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

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

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

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

Examining supervisor undermining through the job-demands resources framework.

INTRODUCTION: Supervisor undermining has recently gained increasing attention due to its negative effects on employee health and well-being. In the healthcare context, negative supervisor behaviors have been linked to unfavorable individual and organizational outcomes as well as medical errors and patient mortality. Our study, therefore, examines the influence that supervisor undermining behavior has on employee engagement and performance within a standard job stress framework. METHODS: Our sample consisted of occupational therapists, a health professions group who is growing in demand and importance in the U.S. and has unique job demands. Using an observational, cross-sectional study design, a convenience sample of 521 occupational therapists completed an online survey. A series of independent t-test and multiple-groups path analytic modeling was used. RESULTS: Participants who had a supervisor perceived as engaging in undermining behaviors reported lower levels of resources, higher levels of demands, less motivation, and more overload than those who did not perceive supervisor undermining. These participants were also less engaged and reported lower levels of performance. CONCLUSION: Our results shed further light on the importance of supervisory behaviors specifically in a healthcare setting and the need for organizations to create an environment that promotes positive and productive workplace behaviors.

Impact of Food Insecurity Nutrition Incentives on Household Fruit and Vegetable Expenditures.

OBJECTIVE: Evaluate the impact of the Food Insecurity Nutrition Incentive (FINI) grant program on self-reported fruit and vegetable (FV) expenditures. DESIGN: Pre-post quasi-experimental study design. SETTING: Farmers markets and grocery stores in states with FINI projects. PARTICIPANTS: A total of 2,471 Supplemental Nutrition Assistance Program (SNAP) households in 4 intervention groups who lived near a FINI retailer (farmers market or grocery store) and 4 matched comparison groups who did not live near a FINI retailer. MAIN OUTCOME MEASURES: Awareness and use of point-of-sale incentives and changes in self-reported monthly household FV expenditures. ANALYSIS: Ordinary least squares intent-to-treat regression model using lagged dependent variable model framework. RESULTS: Awareness of FINI was higher among households who were near a FINI retailer and had shopped there before FINI than those who lived near a FINI retailer but had not shopped there before FINI; the number of information sources from which SNAP participants heard about FINI was positively associated with incentive receipt (P < 0.05). Among those who received incentives, the average amount of incentives received at the last shopping trip ranged from $15 to $23. The FINI program had a positive impact on the average monthly FV expenditures for those in the farmers market shopper, grocery store shopper, and grocery store general intervention groups-increases ranged from $9 to $15 (P < 0.05). CONCLUSIONS AND IMPLICATIONS: Point-of-sale incentives were associated with an increase in FV expenditures among SNAP households. Further research is needed to examine (1) effective messaging strategies to increase incentive awareness and (2) the long-term impact of incentives on FV expenditures.

The Personal and Professional Consequences of Physician Burnout: A Systematic Review of the Literature.

The well-being of the health care workforce has emerged as both a major concern and as a component of the "quadruple aim" to enable the "triple aim" of improving patient experiences, reducing costs, and improving population health. Physician burnout is problematic given its effects on physicians, patients, health care organizations, and society. Using conservation of resources theory as a frame, we conducted a systematic review of the empirical literature on the relationship of physician burnout with physician personal and professional outcomes that includes 43 articles. Nine outcomes were organized into three categories illustrating burnout as a dynamic loss spiral rather than a static end-state. Findings show that emotional exhaustion had the greatest impact with the outcomes explored, while depersonalization and lack of professional accomplishment manifested fewer associations. The results suggest that burnout is a complex, dynamic phenomenon, which unfolds over time. Future research and implications of these results are discussed.

Evidence for the Quadruple Aim: A Systematic Review of the Literature on Physician Burnout and Patient Outcomes.

BACKGROUND: Experts express concern that attaining of the Triple Aim of reducing health care costs, improving patient experiences and ultimately population health, may be compromised by high levels of burnout among physicians. Some have called for a fourth aim of improving the work environment for care providers. OBJECTIVES: Burnout has been linked to poor outcomes in many occupational settings. This study's aim was to investigate linkages between physician burnout and patient outcomes through a systematic review of the literature. RESEARCH DESIGN: Systematic search of 3 databases using Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) guidelines. In total, 1201 articles were reviewed, and 28 were included in the final analysis. Studies needed to be empirical, measure physician burnout as a predictor, and include patient outcome measures. MEASURES: The majority of studies were cross-sectional and measured patient outcomes via physician perception self-reports (n=14). Five studies reported clinical measures (quality, errors), and 9 included patient ratings of their care. RESULTS: Studies using self-reports of suboptimal quality and errors found that physicians higher in burnout consistently reported worse quality, yet studies linking burnout to independent clinical outcomes found no relationships. Similarly, burnout was related to lower patient ratings of care, but when specific behaviors were rated there was no relationship. CONCLUSIONS: Although the interest in burnout's effects is strong, the lack of rigorous empirical studies examining patient outcomes is problematic. Future research should develop and test causal models to better understand which domains of patient care are influenced by physician burnout.

New migraine with visual disturbance after cryoballoon ablation of atrial fibrillation.

We report the case of a 58-year-old woman who developed a headache and visual disturbances after a cryoballoon ablation procedure for atrial fibrillation at our institution. She presented to the emergency department four days post ablation and was admitted the hospital for overnight observation. Serial neurological examinations and neuroimaging were unremarkable for stroke or transient ischemic attack. The patient had some brief transient visual changes which resolved completely after several days, with no further clinical sequelae. She followed up in the outpatient neuro-ophthalmology clinic and had a normal visual field examination. She was given a diagnosis of new onset migraine with visual aura.

Do Work Condition Interventions Affect Quality and Errors in Primary Care? Results from the Healthy Work Place Study.

