Exploring Associations between Stressors and Burnout in Trainee Doctors During the COVID-19 Pandemic in the UK

OBJECTIVE

The authors examined associations between stressors and burnout in trainee doctors during the COVID-19 pandemic.

METHODS

An anonymous online questionnaire including 42 questions on general and pandemic-specific stressors, and the Maslach Burnout Inventory-Health Services Survey (MBI-HSS), was sent to 1000 randomly selected trainee doctors in North-West England. Main outcomes were burnout scores that were stratified into Emotional Exhaustion (EE), Depersonalisation (DP), and reduced Personal Accomplishment (PA) and associations between stressors and burnout using stepwise regression analysis.

RESULTS

A total of 362 complete responses were received giving a response rate of 37%. Mean scores for EE, DP, and PA derived from the MBI-HSS were 27.7, 9.8, and 34.3 respectively. Twenty-three stressors were found to be associated with burnout dimensions. "Increase in workload and hours due to COVID-19," "Poor leadership and management in the National Health Service," and "Not feeling valued" were found to have strong associations with burnout dimensions. Only "Not confident in own abilities" was found to be associated with all burnout dimensions.

CONCLUSIONS

Associations with burnout were found to be identified in a range of work, pandemic, and non-work-related stressors, supporting the need for multi-level interventions to mitigate burnout.

Interventions to improve teamwork and wellbeing in primary care settings: a mixed method review

Background

General practices are experiencing increasing pressures due to rising demand, declining staff numbers, and knock-on impacts on patient care. The COVID-19 pandemic has added further challenges and reinforced the importance of teamwork and organisational settings. We undertook a mixed-method systematic review to explore which interventions can improve teamwork within primary care and improve inter-sector partnerships with other health and social care services.

Methods

Five major bibliographic databases were systematically searched for relevant studies from inception to February 2022. We included controlled intervention study designs and linked qualitative studies. For amenable data, meta-analysis is being undertaken using random effects models taking into account the between study heterogeneity (quantified using the I2 statistic) and potential publication bias (funnel plots and Egger's test). The qualitative studies are analysed using thematic analyses.

Results

The original search yield of 3012 studies, of which 14 studies with 1,534 participants were include in our analyses. Most of the evaluated interventions focused on improving non-technical skills and provided evidence of improvements in the quality of teamwork in primary care. Meta-analysis and narrative synthesis is undertaken to examine the impact of the teamwork interventions on staff outcomes (team attitudes, knowledge, and functioning; wellbeing), and patient outcomes (e.g. quality of patient care, patient satisfaction/experience).

Conclusions

The findings provide information of immediate importance for the mental health and wellbeing and teamwork support of professionals entering primary care and for the organisation of primary care services.

Associations of physician burnout with career engagement and quality of patient care: systematic review and meta-analysis

OBJECTIVE

To examine the association of physician burnout with the career engagement and the quality of patient care globally.

DESIGN

Systematic review and meta-analysis.

DATA SOURCES

Medline, PsycINFO, Embase, and CINAHL were searched from database inception until May 2021.

ELIGIBILITY CRITERIA FOR SELECTING STUDIES

Observational studies assessing the association of physician burnout (including a feeling of overwhelming emotional exhaustion, feelings of cynicism and detachment from job defined as depersonalisation, and a sense of ineffectiveness and little personal accomplishment) with career engagement (job satisfaction, career choice regret, turnover intention, career development, and productivity loss) and the quality of patient care (patient safety incidents, low professionalism, and patient satisfaction). Data were double extracted by independent reviewers and checked through contacting all authors, 84 (49%) of 170 of whom confirmed their data. Random-effect models were used to calculate the pooled odds ratio, prediction intervals expressed the amount of heterogeneity, and meta-regressions assessed for potential moderators with significance set using a conservative level of P<0.10.

RESULTS

4732 articles were identified, of which 170 observational studies of 239 246 physicians were included in the meta-analysis. Overall burnout in physicians was associated with an almost four times decrease in job satisfaction compared with increased job satisfaction (odds ratio 3.79, 95% confidence interval 3.24 to 4.43, I²=97%, k=73 studies, n=146 980 physicians). Career choice regret increased by more than threefold compared with being satisfied with their career choice (3.49, 2.43 to 5.00, I²=97%, k=16, n=33 871). Turnover intention also increased by more than threefold compared with retention (3.10, 2.30 to 4.17, I²=97%, k=25, n=32 271). Productivity had a small but significant effect (1.82, 1.08 to 3.07, I²=83%, k=7, n=9581) and burnout also affected career development from a pooled association of two studies (3.77, 2.77 to 5.14, I²=0%, n=3411). Overall physician burnout doubled patient safety incidents compared with no patient safety incidents (2.04, 1.69 to 2.45, I²=87%, k=35, n=41 059). Low professionalism was twice as likely compared with maintained professionalism (2.33, 1.96 to 2.70, I²=96%, k=40, n=32 321), as was patient dissatisfaction compared with patient satisfaction (2.22, 1.38 to 3.57, I²=75%, k=8, n=1002). Burnout and poorer job satisfaction was greatest in hospital settings (1.88, 0.91 to 3.86, P=0.09), physicians aged 31-50 years (2.41, 1.02 to 5.64, P=0.04), and working in emergency medicine and intensive care (2.16, 0.98 to 4.76, P=0.06); burnout was lowest in general practitioners (0.16, 0.03 to 0.88, P=0.04). However, these associations did not remain significant in the multivariable regressions. Burnout and patient safety incidents were greatest in physicians aged 20-30 years (1.88, 1.07 to 3.29, P=0.03), and people working in emergency medicine (2.10, 1.09 to 3.56, P=0.02). The association of burnout with low professionalism was smallest in physicians older than 50 years (0.36, 0.19 to 0.69, P=0.003) and greatest in physicians still in training or residency (2.27, 1.45 to 3.60, P=0.001), in those who worked in a hospital (2.16, 1.46 to 3.19, P<0.001), specifically in emergency medicine specialty (1.48, 1.01 to 2.34, P=0.042), or situated in a low to middle income country (1.68, 0.94 to 2.97, P=0.08).

