Primary Care 2.0: A Prospective Evaluation of a Novel Model of Advanced Team Care With Expanded Medical Assistant Support

Predicting Primary Care Physician Burnout From Electronic Health Record Use Measures

OBJECTIVE

To evaluate the ability of routinely collected electronic health record (EHR) use measures to predict clinical work units at increased risk of burnout and potentially most in need of targeted interventions.

METHODS

In this observational study of primary care physicians, we compiled clinical workload and EHR efficiency measures, then linked these measures to 2 years of well-being surveys (using the Stanford Professional Fulfillment Index) conducted from April 1, 2019, through October 16, 2020. Physicians were grouped into training and confirmation data sets to develop predictive models for burnout. We used gradient boosting classifier and other prediction modeling algorithms to quantify the predictive performance by the area under the receiver operating characteristics curve (AUC).

RESULTS

Of 278 invited physicians from across 60 clinics, 233 (84%) completed 396 surveys. Physicians were 67% women with a median age category of 45 to 49 years. Aggregate burnout score was in the high range (≥3.325/10) on 111 of 396 (28%) surveys. Gradient boosting classifier of EHR use measures to predict burnout achieved an AUC of 0.59 (95% CI, 0.48 to 0.77) and an area under the precision-recall curve of 0.29 (95% CI, 0.20 to 0.66). Other models' confirmation set AUCs ranged from 0.56 (random forest) to 0.66 (penalized linear regression followed by dichotomization). Among the most predictive features were physician age, team member contributions to notes, and orders placed with user-defined preferences. Clinic-level aggregate measures identified the top quartile of clinics with 56% sensitivity and 85% specificity.

CONCLUSION

In a sample of primary care physicians, routinely collected EHR use measures demonstrated limited ability to predict individual burnout and moderate ability to identify high-risk clinics.

How Primary Care Clinicians Process Patient Death: Logistics, Emotions, and Opportunities for Structural Support

BACKGROUND

Navigating the logistics and emotional processing of a patient's death is an inevitable part of many physicians' roles. While research has primarily examined how inpatient clinicians cope with patient loss, little work has explored how primary care clinicians (PCCs) handle patient death in the outpatient setting, and what support resources could help PCCs process loss.

OBJECTIVE

To explore PCCs' experiences with the logistics and emotional processing of patient deaths and suggestions for supportive resources.

DESIGN

Qualitative study using semi-structured interviews conducted between March and May 2023.

PARTICIPANTS

Recruitment emails were sent to 136 PCCs (physicians and nurse practitioners) at three San Francisco academic primary care clinics. Twelve clinicians participated in the study.

APPROACH

This study used a template analysis approach. Interview transcripts were analyzed in an iterative fashion to identify themes for how PCCs navigate patient death.

RESULTS

Participants (n=12) described outpatient death notification as inconsistent, delayed, and rife with uncertainty regarding subsequent actions. They felt various emotions, notably sadness and guilt, especially with deaths of young, vulnerable patients or those from preventable illnesses. Participants identified strategies for emotional processing and recommended improvements including clear procedural guidance, peer debriefings, and formal acknowledgements of deceased patients.

CONCLUSIONS

Interviewing PCCs about their experiences following a patient death revealed key themes in logistical and emotional processing, and clinic resource recommendations to better support PCCs. Given the distinct characteristics of primary care-such as enduring patient relationships, greater isolation in ambulatory settings compared to inpatient environments, and rising burnout rates-enhancing guidance and support for PCCs is crucial to mitigate administrative burdens and grief after patient loss.

Team-Based Care Model Improves Timely Access to Care and Patient Satisfaction in General Cardiology

ABSTRACT

Appointment wait times have increased nationally since 2014, especially in cardiology. At a mid-Atlantic academic medical center, access to care in the general cardiology clinic was below national standards, which can negatively affect patient outcomes and satisfaction. Adopting a team-based care (TBC) model, advanced practice providers (APPs) were added to care teams with general cardiologists to provide timely outpatient management of cardiac conditions. This aimed to increase access to care and, consequently, patient satisfaction. A formative program evaluation using the Agency for Clinical Innovation framework assessed TBC's impact on these outcomes. Access to care and patient satisfaction measures for TBC and nonteam providers were compared with one another and national benchmarks. Nine months after implementation, the average time to new patient appointment for TBC providers was 31 days (47% decrease) and for nonteam providers was 41 days (20% decrease). TBC had a higher percentage of new patient appointments within 14 days than nonteam providers (39% and 20%, respectively). Patient satisfaction improved to the 98th percentile nationally for TBC but decreased to the 71st percentile for nonteam. These findings suggest that a TBC model using APPs can improve access to care and patient satisfaction in the outpatient general cardiology setting.

