The prevalence of burnout among pulmonologists or respiratory therapists pre- and post-COVID-19: a systematic review and meta-analysis

OBJECTIVES

The coronavirus disease-19 (COVID-19) increased the already heavy workload in the pulmonary and respiratory departments, which therefore possibly increased the prevalence of burnout among pulmonologists or respiratory therapists. We aimed to compare the differences in burnout among pulmonologists or respiratory therapists pre- and post-COVID-19 by doing a systematic review with meta-analysis.

METHODS

We searched pulmonologist, or pulmonary, or respiratory, and burnout up to 29 January 2023 in six databases. We included studies investigating pulmonologists or respiratory therapists and reporting the prevalence of burnout among them. The risk of bias was assessed by a tool for prevalence studies. The overall prevalence of burnout was pooled.

RESULTS

A total of 2859 records were identified and 16 studies were included in the final analysis. The included studies reported 3610 responding individuals and 2336 burnouts. The pooled prevalence of burnout was 61.7% (95% confidence interval (CI), 48.6-73.2%; I² = 96.3%). The pooled prevalence of burnout during COVID-19 was significantly higher than it was prior to the outbreak (68.4% vs. 41.6%, p = .01). The result of the meta-regression revealed that COVID-19 coverage was significantly associated with the prevalence of burnout (p = .04).

CONCLUSIONS

Burnout was widely prevalent among pulmonologists or respiratory therapists and increasingly perceived during COVID-19. Therefore, interventions were needed to reduce burnout in this specialty.KEY MESSASGESThe coronavirus disease-19 increased the already heavy workload in the pulmonary and respiratory departments.Burnout was widely prevalent among pulmonologists or respiratory therapists and increasingly perceived during COVID-19.

Pulmonologists' Perspectives on and Access to Palliative Care for Patients With Idiopathic Pulmonary Fibrosis in South Carolina

Background

Idiopathic pulmonary fibrosis (IPF) is a serious illness with an unpredictable disease course and survival rates comparable with some cancers. Patients with IPF suffer considerable symptom burden, declining quality of life, and high health care resource utilization. Patients and caregivers report many unmet needs, including a desire for more education regarding diagnosis and assistance with navigating disease trajectory. Compelling evidence suggests that palliative care (PC) provides an extra layer of support for patients with serious illness.

Research Question

The purpose of this survey was to gain perspectives regarding PC for patients with IPF by board-certified pulmonologists in South Carolina (SC).

Study Design and Methods

A 24-item survey was adapted (with permission) from the Pulmonary Fibrosis Foundation PC Survey instrument. Data were analyzed and results are presented.

Results

Pulmonologists (n = 32, 44%) completed the survey; 97% practice in urbanized settings. The majority agreed that PC and hospice do not provide the same service. There were varying views about comfort in discussing prognosis, disease trajectory, and addressing advance directives. Options for ambulatory and inpatient PC are limited and early PC referral does not occur. None reported initiating a PC referral at time of initial IPF diagnosis.

Interpretation

Pulmonologists in SC who participated in this survey are aware of the principles of PC in providing comprehensive care to patients with IPF and have limited options for PC referral. PC educational materials provided early in the diagnosis can help facilitate and guide end-of-life planning and discussions. Minimal resources exist for patients in underserved communities.

A 9-Year Investigation of Healthcare Industry Payments to Pulmonologists in the United States

Rationale: The healthcare industry sometimes makes payments to physicians for nonresearch and research purposes in the United States. Objectives: We aimed to evaluate the trends in nonresearch and research industry payments to pulmonologists since the inception of the Open Payments database in 2013. Methods: Using the Open Payments database between August 2013 and December 2021, this population-based observational cohort study examined nonresearch and research payments made by the healthcare industry to pulmonologists registered in the National Plan and Provider Enumeration System in the United States. We performed descriptive analyses on payment data and generalized estimating equations for payment trends. Results: Of 12,488 active pulmonologists, 11,074 (88.7%) accepted a total of 2,246,412 payments totaling $1,053,344,669. Total payments were $253,405,965 (24.1%) in nonresearch, $17,382,904 (1.7%) in direct research, and $782,555,800 (74.3%) in associated research payments between 2013 and 2021. Median per-physician payments (interquartile range) were $2,342 ($496 to $8,299) for nonresearch, $4,688 ($1,435 to $21,803) for direct research, and $95,927 ($20,300 to $344,995) for associated research payments. The top 1%, 5%, and 10% of pulmonologists accepted 37.3%, 71.9%, and 83.7% of the total nonresearch payments. The per-physician nonresearch payments increased by 2.9% (95% confidence interval [CI], 1.2 to 4.7; P = 0.001) annually between 2014 and 2019 and decreased by 50.2% (95% CI, -55.3 to -44.6; P < 0.001) in 2020, whereas there was no yearly change in research payments. Conclusions: Nearly 90% of pulmonologists received nonresearch and research payments from the healthcare industry in the United States. Nonresearch payments have been increasing since the inception of the Open Payments database.