CONCLUSIONS

This meta-analysis provides compelling evidence that physician burnout is associated with poor function and sustainability of healthcare organisations primarily by contributing to the career disengagement and turnover of physicians and secondarily by reducing the quality of patient care. Healthcare organisations should invest more time and effort in implementing evidence-based strategies to mitigate physician burnout across specialties, and particularly in emergency medicine and for physicians in training or residency.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO number CRD42021249492.

Association Between Patient Factors and the Effectiveness of Wearable Trackers at Increasing the Number of Steps per Day Among Adults With Cardiometabolic Conditions: Meta-analysis of Individual Patient Data From Randomized Controlled Trials

BACKGROUND

Current evidence supports the use of wearable trackers by people with cardiometabolic conditions. However, as the health benefits are small and confounded by heterogeneity, there remains uncertainty as to which patient groups are most helped by wearable trackers.

OBJECTIVE

This study examined the effects of wearable trackers in patients with cardiometabolic conditions to identify subgroups of patients who most benefited and to understand interventional differences.

METHODS

We obtained individual participant data from randomized controlled trials of wearable trackers that were conducted before December 2020 and measured steps per day as the primary outcome in participants with cardiometabolic conditions including diabetes, overweight or obesity, and cardiovascular disease. We used statistical models to account for clustering of participants within trials and heterogeneity across trials to estimate mean differences with the 95% CI.

RESULTS

Individual participant data were obtained from 9 of 25 eligible randomized controlled trials, which included 1481 of 3178 (47%) total participants. The wearable trackers revealed that over the median duration of 12 weeks, steps per day increased by 1656 (95% CI 918-2395), a significant change. Greater increases in steps per day from interventions using wearable trackers were observed in men (interaction coefficient -668, 95% CI -1157 to -180), patients in age categories over 50 years (50-59 years: interaction coefficient 1175, 95% CI 377-1973; 60-69 years: interaction coefficient 981, 95% CI 222-1740; 70-90 years: interaction coefficient 1060, 95% CI 200-1920), White patients (interaction coefficient 995, 95% CI 360-1631), and patients with fewer comorbidities (interaction coefficient -517, 95% CI -1188 to -11) compared to women, those aged below 50, non-White patients, and patients with multimorbidity. In terms of interventional differences, only face-to-face delivery of the tracker impacted the effectiveness of the interventions by increasing steps per day.

CONCLUSIONS

In patients with cardiometabolic conditions, interventions using wearable trackers to improve steps per day mostly benefited older White men without multimorbidity.

TRIAL REGISTRATION

PROSPERO CRD42019143012; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=143012.

Effectiveness of cognitive-behavioural therapies of varying complexity in reducing depression in adults: systematic review and network meta-analysis

BACKGROUND

Cognitive-behavioural therapy (CBT) is frequently used as an umbrella term to include a variety of psychological interventions. It remains unclear whether more complex CBT contributes to greater depression reduction.

AIMS

To (a) compare the effectiveness of core, complex and ultra-complex CBT against other psychological intervention, medication, treatment-as-usual and no treatment in reducing depression at post-treatment and in the long term and (b) explore important factors that could moderate the effectiveness of these interventions.

METHOD

MEDLINE, PsycInfo, Embase, Web of Science and the Cochrane Register of Controlled Trials were searched to November 2021. Only randomised controlled trials were eligible for the subsequent network meta-analysis.

RESULTS

We included 107 studies based on 15 248 participants. Core (s.m.d. = -1.14, 95% credible interval (CrI) -1.72 to -0.55 [m.d. = -8.44]), complex (s.m.d. = -1.24, 95% CrI -1.85 to -0.64 [m.d. = -9.18]) and ultra-complex CBT (s.m.d. = -1.45, 95% CrI -1.88 to -1.02 [m.d. = -10.73]) were all significant in reducing depression up to 6 months from treatment onset. The significant benefits of the ultra-complex (s.m.d. = -1.09, 95% CrI -1.61 to -0.56 [m.d. = -8.07]) and complex CBT (s.m.d. = -0.73, 95% CrI -1.36 to -0.11 [m.d. = -5.40]) extended beyond 6 months. Ultra-complex CBT was most effective in individuals presenting comorbid mental health problems and when delivered by non-mental health specialists. Ultra-complex and complex CBT were more effective for people younger than 59 years.

CONCLUSIONS

For people without comorbid conditions healthcare and policy organisations should invest in core CBT. For people <59 years of age with comorbid conditions investments should focus on ultra-complex and complex CBT delivered without the help of mental health professionals.

Youth Culturally adapted Manual Assisted Problem Solving Training (YCMAP) in Pakistani adolescent with a history of self-harm: protocol for multicentre clinical and cost-effectiveness randomised controlled trial

INTRODUCTION

Suicide is a global health concern. Sociocultural factors have an impact on self-harm and suicide rates. In Pakistan, both self-harm and suicide are considered as criminal offence's and are condemned on both religious and social grounds. The proposed intervention 'Youth Culturally Adapted Manual Assisted Problem Solving Training (YCMAP)' is based on principles of problem-solving and cognitive-behavioural therapy. YCMAP is a brief, culturally relevant, scalable intervention that can be implemented in routine clinical practice if found to be effective.