Effects of Advanced Team-Based Care on Care Processes and Health Measures in a Federally Qualified Health Center

In a federally qualified health center, we assess a novel primary care delivery model, advanced team-based care (aTBC), that embeds care team members in patient visits. Using a difference-in-differences research design, we measure visit intensity, compliance with preventive care recommendations, and health outcomes among patients in the aTBC model compared with patients in a traditional team-based delivery model. We find increases in receipt of some recommended preventive care and in visit intensity, but no change in health outcomes. The aTBC model may improve some dimensions of care quality for low-income, vulnerable populations.

Organizational interventions and occupational burnout: a meta-analysis with focus on exhaustion

PURPOSE

To assess whether organizational interventions are effective to prevent or reduce exhaustion, the core dimension of occupational burnout.

METHODS

We searched in PubMed, EMBASE, PsycINFO, and Cochrane Library databases randomized and non-randomized controlled trials conducted among active workers and reporting the outcome as exhaustion score. We calculated the effect sizes using the pre-test-post-test control group design's estimate. We used the random effects model in meta-analysis and Cochrane collaboration's tool for interventions to assess the risk of bias. Overall quality of evidence was appraised using the GRADE.

RESULTS

From the 2425 identified records, we assessed 228 full texts for eligibility and included 11 original articles describing 13 studies, 11 on organizational interventions, and 2 on combined inventions. The interventions were participatory (n = 9), focused on workload (n = 2), or on work schedule (n = 2). The overall effect size was - 0.30 ((95% CI = - 0.42; - 0.18), I2 = 62.28%), corresponding to a small reduction in exhaustion with a very low quality of evidence. Combined interventions had a larger effect (- 0.54 (95% CI = - 0.76; - 0.32)) than organizational interventions. When split by type of intervention, both participatory interventions and interventions focused on workload had a benefic effect of exhaustion reduction, with an estimated effect size of - 0.34 (95% CI = - 0.47; - 0.20) and - 0.44 (95% CI = - 0.68, - 0.20), respectively.

CONCLUSION

Interventions at combined level in workplaces could be helpful in preventing exhaustion. However, the evidence is still limited, due to a high heterogeneity between studies, bias potential, and small number of eligible studies. This calls for further research, using workload interventions at organizational level, especially in sectors with high risk of job stress and exhaustion.

The Association of Teamlets and Teams with Physician Burnout and Patient Outcomes

BACKGROUND

Primary care "teamlets" in which a staff member and physician consistently work together might provide a simple, cost-effective way to improve care, with or without insertion within a team.

OBJECTIVE

To determine the prevalence and performance of teamlets and teams.

DESIGN

Cross-sectional observational study linking survey responses to Medicare claims.

PARTICIPANTS

Six hundred eighty-eight general internists and family physicians.

INTERVENTIONS

Based on survey responses, physicians were assigned to one of four teamlet/team categories (e.g., teamlet/no team) and, in secondary analyses, to one of eight teamlet/team categories that classified teamlets into high, medium, and low collaboration as perceived by the physician (e.g., teamlet perceived-high collaboration/no team).

MAIN MEASURES

Descriptive: percentage of physicians in teamlet/team categories.

OUTCOME MEASURES

physician burnout; ambulatory care sensitive emergency department and hospital admissions; Medicare spending.

KEY RESULTS

77.4% of physicians practiced in teamlets; 36.7% in teams. Of the four categories, 49.1% practiced in the teamlet/no team category; 28.3% in the teamlet/team category; 8.4% in no teamlet/team; 14.1% in no teamlet/no team. 15.7%, 47.4%, and 14.4% of physicians practiced in perceived high-, medium-, and low-collaboration teamlets. Physicians who practiced neither in a teamlet nor in a team had significantly lower rates of burnout compared to the three teamlet/team categories. There were no consistent, significant differences in outcomes or Medicare spending by teamlet/team or teamlet perceived-collaboration/team categories compared to no teamlet/no team, for Medicare beneficiaries in general or for dual-eligible beneficiaries.

