Burnout in primary care and in physicians in the Spanish National Health System

BackgroundPrimary care physicians have been present on the frontline during the ongoing pandemic, adding new tasks to already high workloads. Our aim was to evaluate burnout in primary care physicians during the COVID-19 pandemic, as well as associated contributing factors.MethodsCross-sectional study with an online questionnaire disseminated through social media, applying the snowball technique. The target population was primary care physicians working in Portugal during the first outbreak of the COVID-19 pandemic. In addition to sociodemographic data, the questionnaire collected responses to the Copenhagen Burnout Inventory (CBI), the Resilience Scale and the Depression, Anxiety, and Stress Scales (DASS-21). Data were collected from May 9 to June 8, 2020, a period comprising the declaration of a national calamity and then state of emergency, and the subsequent ease of lockdown measures. Levels of burnout in 3 different dimensions (personal, work, and patient-related), resilience, stress, depression, and anxiety were assessed. Logistic regression analyses were conducted to identify factors associated with burnout levels.ResultsAmong the 214 physician respondents, burnout levels were high in the 3 dimensions. A strong association was found between gender, years of professional experience, depression and anxiety, and burnout levels.ConclusionsPhysician burnout in primary care is high and has increased during the pandemic. More studies are needed in the long term to provide a comprehensive assessment of COVID-19’simpact on burnout levels and how to best approach and mitigate it during such unprecedented times.

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. Estimate associations between patient enrollment and burnout. 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. 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. 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. 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). Studies assessing changes in organizational-level predictors are rare in burnout research. Patient enrollment predicted burnout only among nurses in primary care.

<h3>Context:</h3> Assessment of wellness and burnout in primary care often focuses on providers. Less is known about wellness and burnout in other primary care team members, including actions that would improve wellness. <h3>Objective:</h3> To assess wellness and burnout in primary care providers and staff and identify actions to increase work-related wellness. <h3>Study Design:</h3> Cross-sectional survey. <h3>Setting:</h3> Jefferson Health system, with 100 primary care practices in the Philadelphia region. <h3>Population studied:</h3> Survey was emailed to all primary care providers and staff (N=1155) in February 2021, including providers, behavioral health consultants, nurses, medical assistants and all other clinical staff, quality/research staff, and all administrative staff. <h3>Instrument:</h3> Thirty-item survey: demographic items (age, sex, race/ethnicity, practice region, professional role), Perceived Stress Reactivity Prolonged Reactivity Subscale (PRS), Abbreviated Maslach Burnout Inventory (aMBI) with emotional exhaustion, depersonalization, and personal accomplishment subscales, Mini-Z Burnout Survey, 1-10 rating of work-related wellness, and an open-ended question asking what one thing would improve work-related wellness. <h3>Outcome Measures:</h3> Primary outcomes were average wellness and burnout scores: mean(standard deviation) (SD) PRS, mean (SD) aMBI emotional exhaustion, median and interquartile range aMBI depersonalization and personal accomplishment, mean(SD) Mini-Z score and response to Mini-Z burnout item, and mean(SD) 1-10 wellness rating. Responses were compared across demographic categories for significant differences (p&lt;.05). Open-ended responses were analyzed for themes. <h3>Results:</h3> 429 providers and staff completed the survey (37% response rate). All roles were represented. Mean PRS score was 3.89(1.55), aMBI: emotional exhaustion: 9.11(5.25), depersonalization 1.00(4.00), personal accomplishment 15.00(4.00), Mini-Z 32.09(3.99) with 48% reporting some burnout, and 5.85(2.45) on 1-10 wellness scale. Results varied significantly by region and role. Open-ended responses (N=202) recommended increased staffing, increased administrative time, and better practice and leadership communication/teamwork. <h3>Conclusions:</h3> Our sample reported elevated prolonged stress reactivity but similar/slightly lower burnout than prior studies. Findings were shared with participants and action steps developed; survey will be readministered every 6 months.

