in a PCMH and patients' satisfaction with assigned PCPs, and whether patient-provider communication mediates this relationship. RESEARCH DESIGN: Cross-sectional surveys of Veterans Health Administration PCPs (2011-2012, n=149) matched with their assigned patients' surveys (n=3329). Mediation analyses using a nested data structure, controlling for patient and provider characteristics. MEASURES: Patient satisfaction with PCPs, patient-reported patient-provider communication, and PCP-reported intrateam communication within the PCMH. RESULTS: Intrateam communication and patient-provider communication were independently associated with patients' satisfaction with their PCPs. Patient-provider communication mediated 56% of the association between intrateam communication and patient satisfaction. Better intrateam communication combined with better patient-provider communication predicted high satisfaction (81%), compared with poor intrateam communication and poor patient-provider communication (22%). CONCLUSIONS: PCMH environments with better communication among team members are likely to experience better patient-provider communication and high patient satisfaction. PCMH practices with low ratings of patient satisfaction may need to look beyond individual PCPs to communication within and across teams.
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Continuidad de la Atención al Paciente/organización & administración , Accesibilidad a los Servicios de Salud/organización & administración , Satisfacción del Paciente/estadística & datos numéricos , Atención Dirigida al Paciente/organización & administración , Relaciones Profesional-Paciente , Actitud del Personal de Salud , Comunicación , Estudios Transversales , Humanos , Atención Primaria de Salud/estadística & datos numéricos , Encuestas y CuestionariosRESUMEN
BACKGROUND: The patient-centered medical home (PCMH) is a primary care delivery model predicated on shared responsibility for patient care among members of an interprofessional team. Effective task sharing may reduce burnout among primary care providers (PCPs). However, little is known about the extent to which PCPs share these responsibilities, and which, if any, of the primary care tasks performed independently by the PCPs (vs. shared with the team) are particularly associated with PCP burnout. A better understanding of the relationship between these tasks and their effects on PCP burnout may help guide focused efforts aimed at reducing burnout. OBJECTIVE: To investigate (1) the extent to which PCPs share responsibility for 14 discrete primary care tasks with other team members, and (2) which, if any, of the primary care tasks performed by the PCPs (without reliance on team members) are associated with PCP burnout. DESIGN: Secondary data analysis of Veterans Health Administration (VHA) survey data from two time periods. PARTICIPANTS: 327 providers from 23 VA primary care practices within one VHA regional network. MAIN MEASURES: The dependent variable was PCP report of burnout. Independent variables included PCP report of the extent to which they performed 14 discrete primary care tasks without reliance on team members; team functioning; and PCP-, clinic-, and system-level variables. KEY RESULTS: In adjusted models, PCP reports of intervening on patient lifestyle factors and educating patients about disease-specific self-care activities, without reliance on their teams, were significantly associated with burnout (intervening on lifestyle: b = 4.11, 95% CI = 0.39, 7.83, p = 0.03; educating patients: b = 3.83, 95% CI = 0.33, 7.32, p = 0.03). CONCLUSIONS: Performing behavioral counseling and self-management education tasks without relying on other team members for assistance was associated with PCP burnout. Expanding the roles of nurses and other healthcare professionals to assume responsibility for these tasks may ease PCP burden and reduce burnout.
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Agotamiento Profesional/diagnóstico , Agotamiento Profesional/psicología , Personal de Salud/psicología , Atención Primaria de Salud/métodos , Encuestas y Cuestionarios , United States Department of Veterans Affairs , Adulto , Agotamiento Profesional/epidemiología , Femenino , Humanos , Masculino , Persona de Mediana Edad , Estados Unidos/epidemiología , Salud de los VeteranosRESUMEN
We examined the association of mental health staffing and the utilization of primary care/mental health integration (PCMHI) with facility-level variations in adequacy of psychotherapy and antidepressants received by Veterans with new, recurrent, and chronic depression. Greater likelihood of adequate psychotherapy was associated with increased (1) PCMHI utilization by recurrent depression patients (AOR 1.02; 95% CI 1.00, 1.03); and (2) staffing for recurrent (AOR 1.03; 95% CI 1.01, 1.06) and chronic (AOR 1.02; 95% CI 1.00, 1.03) depression patients (p < 0.05). No effects were found for antidepressants. Mental health staffing and PCMHI utilization explained only a small amount of the variance in the adequacy of depression care.