Expert Opinion Guidance on the Detection of Early Connective Tissue Diseases in Interstitial Lung Disease

There is a significant variation in symptoms and clinical presentation of connective tissue disorders (CTD) associated with interstitial lung disease (ILD) (CTD-ILD). This presents difficulties in the diagnosis and treatment of CTD-ILD. Early detection and treatment of CTD-ILD using a multidisciplinary approach have been shown to enhance patient outcomes. This exercise aims to explore clinical components to develop a screening tool for pulmonologists for early detection of CTD in ILD and to provide a framework for a multidisciplinary approach in managing CTD-ILD. This in turn will lead to early treatment of CTD-ILD in collaboration with rheumatologists. A panel of 12 leading rheumatologists from the Middle East and North Africa (MENA) region met virtually to select the most relevant clinical findings to aid in identifying CTD-ILD. Twelve panellists opted to investigate seven of the most common inflammatory autoimmune disorders. The panel discussed how to improve the early detection of CTD-ILD. Clinical characteristics were categorized, and a nine-item questionnaire was created. A biphasic algorithm was developed to guide early referral to a rheumatologist based on the presence of one of nine clinical features of CTD (Phase 1) or the presence of CTD-specific antibodies (Phase 2). A brief questionnaire has been developed to serve as a simple and practical screening tool for CTD-ILD detection. Additional research is needed to validate and evaluate the tool in longitudinal cohorts.

Effect of COVID-19 Pandemic on Sleep Quality and Mental State of Frontline Pulmonologists

Introduction

This study aims to determine the sleep quality and its relationship with anxiety and depressive symptoms, working conditions and other factors among the frontline pulmonologists on active duty during the COVID-19 pandemic.

Method

An online survey was conducted among pulmonologists in Turkey. The survey link was e-mailed to the members of the professional societies of pulmonologists. The volunteers were asked to fill in questions about their sociodemographics, medical and psychiatric history, working and housing conditions, perceived levels of support during the pandemic, as well as the sleep habits before the pandemic. Also, questions investigating the severity/level of their worries were inquired and they were asked to fill in two scale forms (the Hospital Anxiety Depression Scale and Pittsburgh Sleep Quality Index-PSQI).

Results

The sample consisted of 179 pulmonologists who were divided into two groups according to PSQI as good sleepers (PSQI ≤5) and poor sleepers (PSQI >5). It was observed that 59.2% of the participants had poor sleep quality during the pandemic. Being anxious (p<0.0001, Odds ratio [OR]=0.139, 95% Confidence Interval [CI] [0.052-0.372]), working in intensive care unit (p=0.046, OR=2.363, 95% CI [1.015-5.497]), worry level about excessive increase of the number of patients above the capacity of the institution they worked in (p=0.018, OR=1.755, 95% CI [1.102-2.794]) and being dissatisfied with ones' sleep before the pandemic (p<0.016, OR=0.272, 95% CI [0.094-0.786]) were found to be the main factors that negatively affected the quality of sleep of pulmonologists during the pandemic.

Conclusion

More than half of the pulmonologists in our sample group had low sleep quality during the pandemic. For establishing a good sleep regime for clinicians, its crucial to consider certain interventions on the affecting factors.

Understanding physician's knowledge and perception of chronic cough in Switzerland

BACKGROUND

Cough is one of the most common health issues for which medical attention is sought. A chronic cough (CC) is understood as a cough that lasts longer than 8 weeks. CC encompasses two subsets referred to as refractory chronic cough (RCC) and unexplained chronic cough (UCC). This study aims to assess the current understanding and perceptions of a RCC and UCC, from a physician's perspective in Switzerland and how this understanding and practical work leads to the relevant diagnosis and treatment.