METHOD AND ANALYSIS

A multicentre rater blind randomised controlled trial to evaluate the clinical and cost-effectiveness of YCMAP including a sample of 652 participants, aged 12-18 years, presenting to general physicians/clinicians, emergency room after self harm or self referrals. We will test the effectiveness of 8-10 individual sessions of YCMAP delivered over 3 months compared with treatment as usual. Primary outcome measure is repetition of self-harm at 12 months. The seconday outcomes include reduction in suicidal ideation, hopelessness and distress and improvement in health related quality of life. Assessments will be completed at baseline, 3, 6, 9 and 12 months postrandomisation. The nested qualitative component will explore perceptions about management of self-harm and suicide prevention among adolescents and investigate participants' experiences with YCMAP. The study will be guided by the theory of change approach to ensure that the whole trial is centred around needs of the end beneficiaries as key stakeholders in the process.

ETHICS AND DISSEMINATION

Ethics approval has been obtained from the Ethics Committee of University of Manchester, the National Bioethics Committee in Pakistan. The findings of this study will be disseminated through community workshops, social media, conference presentations and peer-reviewed journals.

TRIAL REGISTRATION NUMBER

NCT04131179.

Transitional Care Interventions for Older Residents of Long-term Care Facilities: A Systematic Review and Meta-analysis

IMPORTANCE

Residents of long-term care facilities (LTCFs) experience high hospitalization rates, yet little is known about the effects of transitional care interventions for these residents.

OBJECTIVE

To assess the association of transitional care interventions with readmission rates and other outcomes for residents of LTCFs who are 65 years and older and LTCF staff and to explore factors that potentially mitigate the association.

DATA SOURCES

MEDLINE, EMBASE, PsycINFO, Cochrane Central Register of Controlled Trials, and Cumulative Index to Nursing and Allied Health Literature were searched for English-language studies published until July 21, 2021. Associated qualitative studies were identified using aspects of the CLUSTER (citations, lead authors, unpublished materials, searched Google Scholar, tracked theories, ancestry search for early examples, and follow-up of related projects) methodology.

STUDY SELECTION

Controlled design studies evaluating transitional care interventions for residents of LTCFs 65 years and older were included. Records were independently screened by 2 reviewers; disagreements were resolved through discussion and involvement of a third reviewer. From 14 538 records identified, 15 quantitative and 4 qualitative studies met the eligibility criteria.

DATA EXTRACTION AND SYNTHESIS

The study followed the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines. Data were extracted by one reviewer and checked by a second reviewer. Fixed-effect and random-effects models were used according to the number of studies reporting the outcomes of interest.

MAIN OUTCOMES AND MEASURES

The primary outcome consisted of 30-, 60-, and 90-day readmission rates (hospital and emergency department [ED]). Other outcomes included length of stay, functional independence (Barthel score), and quality of life. The I2 statistic was used to quantify heterogeneity.

RESULTS

Of 14 538 records identified from searches, 15 quantitative studies (totaling 32 722 participants or records) and 4 qualitative studies were included. People allocated to transitional care interventions were 1.7 times less likely to be readmitted to the hospital or ED compared with those in control groups (14 studies; odds ratio, 1.66 [95% CI, 1.18-2.35]; I2 = 81% [95% CI, 70%-88%]). Length of stay in the ED was significantly decreased for intervention groups (3 studies; standardized mean difference, -3.00 [95% CI, -3.61 to -2.39]; I2 = 99% [95% CI, 98%-99%]). There were no significant differences for other outcomes. Factors associated with outcomes included communication and referral processes between health care professionals.

CONCLUSIONS AND RELEVANCE

Emerging evidence suggests that transitional care interventions are associated with lower readmissions for residents of LTCFs 65 years and older. Despite this and with aging populations, investment in such interventions has been remarkably low across most countries.

Comparative effectiveness of statins on non-high density lipoprotein cholesterol in people with diabetes and at risk of cardiovascular disease: systematic review and network meta-analysis

OBJECTIVE

To compare the efficacy of different statin treatments by intensity on levels of non-high density lipoprotein cholesterol (non-HDL-C) for the prevention of cardiovascular disease in people with diabetes.

DESIGN

Systematic review and network meta-analysis.

DATA SOURCES

Medline, Cochrane Central Register of Controlled Trials, and Embase from inception to 1 December 2021.

REVIEW METHODS

Randomised controlled trials comparing different types and intensities of statins, including placebo, in adults with type 1 or type 2 diabetes mellitus were included. The primary outcome was changes in levels of non-HDL-C, calculated from measures of total cholesterol and HDL-C. Secondary outcomes were changes in levels of low density lipoprotein cholesterol (LDL-C) and total cholesterol, three point major cardiovascular events (non-fatal stroke, non-fatal myocardial infarction, and death related to cardiovascular disease), and discontinuations because of adverse events. A bayesian network meta-analysis of statin intensity (low, moderate, or high) with random effects evaluated the treatment effect on non-HDL-C by mean differences and 95% credible intervals. Subgroup analysis of patients at greater risk of major cardiovascular events was compared with patients at low or moderate risk. The confidence in network meta-analysis (CINeMA) framework was applied to determine the certainty of evidence.