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Antidepresivos/uso terapéutico , Trastorno Depresivo/terapia , Servicios de Salud Mental/organización & administración , Admisión y Programación de Personal/estadística & datos numéricos , Atención Primaria de Salud/organización & administración , Psicoterapia/estadística & datos numéricos , Femenino , Accesibilidad a los Servicios de Salud , Humanos , Masculino , Persona de Mediana Edad , Oportunidad Relativa , Calidad de la Atención de Salud , Estados Unidos , United States Department of Veterans AffairsRESUMEN
BACKGROUND: Work-related burnout is common in primary care and is associated with worse patient safety, patient satisfaction, and employee mental health. Workload, staffing stability, and team completeness may be drivers of burnout. However, few studies have assessed these associations at the team level, and fewer still include members of the team beyond physicians. OBJECTIVE: To study the associations of burnout among primary care providers (PCPs), nurse care managers, clinical associates (MAs, LPNs), and administrative clerks with the staffing and workload on their teams. DESIGN: We conducted an individual-level cross-sectional analysis of survey and administrative data in 2014. PARTICIPANTS: Primary care personnel at VA clinics responding to a national survey. MAIN MEASURES: Burnout was measured with a validated single-item survey measure dichotomized to indicate the presence of burnout. The independent variables were survey measures of team staffing (having a fully staffed team, serving on multiple teams, and turnover on the team), and workload both from survey items (working extended hours), and administrative data (patient panel overcapacity and average panel comorbidity). KEY RESULTS: There were 4610 respondents (estimated response rate of 20.9%). The overall prevalence of burnout was 41%. In adjusted analyses, the strongest associations with burnout were having a fully staffed team (odds ratio [OR] = 0.55, 95% CI 0.47-0.65), having turnover on the team (OR = 1.67, 95% CI 1.43-1.94), and having patient panel overcapacity (OR = 1.19, 95% CI 1.01-1.40). The observed burnout prevalence was 30.1% lower (28.5% vs. 58.6%) for respondents working on fully staffed teams with no turnover and caring for a panel within capacity, relative to respondents in the inverse condition. CONCLUSIONS: Complete team staffing, turnover among team members, and panel overcapacity had strong, cumulative associations with burnout. Further research is needed to understand whether improvements in these factors would lower burnout.
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Agotamiento Profesional/psicología , Personal de Salud/psicología , Grupo de Atención al Paciente/tendencias , Atención Primaria de Salud , United States Department of Veterans Affairs , Carga de Trabajo/psicología , Agotamiento Profesional/diagnóstico , Agotamiento Profesional/epidemiología , Estudios Transversales , Femenino , Personal de Salud/tendencias , Humanos , Masculino , Admisión y Programación de Personal/tendencias , Médicos de Atención Primaria/tendencias , Atención Primaria de Salud/tendencias , Estados Unidos/epidemiología , United States Department of Veterans Affairs/tendenciasRESUMEN
BACKGROUND: Improved anticoagulation control with warfarin reduces adverse events and represents a target for quality improvement. No previous study has described an effort to improve anticoagulation control across a health system. OBJECTIVE: To describe the results of an effort to improve anticoagulation control in the New England region of the Veterans Health Administration (VA). METHODS: Our intervention encompassed 8 VA sites managing warfarin for more than 5000 patients in New England (Veterans Integrated Service Network 1 [VISN 1]). We provided sites with a system to measure processes of care, along with targeted audit and feedback. We focused on processes of care associated with site-level anticoagulation control, including prompt follow-up after out-of-range international normalized ratio (INR) values, minimizing loss to follow-up, and use of guideline-concordant INR target ranges. We used a difference-in-differences (DID) model to examine changes in anticoagulation control, measured as percentage time in therapeutic range (TTR), as well as process measures and compared VISN 1 sites with 116 VA sites located outside VISN 1. RESULTS: VISN 1 sites improved on TTR, our main indicator of quality, from 66.4% to 69.2%, whereas sites outside VISN 1 improved from 65.9% to 66.4% (DID 2.3%, P < 0.001). Improvement in TTR correlated strongly with the extent of improvement on process-of-care measures, which varied widely across VISN 1 sites. CONCLUSIONS: A regional quality improvement initiative, using performance measurement with audit and feedback, improved TTR by 2.3% more than control sites, which is a clinically important difference. Improving relevant processes of care can improve outcomes for patients receiving warfarin.