METHODS

In October 2020, 549 GPs and 338 pulmonologists in Switzerland, received an invite to participate in the online-based quantitative survey. Data collection was carried out through a 25-minute online survey. The questionnaire was based on structured questions, and conducted on a randomized sample of doctors (general practitioners -GPs and pulmonologists) in the German- and French-speaking part of Switzerland.

RESULTS

Overall, 33 pulmonologists and 52 GPs participated in the online survey. Only 39% of GPs, but 73% of pulmonologists, defined chronic cough as a cough lasting 8 weeks or longer. The majority of physicians (72%), especially pulmonologists (88%), perceived a clinical gap regarding the treatment of persistent cough. 74% of the sampled physicians agreed that persistent cough is a high burden of disease for patients. Based on the answers, the annual number of new patients with RCC and UCC in Switzerland is estimated at 9322 patients.

CONCLUSIONS

Results of this study have highlighted differences in the terminology used to describe CC (RCC and UCC), in the diagnostic tests used and, in the treatments used between GPs and pulmonologists. These findings suggest the need to align the current language regarding the disease to facilitate a standardized approach for diagnosis and treatment and towards improving patient care and reduce burden of disease for CC (RCC and UCC) patients.

Management of Acute Exacerbation of Idiopathic Pulmonary Fibrosis in Specialised and Non-specialised ILD Centres Around the World

Background: Acute exacerbation of idiopathic pulmonary fibrosis (AE-IPF) is a severe complication associated with a high mortality. However, evidence and guidance on management is sparse. The aim of this international survey was to assess differences in prevention, diagnostic and treatment strategies for AE-IPF in specialised and non-specialised ILD centres worldwide.

Material and Methods: Pulmonologists working in specialised and non-specialised ILD centres were invited to participate in a survey designed by an international expert panel. Responses were evaluated in respect to the physicians' institutions.

Results: Three hundred and two (65%) of the respondents worked in a specialised ILD centre, 134 (29%) in a non-specialised pulmonology centre. Similarities were frequent with regards to diagnostic methods including radiology and screening for infection, treatment with corticosteroids, use of high-flow oxygen and non-invasive ventilation in critical ill patients and palliative strategies. However, differences were significant in terms of the use of KL-6 and pathogen testing in urine, treatments with cyclosporine and recombinant thrombomodulin, extracorporeal membrane oxygenation in critical ill patients as well as antacid medication and anaesthesia measures as preventive methods.

Conclusion: Despite the absence of recommendations, approaches to the prevention, diagnosis and treatment of AE-IPF are comparable in specialised and non-specialised ILD centres, yet certain differences in the managements of AE-IPF exist. Clinical trials and guidelines are needed to improve patient care and prognosis in AE-IPF.

The Awareness of Pulmonologists and Patients with Respiratory Diseases about the Impact of Air Pollution on Health in Poland

Within the European Union, air pollution is highest in Poland. The aim of this study was to compare the awareness of Polish pulmonologists and that of patients with respiratory diseases about the impact of air pollution on health. It was a crossover study with voluntary and anonymous participation. The study included 309 pulmonologists and 262 patients with respiratory diseases. The majority of the patients declared good knowledge about the impact of air pollution on health, and only 16% of the pulmonologists declared sufficient knowledge on this topic. The main sources of information on air pollution were radio and television for patients and the medical press for doctors. Doctors rarely informed patients about the impact of air pollution on their disease. Patients followed information on the quality of air in their areas more often than doctors. Polish patients’ knowledge about the main sources of air pollution in their areas was higher than the knowledge of pulmonologists. Patients declared knowledge of air pollution standards twice as often as doctors. Patients with respiratory diseases are interested in the effects of air pollution on their health. Polish patients’ knowledge about air pollution and its health effects is higher than that of the specialists treating them. Professional education of Polish pulmonologists in this field is needed.

The CHRONICLE Study of US Adults with Subspecialist-Treated Severe Asthma: Objectives, Design, and Initial Results

BACKGROUND

Approximately 5-10% of patients with asthma have severe disease. High-quality real-world studies are needed to identify areas for improved management.

OBJECTIVE

Aligned with the International Severe Asthma Registry, the CHRONICLE study (ClinicalTrials.gov: NCT03373045) was developed to address this need in the US.

STUDY DESIGN

Learnings from prior studies were applied to develop a real-world, prospective, noninterventional study of US patients with confirmed severe asthma who are treated by subspecialist physicians and require biologic or maintenance systemic immunosuppressant therapy or who are uncontrolled by high-dosage inhaled corticosteroids and additional controllers. Target enrollment is 4000 patients, with patient observation for ≥3 years. A geographically diverse sample of allergist/immunologist and pulmonologist sites approach all eligible patients under their care and report patient characteristics, treatment, and health outcomes every 6 months. Patients complete online surveys every 1-6 months.