The primary health care in the Spanish National Health System is organised in health centres with multi-professional teams, composed of doctors and nurses specialised in family and community health, in addition to other professionals. This article analyses the role of primary health care nurses in the Spanish National Health System. In the last decade, new concepts of task sharing between doctors and nurses as well as advanced nursing roles have been evolved in the health centres that focus on improving care for chronically ill patients and access to primary care. With shared responsibility, nurses are responsible for chronic patients in stable conditions, health prevention and promotion. The scaling up of advanced nursing tasks is limited by uncertainties of roles, disparities between states, and legislations that do not cover the full extent of advanced nursing tasks. The case study of Spain indicates that a strong multi-professional model of primary health care teams is a crucial basis for the evolvement of advanced nursing practice and its acceptance in daily routines. However, advantageous education structures and legislations are needed to allow nurses to develop their contribution in the full potential.

PMH10 - Budgetary Impact Analysis of Reimbursement Varenicline in the Smoking Cessation Treatment of Patients with Major Depression in Spain

AimsWe aim to agree on a set of proposals to improve the current management of heart failure (HF) within the Spanish National Health System (SNHS) and apply the social return on investment (SROI) method to measure the social impact that these proposals would generate.Methods and resultsA multidisciplinary working team of 16 experts was set up, with representation from the main stakeholders regarding HF: medical specialists (cardiologists, internal medicine physicians, general practitioners, and geriatric physicians), nursing professionals, health management professionals, patients, and informal caregivers. This team established a set of proposals to improve the management of HF according to the main areas of HF care: emergency and hospitalization, primary care, cardiology, and internal medicine. A forecast‐type SROI method, with a 1‐year time frame, was applied to measure the social impact resulting from the implementation of these proposals. The required investment and social return were estimated and summarized into a ratio indicating how much social return could be generated for each euro invested. Intangible returns were included and quantified through financial proxies. The approach to improve the management of HF consisted of 28 proposals, including the implementation of a case management nurse network, standardization of operational protocols, psychological support, availability of echocardiography machines at emergency departments, stationary units and primary care, early specialist visits after hospital discharge, and cardiac rehabilitation units, among others. These proposals would benefit not only patients and their informal caregivers but also the SNHS. Regarding patients, proposals would increase their autonomy in everyday activities, decrease anxiety, increase psychological and physical well‐being, improve pharmacological adherence and self‐care, enhance understanding of the disease, delay disease progression, expedite medical assessment, and prevent the decrease in work productivity associated with HF management. Regarding informal caregivers, proposals would increase their quality of life; improve their social, economic, and emotional well‐being; and reduce their care burden. The SNHS would benefit from shorter stays of HF patients at intensive care units and reduction of hospitalizations and admissions to emergency departments. The investment needed to implement these proposals would amount to €548m and yield a social return of €1932m, that is, €3.52 for each euro invested.ConclusionsThe current management of HF could be improved by a set of proposals that resulted in an overall positive social return, varying between areas of analysis. This may guide the allocation of healthcare resources and improve the quality of life of patients with HF.

IntroductionOsteoporosis increases fracture risk and is associated with important morbidity and mortality, among postmenopausal women. In Spain, 1 in 3 women over 50 will have an osteoporosis-related fracture. While bisphosphonates...

Professionals’ perception of circuits of care for hypertensive or diabetic patients between primary and secondary care

Although much attention has been focused on individual-level drivers of burnout in primary care settings, examining the structural and cultural factors of practice environments with no burnout could identify solutions. In this cross-sectional analysis of survey data from 715 small-to-medium-size primary care practices in the United States participating in the Agency for Healthcare Research and Quality's EvidenceNOW initiative, we found that zero-burnout practices had higher levels of psychological safety and adaptive reserve, a measure of practice capacity for learning and development. Compared with high-burnout practices, zero-burnout practices also reported using more quality improvement strategies, more commonly were solo and clinician owned, and less commonly had participated in accountable care organizations or other demonstration projects. Efforts to prevent burnout in primary care may benefit from focusing on enhancing organization and practice culture, including promoting leadership development and fostering practice agency.