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Anticoagulantes/uso terapéutico , Coagulación Sanguínea/efectos de los fármacos , Atención a la Salud/normas , Relación Normalizada Internacional , Mejoramiento de la Calidad , Warfarina/uso terapéutico , Anticoagulantes/administración & dosificación , Anticoagulantes/efectos adversos , Atención a la Salud/tendencias , Humanos , New England , Estados Unidos , United States Department of Veterans Affairs , Warfarina/administración & dosificación , Warfarina/efectos adversosRESUMEN
BACKGROUND: In April 2010, the Veterans Health Administration (VHA) launched the Patient Aligned Care Team (PACT) initiative to implement a patient-centered medical home (PCMH) model. Few evaluations have addressed the effects of PCMH on health care professionals' experiences. PURPOSES: The aim of this study was to contribute to evaluation of the PACT initiative and the broader literature on PCMH by assessing respondents' experiences of implementing a PCMH model and becoming a teamlet. METHODOLOGY/APPROACH: A retrospective qualitative analysis of open-text responses in a survey fielded to all VHA Primary Care personnel (VHA Primary Care physicians, nurse practitioners, physician assistants, nurse care managers, clinical associates, and administrative clerks) in May and June 2012 (approximately 2 years into the 5-year planned implementation of PACT) using deductive and inductive content analysis. The main measures were two open-response fields: "Is there anything else you would like us to relay to the VA leadership in Central Office?" and "Do you have any other comments or feedback on PACT?" The data consisted of free text responses of 3,868 survey participants who provided text for one or both of the open-response fields. FINDINGS: Although respondents viewed PACT positively as a model and reported it improved relationships with patients and increased patient satisfaction, they described multiple barriers to achieving functioning teamlets and unintended consequences, including reduced time with patients, increased participant burnout, and decreased team efficacy because of low-performing team members. A central theme related to staffing being insufficient for the new model. PRACTICE IMPLICATIONS: Insufficient staffing of PCMH teams is a critical barrier to realizing the benefits of the new model. Frontline staff have concrete recommendations for other problems, such as using back-up teams to cover during absences, but that will require providing more opportunities for feedback from staff to be heard.
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Grupo de Atención al Paciente/organización & administración , Atención Dirigida al Paciente/organización & administración , Atención Primaria de Salud/organización & administración , Adulto , Femenino , Humanos , Liderazgo , Admisión y Programación de Personal/normas , Investigación Cualitativa , Estudios Retrospectivos , Estados Unidos , United States Department of Veterans AffairsRESUMEN
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.
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Agotamiento Profesional/epidemiología , Agotamiento Profesional/psicología , Médicos de Atención Primaria/psicología , Psicometría/normas , Carga de Trabajo/psicología , Adulto , Área Bajo la Curva , Estudios Transversales , Femenino , Hospitales de Veteranos , Humanos , Modelos Logísticos , Masculino , Persona de Mediana Edad , Grupo de Atención al Paciente , Prevalencia , Atención Primaria de Salud/organización & administración , Reproducibilidad de los Resultados , Medición de Riesgo , Estrés Psicológico/epidemiología , Estados Unidos , Adulto JovenRESUMEN
BACKGROUND: The Veterans Health Administration (VHA) began implementing a patient-centered medical home (PCMH) model of care delivery in April 2010 through its Patient Aligned Care Team (PACT) initiative. PACT represents a substantial system reengineering of VHA primary care and its potential effect on primary care provider (PCP) turnover is an important but unexplored relationship. This study examined the association between a system-wide PCMH implementation and PCP turnover. METHODS: This was a retrospective, longitudinal study of VHA-employed PCPs spanning 29 calendar quarters before PACT and eight quarters of PACT implementation. PCP employment periods were identified from administrative data and turnover was defined by an indicator on the last quarter of each uncensored period. An interrupted time series model was used to estimate the association between PACT and turnover, adjusting for secular trend and seasonality, provider and job characteristics, and local unemployment. We calculated average marginal effects (AME), which reflected the change in turnover probability associated with PACT implementation. RESULTS: The quarterly rate of PCP turnover was 3.06% before PACT and 3.38% after initiation of PACT. In adjusted analysis, PACT was associated with a modest increase in turnover (AME=4.0 additional PCPs per 1000 PCPs per quarter, P=0.004). Models with interaction terms suggested that the PACT-related change in turnover was increasing in provider age and experience. CONCLUSIONS: PACT was associated with a modest increase in PCP turnover, concentrated among older and more experienced providers, during initial implementation. Our findings suggest that policymakers should evaluate potential workforce effects when implementing PCMH.