INITIAL RESULTS

From February 2018 to February 2019, 102 sites screened 1428 eligible patients; 936 patients enrolled. Study sites (40% allergist/immunologist, 42% pulmonologist, 18% both) were similar to other US asthma subspecialist samples. Enrolled patients were 67% female with median ages at enrollment and diagnosis of 55 (range: 18-89) and 26 (0-80) years, respectively. Median body mass index was 31 kg/m2; 3% and 29% were current or former smokers, respectively, and >60% reported ≥1 exacerbation in the prior year and suboptimal symptom control.

CONCLUSION

CHRONICLE will provide high-quality provider- and patient-reported data from a large, real-world cohort of US adults with subspecialist-treated severe asthma.

Current practice patterns, challenges, and educational needs of asthma care providers in the United States

OBJECTIVE

For severe, uncontrolled asthma (SUA), a gap exists between recent scientific advances and their incorporation into clinical practice. Using a Knowledge-to-Action Framework, new knowledge can be translated into evidence-based interventions to improve outcomes. The AstraZeneca U.S. PRECISION initiative aims to apply this Framework to improve recognition and management of SUA. The study objective was to identify factors contributing to gaps in care for patients with SUA. Results from a needs assessment survey of U.S. pulmonologists and allergists/immunologists were assessed within the Knowledge-to-Action Framework to advance bench-to-bedside care.

METHODS

Pulmonologists and allergists/immunologists from across the United States were invited to complete a customized, quantitative severe asthma survey in person at the 2017 American Thoracic Society annual meeting or via the Internet. Responses were summarized descriptively, and chi-squared tests evaluated associations between variables of interest.

RESULTS

Overall, 140 U.S. providers responded, most of whom were pulmonologists (84%). Most (60%) practiced in a community-based setting; 40% practiced at an academic medical center. Key challenges to providing care for patients with severe asthma included insurance company requirements and identification of the pathophysiology of an individual patient's severe asthma. Traditional measures of asthma-related morbidity were ranked as highly important by significantly more respondents compared with assessment of biomarkers (p < 0.0001). Respondents generally valued online virtual self-education.

CONCLUSIONS

Survey results identified unmet needs for the identification and management of patients with SUA and opportunities to improve patient outcomes through evidence-based management of SUA, including testing for biologic eligibility and subsequent use of biologic therapies.

Diagnosis and management of asthma, COPD and asthma-COPD overlap among primary care physicians and respiratory/allergy specialists: A global survey

INTRODUCTION

Asthma-chronic obstructive pulmonary disease (COPD) overlap (ACO) is a heterogenous condition with clinical features shared by both asthma and COPD.

OBJECTIVES

This online global survey of respiratory/allergy specialists and primary care practitioners (PCPs) was performed to understand current clinical approaches to the differential diagnosis and management of asthma, COPD and ACO.

METHODS

Respondents were recruited through: (a) a global online physician respondent community (49,980 PCPs and 7205 specialists); (b) market research agents; (c) experts; (d) professional societies; (e) colleague invitation. Respondents were presented with a survey including hypothetical clinical scenarios of diagnostic uncertainty to identify management approaches.

RESULTS

891 responses (447 PCPs and 444 specialists) were collected across 13 countries. Reported features used for diagnosis of asthma and COPD were consistent with practice guidelines, but there was variability in those selected for ACO diagnosis. Features typically selected by specialists focused on spirometry/history, while PCPs focused on previous treatment/symptoms. Most respondents could correctly diagnose patients with features of ACO; however, features selected for theoretical diagnosis were often different to those selected in the case scenarios. Additionally, treatment selection was often inconsistent with guidelines, with over half of respondents not recommending inhaled corticosteroids in a patient with ACO and dominant features of asthma.

CONCLUSION

While most PCPs and respiratory/allergy specialists can reach a working diagnosis of ACO, there remains uncertainty around which diagnostic features are most important and what constitutes optimal management. It is imperative that clinical studies including patients with ACO are initiated, allowing the generation of evidence-based management strategies.

Concomitant pulmonologist and primary care for chronic obstructive pulmonary disease: a population study

BACKGROUND

Pulmonologists provide quality care, however, their number is not adequate to take care of all the chronic obstructive pulmonary disease (COPD) needs of the population and their services come with a cost. Their optimal role should be defined, ideally based on evidence, to ensure that their abilities are applied most efficiently where needed.