RESULTS

In 42 randomised controlled trials involving 20 193 adults, 11 698 were included in the meta-analysis. Compared with placebo, the greatest reductions in levels of non-HDL-C were seen with rosuvastatin at high (-2.31 mmol/L, 95% credible interval -3.39 to -1.21) and moderate (-2.27, -3.00 to -1.49) intensities, and simvastatin (-2.26, -2.99 to -1.51) and atorvastatin (-2.20, -2.69 to -1.70) at high intensity. Atorvastatin and simvastatin at any intensity and pravastatin at low intensity were also effective in reducing levels of non-HDL-C. In 4670 patients at greater risk of a major cardiovascular events, atorvastatin at high intensity showed the largest reduction in levels of non-HDL-C (-1.98, -4.16 to 0.26, surface under the cumulative ranking curve 64%). Simvastatin (-1.93, -2.63 to -1.21) and rosuvastatin (-1.76, -2.37 to -1.15) at high intensity were the most effective treatment options for reducing LDL-C. Significant reductions in non-fatal myocardial infarction were found for atorvastatin at moderate intensity compared with placebo (relative risk=0.57, confidence interval 0.43 to 0.76, n=4 studies). No significant differences were found for discontinuations, non-fatal stroke, and cardiovascular deaths.

CONCLUSIONS

This network meta-analysis indicated that rosuvastatin, at moderate and high intensity doses, and simvastatin and atorvastatin, at high intensity doses, were most effective at moderately reducing levels of non-HDL-C in patients with diabetes. Given the potential improvement in accuracy in predicting cardiovascular disease when reduction in levels of non-HDL-C is used as the primary target, these findings provide guidance on which statin types and intensities are most effective by reducing non-HDL-C in patients with diabetes.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42021258819.

Medication-related interventions to improve medication safety and patient outcomes on transition from adult intensive care settings: a systematic review and meta-analysis

Background

Patients recovering from an episode in an intensive care unit (ICU) frequently experience medication errors on transition to the hospital ward. Structured handover recommendations often underestimate the challenges and complexity of ICU patient transitions. For adult ICU patients transitioning to a hospital ward, it is currently unclear what interventions reduce the risks of medication errors.

The aims were to examine the impact of medication-related interventions on medication and patient outcomes on transition from adult ICU settings and identify barriers and facilitators to implementation.

Methods

The systematic review protocol was preregistered on PROSPERO. Six electronic databases were searched until October 2020 for controlled and uncontrolled study designs that reported medication-related (ie, de-prescribing; medication errors) or patient-related outcomes (ie, mortality; length of stay). Risk of bias (RoB) assessment used V.2.0 and ROBINS-I Cochrane tools. Where feasible, random-effects meta-analysis was used for pooling the OR across studies. The quality of evidence was assessed by Grading of Recommendations, Assessment, Development and Evaluations.

Results

Seventeen studies were eligible, 15 (88%) were uncontrolled before-after studies. The intervention components included education of staff (n=8 studies), medication review (n=7), guidelines (n=6), electronic transfer/handover tool or letter (n=4) and medicines reconciliation (n=4). Overall, pooled analysis of all interventions reduced risk of inappropriate medication continuation at ICU discharge (OR=0.45 (95% CI 0.31 to 0.63), I2=55%, n=9) and hospital discharge (OR=0.39 (95% CI 0.2 to 0.76), I2=75%, n=9). Multicomponent interventions, based on education of staff and guidelines, demonstrated no significant difference in inappropriate medication continuation at the ICU discharge point (OR 0.5 (95% CI 0.22 to 1.11), I2=62%, n=4), but were very effective in increasing de-prescribing outcomes on hospital discharge (OR 0.26 (95% CI 0.13 to 0.55), I2=67%, n=6)). Facilitators to intervention delivery included ICU clinical pharmacist availability and participation in multiprofessional ward rounds, while barriers included increased workload associated with the discharge intervention process.

Conclusions

Multicomponent interventions based on education of staff and guidelines were effective at achieving almost four times more de-prescribing of inappropriate medication by the time of patient hospital discharge. Based on the findings, practice and policy recommendations are made and guidance is provided on the need for, and design of theory informed interventions in this area, including the requirement for process and economic evaluations.

Cross-sectional study exploring the association between stressors and burnout in junior doctors during the COVID-19 pandemic in the United Kingdom

OBJECTIVES

This study aims to develop a comprehensive list of stressors relevant to junior doctors and will also report findings exploring the associations between burnout and stressors, which include work and non-work-related stressors as well as pandemic-related stressors.

METHODS

An anonymous online questionnaire was sent to 1000 randomly selected junior doctors in the North-West of England. The questionnaire included 37 questions on general and pandemic-specific stressors, and the Maslach Burnout Inventory Health Services Survey. The main outcomes of interest were junior doctor ratings of stressors and scores for burnout (emotional exhaustion [EE], depersonalisation [DP], and personal accomplishment [PA]). Stepwise regression analysis was undertaken to assess associations between stressors and burnout.

RESULTS

In total, 326 responses were collected (response rate = 33%). Of the top 10 stressors rated by junior doctors, 60% were related to the pandemic. Multiple stressors were found to be associated with the burnout dimensions. Fatigue (β = .43), pandemic-related workload increase (β = .33), and feeling isolated (β = .24) had the strongest associations with EE, whereas fatigue (β = .21), uncertainty around COVID-19 information (β = .22) and doing unproductive tasks (β = .17) had the strongest associations with DP. Working beyond normal scope due to COVID-19 (β = -.26), not confident in own ability (β = -.24) and not feeling valued (β = -.20) were found to have the strongest associations with PA.

CONCLUSIONS

Junior doctors experience a combination of general stressors and additional stressors emerging from the pandemic which significantly impact burnout. Monitoring these stressors and targeting them as part of interventions could help mitigating burnout in junior doctors.

Investigating the links between diagnostic uncertainty, emotional exhaustion, and turnover intention in General Practitioners working in the United Kingdom

BACKGROUND

General Practitioners (GPs) report high levels of burnout, job dissatisfaction, and turnover intention. The complexity of presenting problems to general practice makes diagnostic uncertainty a common occurrence that has been linked to burnout. The interrelationship between diagnostic uncertainty with other factors such as burnout, job satisfaction and turnover intention have not been previously examined.

