Faculty Bibliography

PURPOSE/OBJECTIVE:To determine the effectiveness of a shared decision-making (SDM) tool versus guideline-informed usual care in translating evidence into primary care, and to explore how use of the tool changed patient perspectives about diabetes medication decision making. METHODS:In this mixed methods multicenter cluster randomized trial, we included patients with type 2 diabetes mellitus and their primary care clinicians. We compared usual care with or without a within-encounter SDM conversation aid. We assessed participant-reported decisions made and quality of SDM (knowledge, satisfaction, and decisional conflict), clinical outcomes, adherence, and observer-based patient involvement in decision-making (OPTION12-scale). We used semi-structured interviews with patients to understand their perspectives. RESULTS:We enrolled 350 patients and 99 clinicians from 20 practices and interviewed 26 patients. Use of the conversation aid increased post-encounter patient knowledge (correct answers, 52% vs. 45%, p = 0.02) and clinician involvement of patients (Mean between-arm difference in OPTION12, 7.3 (95% CI 3, 12); p = 0.003). There were no between-arm differences in treatment choice, patient or clinician satisfaction, encounter length, medication adherence, or glycemic control. Qualitative analyses highlighted differences in how clinicians involved patients in decision making, with intervention patients noting how clinicians guided them through conversations using factors important to them. CONCLUSIONS:Using an SDM conversation aid improved patient knowledge and involvement in SDM without impacting treatment choice, encounter length, medication adherence or improved diabetes control in patients with type 2 diabetes. Future interventions may need to focus specifically on patients with signs of poor treatment fit. CLINICAL TRIAL REGISTRATION/BACKGROUND:ClinicalTrial.gov: NCT01502891.

IMPORTANCE:The COVID-19 pandemic has affected clinician health and retention. OBJECTIVE:To describe trends in burnout from 2019 through 2021 with associated mitigating and aggravating factors. DESIGN, SETTING, AND PARTICIPANTS:Cross-sectional surveys were sent to physicians and advanced practice clinicians throughout 120 large US health care organizations between February 2019 and December 2021. From 56 090 surveys, there were 20 627 respondents. EXPOSURES:Work conditions and COVID-19. MAIN OUTCOMES AND MEASURES:Surveys measured time pressure, chaos, work control, teamwork, electronic health record use, values alignment, satisfaction, burnout, intent to leave, and in 2021, feeling valued. Multivariate regressions controlling for gender, race and ethnicity, years in practice, and role determined burnout, satisfaction, and intent-to-leave correlates. RESULTS:Of the 20 627 respondents (median response rate, 58% [IQR, 34%-86%; difference, 52%]), 67% were physicians, 51% female, and 66% White. Burnout was 45% in 2019, 40% to 45% in early 2020, 50% in late 2020, and 60% in late 2021. Intent to leave increased from 24% in 2019 to more than 40% as job satisfaction decreased. Higher burnout was seen in chaotic workplaces (odds ratio [OR], 1.51; 95% CI, 1.38-1.66; P < .001) and with low work control (OR, 2.10; 95% CI, 1.91-2.30; P < .001). Higher burnout was associated with poor teamwork (OR, 2.08; 95% CI, 1.78-2.43; P < .001), while feeling valued was associated with lower burnout (OR, 0.22; 95% CI, 0.18-0.27; P < .001). In time trends, burnout was consistently higher with chaos and poor work control. For example, in the fourth quarter of 2021 burnout was 36% (95% CI, 31%-42%) in calm environments vs 78% (95% CI, 73%-84%) if chaotic (absolute difference, 42%; 95% CI, 34%-49%; P < .001), and 39% (95% CI, 33%-44%) with good work control vs 75% (95% CI, 69%-81%) if poor (absolute difference, 36%; 95% CI, 27%-44%; P < .001). Good teamwork was associated with lower burnout rates (49%; 95% CI, 44%-54%) vs poor teamwork (88%; 95% CI, 80%-97%; absolute difference, 39%; 95% CI, 29%-48%; P < .001), as was feeling valued (37%; 95% CI, 31%-44%) vs not feeling valued (69%; 95% CI, 63%-74%; absolute difference, 32%; 95% CI, 22%-39%; P < .001). CONCLUSIONS AND RELEVANCE:Results of this survey study show that in 2020 through 2021, burnout and intent to leave gradually increased, rose sharply in late 2021, and varied by chaos, work control, teamwork, and feeling valued. Monitoring these variables could provide mechanisms for worker protection.