Asunto(s)
Atención Dirigida al Paciente/organización & administración , Reorganización del Personal/estadística & datos numéricos , Atención Primaria de Salud/organización & administración , United States Department of Veterans Affairs/organización & administración , Adulto , Factores de Edad , Femenino , Accesibilidad a los Servicios de Salud , Humanos , Estudios Longitudinales , Masculino , Persona de Mediana Edad , Atención Dirigida al Paciente/estadística & datos numéricos , Atención Primaria de Salud/estadística & datos numéricos , Estudios Retrospectivos , Factores Sexuales , Estados Unidos , United States Department of Veterans Affairs/estadística & datos numéricosRESUMEN
BACKGROUND: Older persons account for the majority of hospitalizations in the United States.1 Identifying risk factors for hospitalization among elders, especially potentially preventable hospitalization, may suggest opportunities to improve primary care. Certain factors-for example, living alone-may increase the risk for hospitalization, and their effect may be greater among persons with dementia and the old-old (aged 85+). OBJECTIVES: To determine the association of living alone and risk for hospitalization, and see if the observed effect is greater among persons with dementia or the old-old. DESIGN: Retrospective longitudinal cohort study. PARTICIPANTS: 2,636 participants in the Adult Changes in Thought (ACT) study, a longitudinal cohort study of dementia incidence. Participants were adults aged 65+ enrolled in an integrated health care system who completed biennial follow-up visits to assess for dementia and living situation. MAIN MEASURES: Hospitalization for all causes and for ambulatory care sensitive conditions (ACSCs) were identified using automated data. KEY RESULTS: At baseline, the mean age of participants was 75.5 years, 59 % were female and 36 % lived alone. Follow-up time averaged 8.4 years (SD 3.5), yielding 10,431 approximately 2-year periods for analysis. Living alone was positively associated with being aged 85+, female, and having lower reported social support and better physical function, and negatively associated with having dementia. In a regression model adjusted for age, sex, comorbidity burden, physical function and length of follow-up, living alone was not associated with all-cause (OR = 0.93; 95 % CI 0.84, 1.03) or ambulatory care sensitive condition (ACSC) hospitalization (OR = 0.88; 95 % CI 0.73, 1.07). Among participants aged 85+, living alone was associated with a lower risk for all-cause (OR = 0.76; 95 % CI 0.61, 0.94), but not ACSC hospitalization. Dementia did not modify any observed associations. CONCLUSION: Living alone in later life did not increase hospitalization risk, and in this population may be a marker of healthy aging in the old-old.
Asunto(s)
Demencia/epidemiología , Hospitalización/estadística & datos numéricos , Características de la Residencia/estadística & datos numéricos , Anciano , Anciano de 80 o más Años , Femenino , Estudios de Seguimiento , Humanos , Masculino , Estudios Retrospectivos , Factores de Riesgo , Factores Socioeconómicos , Estados Unidos/epidemiologíaRESUMEN
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.