OBJECTIVES

To examine associations between diagnostic uncertainty, emotional exhaustion (EE), depersonalization (DP), job satisfaction, and turnover intention in GPs.

METHODS

Seventy general practices in England were randomly selected through the Oxford-Royal College of General Practitioners Research and Surveillance Centre (RCGP-RSC). A total of 348 GPs within 67 these practices completed a 10-item online questionnaire which included questions on GP characteristics, work-life balance, job satisfaction, sickness presenteeism, diagnostic uncertainty, turnover intention as well as EE and DP. Associations between diagnostic uncertainty and each of EE, DP, job satisfaction, and turnover intention were evaluated in multivariate mixed-effect ordinal logistic regressions whilst adjusting for covariates, to account for the correlation in the three outcomes of interest.

RESULTS

Almost one-third of GPs (n = 101; 29%) reported experiencing >10% of diagnostic uncertainty in their day-to-day practice over the past year. GPs reporting greater diagnostic uncertainty had higher levels of EE [OR = 3.90; 95% CI = (2.54, 5.99)], job dissatisfaction [OR = 2.01; 95% CI = (1.30, 3.13)] and turnover intention [OR = 4.51; 95% CI = (2.86, 7.11)]. GPs with no sickness presenteeism had lower levels of EE [OR = 0.53; 95% CI = (0.35, 0.82)], job dissatisfaction [OR = 0.56; 95% CI = (0.35, 0.88)], and turnover intention [OR = 0.61; 95% CI = (0.41, 0.91)].

CONCLUSION

Diagnostic uncertainty may not only negatively impact on the wellbeing of GPs, but could also have adverse implications on workforce retention in primary care.

Consultation patterns and frequent attenders in UK primary care from 2000 to 2019: a retrospective cohort analysis of consultation events across 845 general practices

OBJECTIVE

To describe the distribution of consultations at the practice level and examine whether increases are uniform or driven by people who consult more frequently.

DESIGN

Retrospective cohort study.

SETTING

UK general practice data from the Clinical Practice Research Datalink (CPRD) GOLD database.

PARTICIPANTS

1 699 709 314 consultation events from 12 330 545 patients, in 845 general practices (1 April 2000 to 31 March 2019).

METHODS

Consultation information was aggregated by financial year into: all consultations/all staff; all consultations/general practitioners (GPs); face-to-face consultations/all staff; face-to-face consultations/GPs. Patients with a number of consultations above the 90th centile, within each year, were classified as frequent attenders. Negative binomial regressions examined the association between available practice characteristics and consultation distribution.

RESULTS

Among frequent attenders, all consultations by GPs increased from a median (25th and 75th centile) of 13 (10 and 16) to 21 (18 and 25) and all consultations by all staff increased from 27 (23-30) to 60 (51-69) over the study period. Approximately four out of ten consultations of any type concerned frequent attenders and the proportion of consultations attributed to them increased over time, particularly for face-to-face consultations with GPs, from a median of 38.0% (35.9%-40.3%) in 2000-2001 to 43.0% (40.6%-46.4%) in 2018-2019. Regression analyses indicated decreasing trends over time for face-to-face consultations and increasing trends for all consultation types, for both GPs and all staff. Frequent attenders consulted approximately five times more than the rest of the practice population, on average, with adjusted incidence rate ratios ranging between 4.992 (95% CI 4.917 to 5.068) for face-to-face consultations with all staff and 5.603 (95% CI 5.560 to 5.647) for all consultations with GPs.

CONCLUSIONS

Frequent attenders progressively contributed to increased workload in general practices across the UK from 2000 to 2019. Important knowledge gaps remain in terms of the demographic, social and health characteristics of frequent attenders and how UK general practices can be prepared to meet the needs of these patients.

Prevalence of depression and anxiety in patients with chronic obstructive pulmonary disease and their association with psychosocial outcomes: A cross-sectional study from Pakistan

Objectives:

Chronic obstructive pulmonary disease contributes to substantial health and economic burden worldwide. Co-morbid depression and anxiety are highly prevalent in patients with chronic obstructive pulmonary disease. Depressive symptoms in chronic obstructive pulmonary disease are associated with poorer survival, longer hospitalisation and impaired quality of life. Literature on chronic obstructive pulmonary disease is largely derived from high-income countries; yet 90% of deaths related to chronic obstructive pulmonary disease occur in low- and middle-income countries. We aimed to establish the prevalence of anxiety and depression in patients with chronic obstructive pulmonary disease, as well as the association with psychosocial outcomes.

Methods:

This was a cross-sectional study of chronic obstructive pulmonary disease patients attending outpatient primary care clinics in Karachi, Pakistan. The Patient Health Questionnaire-9 was used to assess depression and the Generalised Anxiety Disorder-7 scale was used for the assessment of anxiety. Health-related quality of life was assessed with EuroQol–Five Dimensions, social support with Oslo-3 and social stress with Life Events Checklist. We recruited 293 subjects.

Results:

The prevalence of depression and anxiety in the sample was 51% (n = 149) and 20% (n = 59), respectively. Depressed chronic obstructive pulmonary disease patients reported significantly lower health-related quality of life scores as compared to non-depressed patients. Participants with depression had significantly higher levels of anxiety, less social support, higher social stress and more subjective impairment in quality of life.

Conclusion:

Given the association with reduced social support and increased perceived stress, the role of psychosocial interventions must be explored in improving outcomes of chronic obstructive pulmonary disease patients in Pakistan.