Rates of burnout among clinicians have been exacerbated by the COVID-19 (COVID)pandemic. A survey of Missouri primary care professionals at federally qualified health centers was conducted during a COVID surge in August 2021 to assess burnout, stress, and job satisfaction as well as if respondents had sought assistance for burnout or attended resiliency training. Despite respondents reporting rates of burnout (56%) that exceed those reported nationally (48%), only 17% sought help for burnout. Most (81%) had not attended resiliency training; of those who did, 16% said sessions "make me feel less alone," while an equivalent number found sessions not useful, identifying an absence of resources within their organization. Comments focused on the need for dedicated time to receive support, including time to seek assistance during working hours, time to take breaks, and time for self-care. The data suggest one path forward to remediate burnout: provide the workforce with time to access support.

INTRODUCTION/UNASSIGNED:The learning health system (LHS) aligns science, informatics, incentives, stakeholders, and culture for continuous improvement and innovation. The Agency for Healthcare Research and Quality and the Patient-Centered Outcomes Research Institute designed a K12 initiative to grow the number of LHS scientists. We describe approaches developed by 11 funded centers of excellence (COEs) to promote partnerships between scholars and health system leaders and to provide mentored research training. METHODS/UNASSIGNED:Since 2018, the COEs have enlisted faculty, secured institutional resources, partnered with health systems, developed and implemented curricula, recruited scholars, and provided mentored training. Program directors for each COE provided descriptive data on program context, scholar characteristics, stakeholder engagement, scholar experiences with health system partnerships, roles following program completion, and key training challenges. RESULTS/UNASSIGNED:To date, the 11 COEs have partnered with health systems to train 110 scholars. Nine (82%) programs partner with a Veterans Affairs health system and 9 (82%) partner with safety net providers. Clinically trained scholars (n = 87; 79%) include 70 physicians and 17 scholars in other clinical disciplines. Non-clinicians (n = 29; 26%) represent diverse fields, dominated by population health sciences. Stakeholder engagement helps scholars understand health system and patient/family needs and priorities, enabling opportunities to conduct embedded research, improve outcomes, and grow skills in translating research methods and findings into practice. Challenges include supporting scholars through roadblocks that threaten to derail projects during their limited program time, ranging from delays in access to data to COVID-19-related impediments and shifts in organizational priorities. CONCLUSIONS/UNASSIGNED:Four years into this novel training program, there is evidence of scholars' accomplishments, both in traditional academic terms and in terms of moving along career trajectories that hold the potential to lead and accelerate transformational health system change. Future LHS training efforts should focus on sustainability, including organizational support for scholar activities.

BACKGROUND:Recruiting participants to clinical research studies is challenging, especially when conducted in safety net settings. We sought to compare the efficacy of different recruitment strategies in an NIH-funded study assessing treatment burden in patients with multiple chronic conditions (MCCs). METHODS:Targeted mailing, in-person table-based recruitment ("tabling") in the waiting room, and telephone calling were used to enroll subjects into one of two studies of treatment burden: a survey study to validate a brief measure of treatment burden for quality assessment (study 1) or a qualitative study to develop a treatment burden clinical communication tool (study 2). RESULTS:Over 50% of subjects in each study were African American or African immigrants. In study 1, the enrollment goal of 200 was reached within 4 months. Tabling enrolled 78.5% of patients, while the remainder (21.5%) were enrolled from phone calls to eligible patients identified through the electronic medical record (EMR). In study 2, 340 eligible patients were identified through the EMR, and 7 (2.1%) were successfully enrolled via mailed invitations and responses. Retention rates (66% in study 1 and 71% in study 2) were reasonable in all groups. CONCLUSIONS:Study recruiting goals in our safety net population were rapidly reached using the tabling method, which had substantively higher enrollment rates than mailings or telephone calls based on EMR reports. Future trials could compare recruitment strategies across settings and clinical populations.

OBJECTIVE:During the coronavirus disease 2019 pandemic, as a safety-net organization with a substantial percentage of patients of color and with limited English proficiency (LEP), we were wary of furthering health disparities in our community. We analyzed gaps in telemedicine (telephone and video) delivery in our communities, quantified the effects of our tests of change, and began the process of accumulating evidence to create a road map for other organizations. METHODS:We leveraged Lean problem-solving strategies to identify modifiable gaps across multiple domains that could inhibit equity in telemedicine. We implemented tests of change across domains of community engagement, technology, education, and access. We observed the proportion of telemedicine encounters across races and languages between April and November, 2020. Regression analyses tested the impact of race and language on telemedicine controlling for age, gender, insurance, and time. RESULTS: < 0.05). CONCLUSION:Our roadmap to improve equitable delivery of telemedicine was associated with a significant improvement in telemedicine use among certain minority populations. Most populations of color used telephone more often than video. This preference changed over time and with equity-focused changes in telemedicine delivery.