Asunto(s)
Actitud del Personal de Salud , Agotamiento Profesional/psicología , Personal de Salud/psicología , Hospitales de Veteranos , Atención Dirigida al Paciente , Agotamiento Profesional/diagnóstico , Agotamiento Profesional/epidemiología , Estudios Transversales , Humanos , Grupo de Atención al Paciente , Atención Dirigida al Paciente/métodos , Atención Primaria de Salud/métodosRESUMEN
OBJECTIVE: To determine how a large scale, multicomponent, pharmacy based intervention to reduce proton pump inhibitor (PPI) overuse affected prescribing patterns, healthcare utilization, and clinical outcomes. DESIGN: Difference-in-difference study. SETTING: US Veterans Affairs Healthcare System, in which one regional network implemented the overuse intervention and all 17 others served as controls. PARTICIPANTS: All individuals receiving primary care from 2009 to 2019. INTERVENTION: Limits on PPI refills for patients without a documented indication for long term use, voiding of PPI prescriptions not recently filled, facilitated electronic prescribing of H2 receptor antagonists, and education for patients and clinicians. MAIN OUTCOME MEASURES: The primary outcome was the percentage of patients who filled a PPI prescription per 6 months. Secondary outcomes included percentage of days PPI gastroprotection was prescribed in patients at high risk for upper gastrointestinal bleeding, percentage of patients who filled either a PPI or H2 receptor antagonist prescription, hospital admission for acid peptic disease in older adults appropriate for PPI gastroprotection, primary care visits for an upper gastrointestinal diagnosis, upper endoscopies, and PPI associated clinical conditions. RESULTS: The number of patients analyzed per interval ranged from 192 607 to 250 349 in intervention sites and from 3 775 953 to 4 360 868 in control sites, with 26% of patients receiving PPIs before the intervention. The intervention was associated with an absolute reduction of 7.3% (95% confidence interval -7.6% to -7.0%) in patients who filled PPI prescriptions, an absolute reduction of 11.3% (-12.0% to -10.5%) in PPI use among patients appropriate for gastroprotection, and an absolute reduction of 5.72% (-6.08% to -5.36%) in patients who filled a PPI or H2 receptor antagonist prescription. No increases were seen in primary care visits for upper gastrointestinal diagnoses, upper endoscopies, or hospital admissions for acid peptic disease in older patients appropriate for gastroprotection. No clinically significant changes were seen in any PPI associated clinical conditions. CONCLUSIONS: The multicomponent intervention was associated with reduced PPI use overall but also in patients appropriate for gastroprotection, with minimal evidence of either clinical benefits or harms.
Asunto(s)
Prestación Integrada de Atención de Salud , Enfermedades Gastrointestinales , Humanos , Anciano , Inhibidores de la Bomba de Protones/uso terapéutico , Antagonistas de los Receptores H2 de la Histamina/uso terapéutico , Hemorragia Gastrointestinal/inducido químicamenteRESUMEN
Objectives: The Department of Veterans Affairs (VA) is transitioning from its legacy electronic health record (EHR) to a new commercial EHR in a nationwide, rolling-wave transition. We evaluated clinician and staff experiences to identify strategies to improve future EHR rollouts. Materials and Methods: We completed a convergent mixed-methods formative evaluation collecting survey and interview data to measure and describe clinician and staff experiences. Survey responses were analyzed using descriptive statistics; interview transcripts were coded using a combination of a priori and emergent codes followed by qualitative content analysis. Qualitative and quantitative findings were compared to provide a more comprehensive understanding of participant experience. Employees of specialty and primary care teams at the first nationwide EHR transition site agreed to participate in our study. We distributed surveys at 1-month pre-transition, 2 months post-transition, and 10 months post-transition to each of the 68 identified team members and completed longitudinal interviews with 30 of these individuals totaling 122 semi-structured interviews. Results: Interview participants reported profoundly disruptive experiences during the EHR transition that persisted at 1-year post implementation. Survey responses indicated training difficulties throughout the transition, and sharp declines (P ≤ .05) between pre- and post-go-live measures of EHR usability and increase in EHR burden that were perceived to be due in part to system inefficiencies, discordant positive messaging that initially ignored user challenges, and inadequate support for and attention to ongoing EHR issues. Participants described persistent high levels of stress associated with these disruptions. Discussion: Our findings highlight strategies to improve employee experiences during EHR transitions: (1) working with Oracle Cerner to resolve known issues and improve usability; (2) role-based training with opportunities for self-directed learning; (3) peer-led support systems and timely feedback on issues; (4) messaging that responds to challenges and successes; and (5) continuous efforts to support staff with issues and address clinician and staff stress and burnout. Conclusion: Our findings provide relevant strategies to navigate future EHR transitions while supporting clinical teams.