BackgroundHealth professionals’ training is a key element to address unhealthy alcohol use in Primary Care (PC). Education about alcohol use can be effective in improving PC provider’s knowledge and skills addressing alcohol-related problems. The aim of the study was to evaluate the training of health professionals to address unhealthy alcohol use in PC.MethodsAn observational, descriptive, cross-sectional, multicenter study was performed. Location: PC centres of the Spanish National Health System (SNHS). Participants: Family physicians, residents and nurses completed an online questionnaire that inquired about their training (none, basic, medium or advanced), knowledge and preventive practices aimed at reducing unhealthy alcohol use. The study population was recruited via random sampling, stratified by the regions of the SNHS’s PC centre, and by email invitation to members of two Spanish scientific societies of Family Medicine.ResultsA total of 1760 professionals participated in the study. Sixty-seven percent (95% CI: 67.5–71.8) reported not having received specific training to address unhealthy alcohol use, 30% (95% CI: 27.4–31.7) reported having received basic training, and 3% (95% CI: 2.3–4.0) medium/advanced training. The training received was greater in younger providers (p < 0.001) who participated in the PAPPS (Preventive Activities and Health Promotion Programme) (p < 0.001). Higher percentages of providers with intermediate or advanced training reported performing screening for unhealthy alcohol use (p < 0.001), clinical assessment of alcohol consumption (p < 0.001), counselling of patients to reduce their alcohol intake (p < 0.001) or to abstain, in the cases of pregnant women and drivers (p < 0.001).ConclusionOur study reveals a low level of training among Spanish PC providers to address unhealthy alcohol use. A higher percentage of screening, clinical assessment and counselling interventions aimed at reducing unhealthy alcohol use was reported by health professionals with an intermediate or advanced level of training.

Many people attending primary care (PC) have anxiety-depressive symptoms and work-related burnout compounded by a lack of resources to meet their needs. The COVID-19 pandemic has exacerbated this problem, and digital tools have been proposed as a solution. We aimed to present the development, feasibility, and potential effectiveness of Vickybot, a chatbot aimed at screening, monitoring, and reducing anxiety-depressive symptoms and work-related burnout, and detecting suicide risk in patients from PC and health care workers. Healthy controls (HCs) tested Vickybot for reliability. For the simulation study, HCs used Vickybot for 2 weeks to simulate different clinical situations. For feasibility and effectiveness study, people consulting PC or health care workers with mental health problems used Vickybot for 1 month. Self-assessments for anxiety (Generalized Anxiety Disorder 7-item) and depression (Patient Health Questionnaire-9) symptoms and work-related burnout (based on the Maslach Burnout Inventory) were administered at baseline and every 2 weeks. Feasibility was determined from both subjective and objective user-engagement indicators (UEIs). Potential effectiveness was measured using paired 2-tailed t tests or Wilcoxon signed-rank test for changes in self-assessment scores. Overall, 40 HCs tested Vickybot simultaneously, and the data were reliably transmitted and registered. For simulation, 17 HCs (n=13, 76% female; mean age 36.5, SD 9.7 years) received 98.8% of the expected modules. Suicidal alerts were received correctly. For the feasibility and potential effectiveness study, 34 patients (15 from PC and 19 health care workers; 76% [26/34] female; mean age 35.3, SD 10.1 years) completed the first self-assessments, with 100% (34/34) presenting anxiety symptoms, 94% (32/34) depressive symptoms, and 65% (22/34) work-related burnout. In addition, 27% (9/34) of patients completed the second self-assessment after 2 weeks of use. No significant differences were found between the first and second self-assessments for anxiety (t8=1.000; P=.34) or depressive (t8=0.40; P=.70) symptoms. However, work-related burnout scores were moderately reduced (z=-2.07, P=.04, r=0.32). There was a nonsignificant trend toward a greater reduction in anxiety-depressive symptoms and work-related burnout with greater use of the chatbot. Furthermore, 9% (3/34) of patients activated the suicide alert, and the research team promptly intervened with successful outcomes. Vickybot showed high subjective UEI (acceptability, usability, and satisfaction), but low objective UEI (completion, adherence, compliance, and engagement). Vickybot was moderately feasible. The chatbot was useful in screening for the presence and severity of anxiety and depressive symptoms, and for detecting suicidal risk. Potential effectiveness was shown to reduce work-related burnout but not anxiety or depressive symptoms. Subjective perceptions of use contrasted with low objective-use metrics. Our results are promising but suggest the need to adapt and enhance the smartphone-based solution to improve engagement. A consensus on how to report UEIs and validate digital solutions, particularly for chatbots, is required.