Visual impairment and medication safety: a protocol for a scoping review

BACKGROUND

The number of individuals with a visual impairment in the UK was estimated a few years ago to be around 1.8 million. People can be visually impaired from birth, childhood, early adulthood or later in life. Those with visual impairment are subject to health inequities and increased risk for patient safety incidents in comparison to the general population. They are also known to be at an increased risk of experiencing medication errors compared to those without visual impairment. In view of this, this review aims to understand the issues of medication safety for VI people.

METHODS/DESIGN

Four electronic bibliographic databases will be searched: MEDLINE, Embase, PsycInfo and CINAHL. Our search strategy will include search combinations of two key blocks of terms. Studies will not be excluded based on design. Included studies will be empirical studies. They will include studies that relate to both medication safety and visual impairment. Two reviewers (SG and LR) will screen all the titles and abstracts. SG, LR, RM, SCS and PL will perform study selection and data extraction using standard forms. Disagreements will be resolved through discussion or third party adjudication. Data to be collected will include study characteristics (year, objective, research method, setting, country), participant characteristics (number, age, gender, diagnoses), medication safety incident type and characteristics.

DISCUSSION

The review will summarise the literature relating to medication safety and visual impairment.

Effects of the first COVID-19 lockdown on quality and safety in mental healthcare transitions in England

BACKGROUND

The COVID-19 pandemic forced the rapid implementation of changes to practice in mental health services, in particular transitions of care. Care transitions pose a particular threat to patient safety.

AIMS

This study aimed to understand the perspectives of different stakeholders about the impact of temporary changes in practice and policy of mental health transitions as a result of coronavirus disease 2019 (COVID-19) on perceived healthcare quality and safety.

METHOD

Thirty-four participants were interviewed about quality and safety in mental health transitions during May and June 2020 (the end of the first UK national lockdown). Semi-structured remote interviews were conducted to generate in-depth information pertaining to various stakeholders (patients, carers, healthcare professionals and key informants). Results were analysed thematically.

RESULTS

The qualitative data highlighted six overarching themes in relation to practice changes: (a) technology-enabled communication; (b) discharge planning and readiness; (c) community support and follow-up; (d) admissions; (e) adapting to new policy and guidelines; (f) health worker safety and well-being. The COVID-19 pandemic exacerbated some quality and safety concerns such as tensions between teams, reduced support in the community and increased threshold for admissions. Also, several improvement interventions previously recommended in the literature, were implemented locally.

DISCUSSION

The practice of mental health transitions has transformed during the COVID-19 pandemic, affecting quality and safety. National policies concerning mental health transitions should concentrate on converting the mostly local and temporary positive changes into sustainable service quality improvements and applying systematic corrective policies to prevent exacerbations of previous quality and safety concerns.

Benefits and harms of Risperidone and Paliperidone for treatment of patients with schizophrenia or bipolar disorder: a meta-analysis involving individual participant data and clinical study reports

BACKGROUND

Schizophrenia and bipolar disorder are severe mental illnesses which are highly prevalent worldwide. Risperidone and Paliperidone are treatments for either illnesses, but their efficacy compared to other antipsychotics and growing reports of hormonal imbalances continue to raise concerns. As existing evidence on both antipsychotics are solely based on aggregate data, we aimed to assess the benefits and harms of Risperidone and Paliperidone in the treatment of patients with schizophrenia or bipolar disorder, using individual participant data (IPD), clinical study reports (CSRs) and publicly available sources (journal publications and trial registries).

METHODS

We searched MEDLINE, Central, EMBASE and PsycINFO until December 2020 for randomised placebo-controlled trials of Risperidone, Paliperidone or Paliperidone palmitate in patients with schizophrenia or bipolar disorder. We obtained IPD and CSRs from the Yale University Open Data Access project. The primary outcome Positive and Negative Syndrome Scale (PANSS) score was analysed using one-stage IPD meta-analysis. Random-effect meta-analysis of harm outcomes involved methods for coping with rare events. Effect-sizes were compared across all available data sources using the ratio of means or relative risk. We registered our review on PROSPERO, CRD42019140556.

RESULTS

Of the 35 studies, IPD meta-analysis involving 22 (63%) studies showed a significant clinical reduction in the PANSS in patients receiving Risperidone (mean difference - 5.83, 95% CI - 10.79 to - 0.87, I2 = 8.5%, n = 4 studies, 1131 participants), Paliperidone (- 6.01, 95% CI - 8.7 to - 3.32, I2 = 4.3%, n = 13, 3821) and Paliperidone palmitate (- 7.89, 95% CI - 12.1 to - 3.69, I2 = 2.9%, n = 5, 2209). CSRs reported nearly two times more adverse events (4434 vs. 2296 publication, relative difference (RD) = 1.93, 95% CI 1.86 to 2.00) and almost 8 times more serious adverse events (650 vs. 82; RD = 7.93, 95% CI 6.32 to 9.95) than the journal publications. Meta-analyses of individual harms from CSRs revealed a significant increased risk among several outcomes including extrapyramidal disorder, tardive dyskinesia and increased weight. But the ratio of relative risk between the different data sources was not significant. Three treatment-related gynecomastia events occurred, and these were considered mild to moderate in severity.

CONCLUSION

IPD meta-analysis conclude that Risperidone and Paliperidone antipsychotics had a small beneficial effect on reducing PANSS score over 9 weeks, which is more conservative than estimates from reviews based on journal publications. CSRs also contained significantly more data on harms that were unavailable in journal publications or trial registries. Sharing of IPD and CSRs are necessary when performing meta-analysis on the efficacy and safety of antipsychotics.

Beyond the control of the care home: A meta-ethnography of qualitative studies of Infection Prevention and Control in residential and nursing homes for older people

Objective

This study aimed to develop interpretive insights concerning Infection Prevention and Control (IPC) in care homes for older people.

Design

This study had a meta‐ethnography design.

