New
data suggests that the link between provider burnout and poor patient
experience and care quality may be exaggerated.
By Sara Heath
October
09, 2019 - It may be well documented that provider burnout has
negative consequences for patient experience and care quality, but has the
medical industry been overstating those issues? Perhaps so, according to new data from Stanford University
School of Medicine.
Physician
burnout runs rampant throughout the medical industry.
Data published in 2019 by the American
Academy of Family Physicians (AAFP) revealed that although rates of physician
burnout are going down, about 44 percent of family doctors are still reporting
at least one symptom of burnout.
And
conventional wisdom has stated that high levels of provider burnout can be bad
news for patients. Clinicians who are “checked out,” distracted, stressed, or
overburdened cannot make meaningful connections with patients and run the risk
of making medical mistakes, experts have long stated.
Data
has confirmed these theories, with numerous studies tying physician burnout to
lower care quality scores, said the Stanford researchers, led by Daniel S.
Tawfik, MD, MS.
“Recent attention has been focused on the
relation between health care provider burnout and reduced quality of care, with
a growing body of primary literature and systematic reviews reporting
associations between burnout and adherence to practice guidelines,
communication, medical errors, patient outcomes, and safety metrics,” Tawfik
and colleagues wrote.
But
this latest data from Stanford calls those studies into question, looking
specifically at study methodology and how it may have led to exaggerated
connections between physician burnout and patient care quality.
The
researchers looked at 145 studies related to physician burnout and patient care
quality, segmenting care quality into five key categories including adherence
to best practices, provider communication, occurrence of
medical errors, patient outcomes, and quality and safety scores.
The
researchers observed a total of 114 burnout and quality combinations, with 58
of them tying burnout to poor quality outcomes. Six of the combinations
revealed a connection between physician burnout and high-quality care, while 50
of them were neutral, the team found.
However,
the researchers also observed a high level of excess significance, meaning the
studies yielded results that were shown to be more significant than they
actually were.
In
total, 73 percent of studies observed had excess significance compared to the
62 percent of studies the researchers predicted would have significant results.
In other words, many of the study’s results were exaggerated because of study
design, the team said.
“Although
the effect sizes in the published literature are modestly strong, our finding
of excess significance implies that the true magnitude may be smaller than
reported, and the studies that attempted to lower the risk of bias demonstrate
fewer significant associations than the full evidence base,” the researchers
wrote.
Specifically,
the researchers found excess significance in the best practices guidelines and
quality and safety assessments.
“Investigations
of burnout in relation to these outcomes are typically retrospective studies of
routinely collected outcome metrics in existing data sets, without
preregistered protocols,” the team explained. “The relative ease of defining
and evaluating many outcomes in many ways with these data sets increases the
risk for selective outcome and selective analysis reporting, which may have
contributed to excess significance.”
Study
methodology is the likely culprit for these overstated results.
In a
separate editorial about the study, a group of
researchers led by Carolyn S. Dewa, MPH, PhD from the University of California
Davis outlined the reasons why physician burnout studies may yield excess
significance. Specifically, studies used variable burnout measures, clinical quality measures, and study
methods, the team said.
Additionally,
studies may be confounding work environment factors that may lead to poor
quality outcomes. For example, a study may indicate that physician burnout in
the emergency department (ED) leads to patient safety errors. However, the
study may not account for the high risk for medical errors in the ED that arise
separately of physician burnout.
“If
providers who were experiencing burnout practiced in high-risk environments and
were more likely to answer the questionnaire, the relationship between burnout
and medical error would be confounded,” Dewa and her colleagues wrote. “Thus,
it is important for future studies, when appropriate, to adjust for potential
confounders.”
Compounding
of provider groups – physicians versus nurses versus physician assistants, for
example – may also skew results.
To be
clear, none of these researchers are suggesting that physician burnout does not
impact patient experiences and outcomes, nor are they denying that physician burnout is a current
industry challenge. However, more data is needed to understand the extent to
which burnout impacts patient care.
“Considering
the limitations of the available literature, prior reviews, and Tawfik and
colleagues' current meta-analysis, we conclude that higher burnout is
associated with lower quality, but we are left without clear answers about of
the magnitude or clinical significance of the relationship,” Dewa wrote.
In
gaining that understanding, future researchers can better design their studies
to more accurately predict the impact of provider burnout on patient care.
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