BACKGROUND: While primary care work conditions are associated with adverse clinician outcomes, little is known about the effect of work condition interventions on quality or safety. DESIGN: A cluster randomized controlled trial of 34 clinics in the upper Midwest and New York City. PARTICIPANTS: Primary care clinicians and their diabetic and hypertensive patients. INTERVENTIONS: Quality improvement projects to improve communication between providers, workflow design, and chronic disease management. Intervention clinics received brief summaries of their clinician and patient outcome data at baseline. MAIN MEASURES: We measured work conditions and clinician and patient outcomes both at baseline and 6-12 months post-intervention. Multilevel regression analyses assessed the impact of work condition changes on outcomes. Subgroup analyses assessed impact by intervention category. KEY RESULTS: There were no significant differences in error reduction (19 % vs. 11 %, OR of improvement 1.84, 95 % CI 0.70, 4.82, p = 0.21) or quality of care improvement (19 % improved vs. 44 %, OR 0.62, 95 % CI 0.58, 1.21, p = 0.42) between intervention and control clinics. The conceptual model linking work conditions, provider outcomes, and error reduction showed significant relationships between work conditions and provider outcomes (p ≤ 0.001) and a trend toward a reduced error rate in providers with lower burnout (OR 1.44, 95 % CI 0.94, 2.23, p = 0.09). LIMITATIONS: Few quality metrics, short time span, fewer clinicians recruited than anticipated. CONCLUSIONS: Work-life interventions improving clinician satisfaction and well-being do not necessarily reduce errors or improve quality. Longer, more focused interventions may be needed to produce meaningful improvements in patient care. CLINICAL TRIAL REGISTRATION NUMBER: ClinicalTrials.gov # NCT02542995.

Defining, Achieving, and Maintaining Competence in Cardiovascular Training and Practice.

Patients, hospitals, insurers, and the public rely on competent physicians. The definition and documentation of competency in cardiovascular training and practice continues to evolve. New tools, such as the American College of Cardiology's in-training examination, restructured Core Cardiovascular Training Statement, curricular and lifelong learning competencies, and the Accreditation Council for Graduate Medical Education Milestones help define competent trainees and practitioners, and level the playing field. The American Board of Internal Medicine's Maintenance of Certification program is undergoing critical review, and a common vision of its future form and role are not yet clear. This paper explores present-day cardiovascular competency components, assessment tools, and strategies, and identifies challenges for the future.

Patient perceptions of patient-centred care: empirical test of a theoretical model.

AIM: Patient perception measures are gaining increasing interest among scholars and practitioners. The aim of this study was to empirically examine a conceptual model of patient-centred care using patient perception survey data. BACKGROUND: Patient-centred care is one of the Institute of Medicine's objectives for improving health care in the 21st century. Patient interviews conducted by the Picker Institute/Commonwealth Fund in the 1980s resulted in a theoretical model and survey questions with dimensions and attributes patients defined as patient-centered. METHOD: The present study used survey data from patients with overnight visits at 142 U.S. hospitals. RESULTS: Regression analysis found significant support for the theoretical model. Perceptions of emotional support had the strongest relationship with overall care ratings. Coordination of care, and physical comfort were strongly related as well. CONCLUSION: Understanding how patients experience their care can help improve understanding of what patients believe is patient-centred, and of how care processes relate to important patient outcomes.

CT brain findings in a patient with elevated brain cesium levels.

We describe the CT findings in the brain of a woman with pathologically proven elevated levels of blood and tissue cesium. The 42-year-old woman had been receiving cesium chloride as a non-mainstream treatment for metastatic breast carcinoma. She presented to hospital following a seizure, and died 48 hours after admission. A brain CT performed on hospital admission showed a diffuse increase in attenuation of brain parenchyma. Autopsy revealed elevated levels of cesium in blood and solid organs including the brain. We hypothesize that the imaging findings are attributable to the abnormally elevated level of brain cesium at the time of the CT scan. To our knowledge, this is the first reported case of this imaging finding.

Rate versus rhythm control and outcomes in patients with atrial fibrillation and chronic kidney disease: data from the GUSTO-III Trial.

BACKGROUND: Atrial fibrillation (AF) and chronic kidney disease (CKD) have both been shown to portend worse outcomes after acute myocardial infarction (MI); however, the benefit of a rhythm control strategy in patients with CKD post-MI is unclear. METHODS: We prospectively studied 985 patients with new-onset AF post-MI in the GUSTO-III trial, of whom 413 (42%) had CKD (creatinine clearance < 60 mL/min). A rhythm control strategy, defined as the use of an antiarrhythmic medication and/or electrical cardioversion, was used in 346 (35%) of patients. RESULTS: A rhythm control strategy was used in 34% of patients with CKD and 36% of patients with no CKD. At hospital discharge, sinus rhythm was present in 487 (76%) of patients treated with a rate control strategy, vs. 276 (80%) in those treated with rhythm control (p = 0.20). CKD was associated with a lower odds of sinus rhythm at discharge (unadjusted OR 0.56, 95% CI 0.38-0.84, p < 0.001). However, in multivariable analyses, treatment with a rhythm control strategy was not associated with discharge rhythm (HR 1.068, 95% CI 0.69-1.66, p = 0.77), 30-day mortality (HR 0.78, 95% CI 0.54-1.12, p = 0.18) or mortality from day 30 to 1 year (HR 1.00, 95% CI 0.59-1.69, p = 0.99). CKD status did not significantly impact the relationship between rhythm control and outcomes. CONCLUSIONS: Treatment with a rhythm or rate control strategy does not signifi cantly impact short-term or long-term mortality in patients with post-MI AF, regardless of kidney disease status. Future studies to investigate the optimal management of AF in CKD patients are needed.