Data Sources

Six bibliographic databases were searched from inception to May 2020 to identify the relevant literature.

Review Methods

A meta‐ethnography was performed.

Results

Searches yielded 652 records; 15 were included. Findings were categorized into groups: The difficulties of enacting IPC measures in the care home environment; workload as an impediment to IPC practice; the tension between IPC and quality of life for care home residents; and problems dealing with medical services located outside the facility including diagnostics, general practice and pharmacy. Infection was revealed as something seen to lie ‘outside’ the control of the care home, whether according to origins or control measures. This could help explain the reported variability in IPC practice. Facilitators to IPC uptake involved repetitive training and professional development, although such opportunities can be constrained by the ways in which services are organized and delivered.

Conclusions

Significant challenges were revealed in implementing IPC in care homes including staffing skills, education, workloads and work routines. These challenges cannot be properly addressed without resolving the tension between the objectives of maintaining resident quality of life while enacting IPC practice. Repetitive staff training and professional development with parallel organisational improvements have prospects to enhance IPC uptake in residential and nursing homes.

Patient or Public Contribution

A carer of an older person joined study team meetings and was involved in writing a lay summary of the study findings.

Effectiveness of collaborative care in reducing suicidal ideation: An individual participant data meta-analysis

To assess whether CC is more effective at reducing suicidal ideation in people with depression compared with usual care, and whether study and patient factors moderate treatment effects.

METHOD

We searched Medline, Embase, PubMed, PsycINFO, CINAHL, CENTRAL from inception to March 2020 for Randomised Controlled Trials (RCTs) that compared the effectiveness of CC with usual care in depressed adults, and reported changes in suicidal ideation at 4 to 6 months post-randomisation. Mixed-effects models accounted for clustering of participants within trials and heterogeneity across trials. This study is registered with PROSPERO, CRD42020201747.

RESULTS

We extracted data from 28 RCTs (11,165 patients) of 83 eligible studies. We observed a small significant clinical improvement of CC on suicidal ideation, compared with usual care (SMD, -0.11 [95%CI, -0.15 to -0.08]; I², 0·47% [95%CI 0.04% to 4.90%]). CC interventions with a recognised psychological treatment were associated with small reductions in suicidal ideation (SMD, -0.15 [95%CI -0.19 to -0.11]). CC was more effective for reducing suicidal ideation among patients aged over 65 years (SMD, - 0.18 [95%CI -0.25 to -0.11]).

CONCLUSION

Primary care based CC with an embedded psychological intervention is the most effective CC framework for reducing suicidal ideation and older patients may benefit the most.

Interventions Using Wearable Physical Activity Trackers Among Adults With Cardiometabolic Conditions: A Systematic Review and Meta-analysis

IMPORTANCE

Wearable physical activity (PA) trackers, such as accelerometers, fitness trackers, and pedometers, are accessible technologies that may encourage increased PA levels in line with current recommendations. However, whether their use is associated with improvements in PA levels in participants who experience 1 or more cardiometabolic conditions, such as diabetes, prediabetes, obesity, and cardiovascular disease, is unknown.

OBJECTIVE

To assess the association of interventions using wearable PA trackers (accelerometers, fitness trackers, and pedometers) with PA levels and other health outcomes in adults with cardiometabolic conditions.

DATA SOURCES

For this systematic review and meta-analysis, searches of MEDLINE, Embase, Cochrane Central Register of Controlled Trials, and PsycINFO were performed from January 1, 2000, until December 31, 2020, with no language restriction. A combination of Medical Subject Heading terms and text words of diabetes, obesity, cardiovascular disease, pedometers, accelerometers, and Fitbits were used.

STUDY SELECTION

Randomized clinical trials or cluster randomized clinical trials that evaluated the use of wearable PA trackers, such as pedometers, accelerometers, or fitness trackers, were included. Trials were excluded if they assessed the trackers only as measuring tools of PA before and after another intervention, they required participants to be hospitalized, assessors were not blinded to the trackers, or they used a tracker to measure the effect of a pharmacological treatment on PA among individuals.

DATA EXTRACTION AND SYNTHESIS

The study followed the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) reporting guideline. A random-effects model was used for the meta-analysis.

MAIN OUTCOMES AND MEASURES

The primary outcome was mean difference in PA levels. When the scale was different across studies, standardized mean differences were calculated. Heterogeneity was quantified using the I2 statistic and explored using mixed-effects metaregression.

RESULTS

A total of 38 randomized clinical trials with 4203 participants were eligible in the systematic review; 29 trials evaluated pedometers, and 9 evaluated accelerometers or fitness trackers. Four studies did not provide amenable outcome data, leaving 34 trials (3793 participants) for the meta-analysis. Intervention vs comparator analysis showed a significant association of wearable tracker use with increased PA levels overall (standardized mean difference, 0.72; 95% CI, 0.46-0.97; I2 = 88%; 95% CI, 84.3%-90.8%; P < .001) in studies with short to medium follow-up for median of 15 (range, 12-52) weeks. Multivariable metaregression showed an association between increased PA levels and interventions that involved face-to-face consultations with facilitators (23 studies; β = -0.04; 95% CI, -0.11 to -0.01), included men (23 studies; β = 0.48; 95% CI, 0.01-0.96), and assessed pedometer-based interventions (26 studies; β = 0.20; 95% CI, 0.02-0.32).

CONCLUSIONS AND RELEVANCE

In this systematic review and meta-analysis, interventions that combined wearable activity trackers with health professional consultations were associated with significant improvements in PA levels among people with cardiometabolic conditions.

What does safety in mental healthcare transitions mean for service users and other stakeholder groups: An open-ended questionnaire study

BACKGROUND

Historically, safety mental health research has tended to focus on risks of homicide, suicide and deaths. Although wider safety issues are now recognized in regards to mental health services, the safety of mental health transitions, a key research and policy priority according to World Health Organisation, has not been explored.