…are greatly exaggerated.It was with great fascination that I recently read my obituary.1 I had just seen a clinic of patients that I have cared for over many years—patients I had celebrated the births with, helped kick a smoking habit, or followed through knee surgery and its complications. Most I have laughed with. Several I have talked baseball with. Some I have cried with.It is not the first time I have been pronounced dead or dying.2 It will not be the last. To be fair, there were accurate statements. The long-standing need for payment reform that has kept primary care physicians underpaid truly has taken a toll. Compounded with rising student debt, it has made primary care unappealing to many who may have considered it.I agree that any prestige primary care enjoyed has been tarnished. Few ever signed up for the field for prestige. Marcus Wellby is the closest primary care ever came to icon status. Yes, burnout in primary care is high—burnout is high in all specialties. It is not the work itself leading to burnout, it is the volume of work and the relative lack of compensation.3 Yes, I will admit primary care is struggling.Other claims I feel were inaccurate. Providing primary care to every American will take a large and diverse team. Nurse practitioners and physician assistants will be necessary and valued members of this team. On any good team, each member performs their role well and knows how to rely on teammates when appropriate. The primary care physician will be the most trained and experienced member of this team and will therefore be a natural team leader.Artificial intelligence (AI) will be another team member. AI retrieves medical facts and creates differential diagnoses faster than I can. AI will not explain the impact of a new diagnosis to a patient in the personalized and compassionate way that I do. AI will not fist bump in celebration of new grandchildren or hold the hand of a mourning spouse.Most inaccurate was the assumption that the last, or close to the last, learner has chosen to enter primary care. I have taught medical learners for more than 2 decades. The raw numbers entering primary care have ticked down. However, the character of those pursuing primary care has not changed. I see intelligent, compassionate, and idealistic learners following the path I followed. Large numbers of altruistic learners continue undaunted by lower pay and the dire warnings of burnout—learners who tolerate higher levels of uncertainty, embrace complexity, and value prevention, who want to build long-term relationships with patients. Every year bright young doctors proudly assume the moniker of primary care physician.Primary care has repeatedly been shown to be the best medicine.4 With some well-reasoned policy changes, primary care can thrive again. This will take hard work, resilience, and continuous advocacy—not throwing up our hands in surrender.I am still here, and do not plan on going anywhere.

Reducing Burnout in Primary Care: A Step Toward Solutions.

Appropriate delegation of clinical tasks from primary care providers (PCPs) to other team members may reduce employee burnout in primary care. However, (1) the extent to which delegation occurs within multidisciplinary teams, (2) factors associated with greater delegation, and (3) whether delegation is associated with burnout are all unknown. We performed a national cross-sectional survey of Veterans Affairs (VA) PCP-nurse dyads in Department of VA primary care clinics, 4 years into the VA's patient-centered medical home initiative. PCPs reported the extent to which they relied on other team members to complete 15 common primary care tasks; paired nurses reported how much they were relied on to complete the same tasks. A composite score of task delegation/reliance was developed by taking the average of the responses to the 15 questions. We performed multivariable regression to explore predictors of task delegation and burnout. Among 777 PCP-nurse dyads, PCPs reported delegating tasks less than nurses reported being relied on (PCP mean ± standard deviation composite delegation score, 2.97± 0.64 [range, 1-4]; nurse composite reliance score, 3.26 ± 0.50 [range, 1-4]). Approximately 48% of PCPs and 35% of nurses reported burnout. PCPs who reported more task delegation reported less burnout (odds ratio [OR], 0.62 per unit of delegation; 95% confidence interval [CI], 0.49-0.78), whereas nurses who reported being relied on more reported more burnout (OR, 1.83 per unit of reliance; 95% CI, 1.33-2.5). Task delegation was associated with less burnout for PCPs, whereas task reliance was associated with greater burnout for nurses. Strategies to improve work life in primary care by increasing PCP task delegation must consider the impact on nurses.

RECALSEEN 2024. Resources and quality in the endocrinology and nutrition units of the National Health System of Spain.