BACKGROUND:Physician burnout is often assessed by healthcare organizations. Yet, scores from different burnout measures cannot currently be directly compared, limiting the interpretation of results across organizations or studies. OBJECTIVE:To link common measures of burnout to a single metric in psychometric analyses such that group-level scores from different assessments can be compared. DESIGN:Cross-sectional survey. SETTING:US practices. PARTICIPANTS:A total of 1355 physicians sampled from the American Medical Association Physician Masterfile. MAIN MEASURES:We linked the Stanford Professional Fulfillment Index (PFI) and Mini-Z Single-Item Burnout (MZSIB) scale to the Maslach Burnout Inventory (MBI) in item response theory (IRT) fixed-calibration and equipercentile analyses and created crosswalks mapping PFI and MZSIB scores to corresponding MBI scores. We evaluated the accuracy of the results by comparing physicians' actual MBI scores to those predicted by linking and described the closest cut-point equivalencies across scales linked to the same MBI subscale using the resulting crosswalks. KEY RESULTS:IRT linking produced the most accurate results and was used to create crosswalks mapping (1) PFI Work Exhaustion (PFI-WE) and MZSIB scores to MBI Emotional Exhaustion (MBI-EE) scores and (2) PFI Interpersonal Disengagement (PFI-ID) scores to MBI Depersonalization (MBI-DP) scores. The commonly used MBI-EE raw score cut-point of ≥27 corresponded most closely with respective PFI-WE and MZSIB raw score cut-points of ≥7 and ≥3. The commonly used MBI-DP raw score cut-point of ≥10 corresponded most closely with a PFI-ID raw score cut-point of ≥9. CONCLUSIONS:Our findings allow healthcare organizations using the PFI or MZSIB to compare group-level scores to historical, regional, or national MBI scores (and vice-versa).

Background Guidelines promote shared decision-making (SDM) for anticoagulation in patients with atrial fibrillation. We recently showed that adding a within-encounter SDM tool to usual care (UC) increases patient involvement in decision-making and clinician satisfaction, without affecting encounter length. We aimed to estimate the extent to which use of an SDM tool changed adherence to the decided care plan and clinical safety end points. Methods and Results We conducted a multicenter, encounter-level, randomized trial assessing the efficacy of UC with versus without an SDM conversation tool for use during the clinical encounter (Anticoagulation Choice) in patients with nonvalvular atrial fibrillation considering starting or reviewing anticoagulation treatment. We conducted a chart and pharmacy review, blinded to randomization status, at 10 months after enrollment to assess primary adherence (proportion of patients who were prescribed an anticoagulant who filled their first prescription) and secondary adherence (estimated using the proportion of days for which treatment was supplied and filled for direct oral anticoagulant, and as time in therapeutic range for warfarin). We also noted any strokes, transient ischemic attacks, major bleeding, or deaths as safety end points. We enrolled 922 evaluable patient encounters (Anticoagulation Choice=463, and UC=459), of which 814 (88%) had pharmacy and clinical follow-up. We found no differences between arms in either primary adherence (78% of patients in the SDM arm filled their first prescription versus 81% in UC arm) or secondary adherence to anticoagulation (percentage days covered of the direct oral anticoagulant was 74.1% in SDM versus 71.6% in UC; time in therapeutic range for warfarin was 66.6% in SDM versus 64.4% in UC). Safety outcomes, mostly bleeds, occurred in 13% of participants in the SDM arm and 14% in the UC arm. Conclusions In this large, randomized trial comparing UC with a tool to promote SDM against UC alone, we found no significant differences between arms in primary or secondary adherence to anticoagulation or in clinical safety outcomes. Registration URL: https://www.clinicaltrials.gov; Unique identifier: clinicaltrials.gov. Identifier: NCT02905032.

OBJECTIVES/UNASSIGNED:Determine whether there are different longitudinal patterns of treatment burden in people living with multiple chronic conditions (MCC) and, if so, explore predictors that might reveal potential routes of intervention. METHODS/UNASSIGNED:We analyzed data from a prospective mailed survey study of 396 adults living with MCC in southeastern Minnesota, USA. Participants completed a measure of treatment burden, the Patient Experience with Treatment and Self-management (PETS), and valid measures of health-related and psycho-social concepts at baseline, 6, 12, and 24 months. Latent class growth mixture modeling (LCGM) determined trajectories of treatment burden in two summary index scores of the PETS: Workload and Impact. Multivariable logistic regressions were used to identify independent predictors of the trajectories. RESULTS/UNASSIGNED:< .05). CONCLUSIONS/UNASSIGNED:Different longitudinal patterns of treatment burden exist among people with MCC. Raising health literacy, enhancing self-efficacy, and lessening the effects of negative social interactions might help reduce treatment burden.