CONCLUSIONS

Most general internists and family physicians practice in teamlets, and some practice in teams, but neither practicing in a teamlet, in a team, or in the two together was associated with lower physician burnout, better outcomes for patients, or lower Medicare spending. Further study is indicated to investigate whether certain types of teamlet, teams, or teamlets within teams can achieve higher performance.

A Prospective Intervention to Reduce Burnout Among Academic Radiologists

RATIONALE AND OBJECTIVES

Few studies have examined what constitutes effective interventions to reduce burnout among radiologists. We compared self-reported burnout among academic medical center radiologists before and after a series of departmental initiatives intended to increase wellbeing and professional satisfaction.

MATERIALS AND METHODS

This Institutional Review Board-approved, prospective study took place 2017-2019 in a tertiary academic medical center. In pre- (2017) and post-intervention (2019) periods, we administered the previously-validated Stanford Physician Wellness Survey to faculty in our 11-division radiology department. Faculty rated their burnout level across 8 domains (professional fulfillment, emotional exhaustion, interpersonal disengagement, sleep difficulties, self-compassion, negative work impact on personal relations, organizational/personal values alignment, perceived quality of supervisory leadership). Between the two surveys, departmental initiatives focusing on culture, team building, work-life balance, and personal well-being were implemented (e.g., electronic medical record training, shorter work hours). Pre- and post-survey results were compared, using Whitney-Mann U test to calculate Z scores.

RESULTS

Faculty members rated lower professional fulfillment (Z-3.04, p=0.002), higher emotional exhaustion (Z=2.52, p=0.012), increased sleep-related impairment (Z=2.38, p=0.012), and reduced organizational/personal values alignment (Z=-4.10, p<0.0001) between the two surveys. No significant differences were identified associated with interpersonal disengagement (Z=1.82, p=0.069), self-compassion (Z=1.39, p=0.164), negative impact of work on personal relationship (Z=0.89, p=0.372) and perceived supervisory leadership quality (Z=0.07, p=0.942).

CONCLUSION

Despite numerous departmental initiatives intended to improve culture, workplace efficiency, work-life balance, and personal wellness, self-reported burnout was unchanged or worsened over time.Physician and employee wellness embedded into institutional culture maybe more effective than departmental improvement initiatives.

Implementation and Qualitative Evaluation of a Primary Care Redesign Model with Expanded Scope of Work for Medical Assistants

BACKGROUND

Implementation of primary care models involving expanded scope of work and redesigned workflows for medical assistants (MAs) as primary care team members can be challenging. Implementation strategies and participatory evaluation informed by implementation science frameworks may inform organizational decisions about model scale-up and sustainment.

OBJECTIVE

This paper reports implementation strategies and qualitative evaluation of a primary care redesign (PCR) model implementation that included an expanded scope of work for MAs.

DESIGN

Qualitative evaluation of implementation strategies and clinician and staff experience with implementation of PCR using semi-structured key informant interviews. The evaluation was guided by the RE-AIM framework and the Consolidated Framework for Implementation Research.

PARTICIPANTS

Sixty-nine clinicians, staff, practice leaders, and administrators from 7 primary care practices (4 general internal medicine, 3 family medicine) implementing PCR.

INTERVENTIONS

The PCR model included enhanced rooming and documentation support. The health system used multiple strategies to implement PCR, including rapid improvement events, changing clinic space configurations, developing electronic health record templates and performance dashboards, and practice coaching.

APPROACH

The Consolidated Framework for Implementation Research and the RE-AIM evaluation and planning framework guided development of semi-structured interview guides. A deductive, structural coding approach was used for analysis.

KEY RESULTS

PCR implementation was facilitated by clear communication about the intervention source, mechanisms for feedback about model goals, and physical environments and electronic health record (EHR) systems that supported the added staff and modified clinic workflow. Clinicians and staff benefited from the ability to see the model in action prior to go-live and opportunities for consistent provider-MA pairings.

CONCLUSIONS

The PCR model can support achieving the Quadruple Aim when fully implemented with paired MAs and clinicians who are well prepared to follow redesigned workflows and function as a team. Implementation can be effectively supported by a participatory evaluation guided by implementation science frameworks.