OBJECTIVE

The purpose of this study was to investigate perceptions of safety in mental health transitions (hospital to community) amongst five stakeholder groups.

DESIGN AND SETTING

An online, international cross-sectional, open-ended questionnaire.

PARTICIPANTS

There were five stakeholder participant groups: service users; families/carers; mental health-care professionals; researchers; and end users of research.

RESULTS

Ninety-three participants from 12 different countries responded. Three overarching themes emerged: 'individual/clinical', 'systems/services' and 'human, behavioural and social' elements of safe mental health transitions. Whilst there was a great focus on clinical elements from researchers and healthcare professionals, service users and carers considered safety in terms of human, behavioural and social elements of transitional safety (ie loneliness, emotional readiness for discharge) and systems/services (ie inter-professional communication).

DISCUSSION

Safety in mental health-care transitions is perceived differently by service users and families compared to healthcare professionals and researchers. Traditional safety indicators for care transitions such as suicide, self-harm and risk of adverse drug events are raised as important. However, service users and families in particular have a much wider perception of transitions safety.

CONCLUSION

Future quality and safety research and policy should consider including a service user voice and consider integration of psychosocial elements in discharge interventions.

Enhancing the multi-dimensional assessment of quality of life: introducing the WHOQOL-Combi

INTRODUCTION

We revisited the global concept of subjective quality of life (QoL) as assessed by the WHOQOL-BREF to investigate whether it could be elaborated into a conceptually more comprehensive instrument with good psychometric properties. Responding to a growing need for shorter QoL measures with broader social, spiritual and environmental contents, facets from WHOQOL international modules were examined for potential integration into the new WHOQOL-Combi.

METHOD

Adults over 65 years, diagnosed with one or more chronic diseases (n = 2833), completed 41 WHOQOL items during the CLASSIC survey; each item represented a WHOQOL facet. This pool of specific QoL facets contained 24 from the WHOQOL-BREF (excluding general items), and 17 from recent international WHOQOL short-form modules, selected for their generic properties. Rasch modelling reduced the final item pool when assessing the WHOQOL-Combi's conceptual structure. Comparisons are made with the WHOQOL-BREF.

RESULTS

Modelling confirmed the tenability of a 36-item solution scored as a five-domain profile, comprised of 24 WHOQOL-BREF facets and 12 new facets from modules. Social and psychological domains were strengthened by three facets, spiritual QoL by five, and physical QoL by one. The WHOQOL-Combi showed sound model fit, excellent internal consistency (α = .95), and scores discriminated between socio-demographic categories. Concurrent validity with the EQ-5D-5L was confirmed for physical and psychological domains. Performance was similar to the WHOQOL-BREF.

CONCLUSION

The WHOQOL-Combi offers a contemporary, comprehensive, integrated, multi-dimensional subjective QoL instrument with enhanced evaluations of social, spiritual, psychological and physical QoL. Acceptable to older people, future research should evaluate younger age groups and other cultures.

The importance of teamwork climate for preventing burnout in UK general practices

This short report aims to investigate the association between teamwork and burnout among general practitioners (GPs). A two-stage survey was conducted. In stage one, validated self-report measures of burnout and teamwork were completed by 50 GPs across 12 general practices in Greater Manchester, UK. In stage two, staff members across 3 of the 12 general practices (GPs, nursing staff, managers and admin staff) responded to free text questions about teamwork (n = 20). The results of the stage one survey showed that teamwork in GPs was significantly negatively associated with the emotional exhaustion (r = −0.326, P < 0.05) and depersonalization (r = −0.421, P < 0.01) domains of the burnout measure and significantly positively associated with the personal accomplishment (r = 0.296, P < 0.05) domain. Free text responses in stage two were assigned into three themes: (i) addressing organizational barriers which might threaten teamwork, (ii) promoting the view of teamwork as a shared responsibility among all staff members of the general practice and (iii) implementing improvement strategies which can be embedded in the busy environment of general practices. GPs and other staff members of general practices valued the importance of teamwork for boosting their morale and mitigating burnout. Future research should focus on designing and embedding brief teamwork improvement strategies in general practices.

Meta-ethnography in healthcare research: a guide to using a meta-ethnographic approach for literature synthesis

BACKGROUND

Qualitative synthesis approaches are increasingly used in healthcare research. One of the most commonly utilised approaches is meta-ethnography. This is a systematic approach which synthesises data from multiple studies to enable new insights into patients' and healthcare professionals' experiences and perspectives. Meta-ethnographies can provide important theoretical and conceptual contributions and generate evidence for healthcare practice and policy. However, there is currently a lack of clarity and guidance surrounding the data synthesis stages and process.

METHOD

This paper aimed to outline a step-by-step method for conducting a meta-ethnography with illustrative examples.

RESULTS

A practical step-by-step guide for conducting meta-ethnography based on the original seven steps as developed by Noblit & Hare (Meta-ethnography: Synthesizing qualitative studies.,1998) is presented. The stages include getting started, deciding what is relevant to the initial interest, reading the studies, determining how the studies are related, translating the studies into one another, synthesising the translations and expressing the synthesis. We have incorporated adaptations and developments from recent publications. Annotations based on a previous meta-ethnography are provided. These are particularly detailed for stages 4-6, as these are often described as being the most challenging to conduct, but with the most limited amount of guidance available.

CONCLUSION

Meta-ethnographic synthesis is an important and increasingly used tool in healthcare research, which can be used to inform policy and practice. The guide presented clarifies how the stages and processes involved in conducting a meta-synthesis can be operationalised.