OBJECTIVE

To determine if concomitant pulmonologist and primary care physician care after COPD hospital or emergency department discharge was associated with better health outcomes than primary care services alone.

METHODS

A population cohort study was conducted in Ontario, Canada from 2004 to 2011. All individuals with a COPD hospital or emergency department discharge were included. Patients who visited both a pulmonologist and a primary care physician within 30 days of the index discharge were matched to patients who had visited a primary care physician alone using propensity scores. The composite outcome of death, COPD hospitalization or COPD emergency department visit was compared using proportional hazards regression.

RESULTS

In the propensity score matched sample, 39.7% of patients who received concomitant care and 38.9% who received primary care only died or visited the emergency department visit or hospital for COPD within 1 year (adjusted hazard ratio 1.08, 95% confidence interval 1.00-1.17). The former, however, were more likely to receive diagnostic testing and medications.

CONCLUSION

Patients who received concomitant care after COPD emergency department or hospital discharge did not have better outcomes than those who received primary care alone, however, they did receive more testing and medical management.

The view of pulmonologists on palliative care for patients with COPD: a survey study

Introduction

Early palliative care is not a common practice for patients with COPD. Important barriers are the identification of patients for palliative care and the organization of such care in this patient group.

Objective

Pulmonologists have a central role in providing good quality palliative care for patients with COPD. To guide future research and develop services, their view on palliative care for these patients was explored.

Methods

A survey study was performed by the members of the Netherlands Association of Physicians for Lung Diseases and Tuberculosis.

Results

The 256 respondents (31.8%) covered 85.9% of the hospital organizations in the Netherlands. Most pulmonologists (92.2%) indicated to distinguish a palliative phase in the COPD trajectory, but there was no consensus about the different criteria used for its identification. Aspects of palliative care in COPD considered important were advance care planning conversation (82%), communication between pulmonologist and general practitioner (77%), and identification of the palliative phase (75.8%), while the latter was considered the most important aspect for improvement (67.6%). Pulmonologists indicated to prefer organizing palliative care for hospitalized patients with COPD themselves (55.5%), while 30.9% indicated to prefer cooperation with a specialized palliative care team (SPCT). In the ambulatory setting, a multidisciplinary cooperation between pulmonologist, general practitioner, and a respiratory nurse specialist was preferred (71.1%).

Conclusion

To encourage pulmonologists to timely initiate palliative care in COPD, we recommend to conduct further research into more specific identification criteria. Furthermore, pulmonologists should improve their skills of palliative care, and the members of the SPCT should be better informed about the management of COPD to improve care during hospitalization. Communication between pulmonologist and general practitioner should be emphasized in training to improve palliative care in the ambulatory setting.

Follow-up study on management of chronic obstructive pulmonary disease in Hunan Province, the People's Republic of China

Background

In 2009, our study showed an extreme imbalance and disparity in COPD-related health resources allocation at three levels of public hospitals (PHs) in Hunan Province of the People’s Republic of China, especially in second-level PHs. Moreover, most Chinese citizens accept their health care services in first- and second-level PHs for economic and geographical reasons, as well as because of the incomplete transfer system in the health care services. To improve diagnosis and treatment ability of pulmonologists in second-level PHs, an intervention that provided training combined with spirometry equipment was carried out in three PHs from six second-level PHs. The aim of this follow-up study was to evaluate the changes associated with COPD-related health resources allocation and the effect of the intervention 4 years later.

Methods

The data regarding the availability of spirometers, inhalation agents for COPD, and COPD-related health care education for local residents were collected from 57 PHs in 2009 and 48 PHs in 2013. Pulmonologists working in these PHs were asked to complete a questionnaire individually. Six second-level PHs (three in the intervention group and the other three in the control group [without training and spirometry equipment]) that further took part in the survey in 2009 were reevaluated to determine the doubtful diagnostic ratio and the confirmation ratio of COPD. The differences between 2009 and 2013 data was analyzed.

Results

A total of 762 questionnaires were completed. Compared with 2009, spirometer-equipped ratio raised from 40% to 69% in 2013 (P=0.03). The overall inhalation agent-equipped ratio increased from 58% in 2009 to 88% in 2013 (P=0.001). The total rate of health education raised from 35% in 2009 to 63% in 2013 (P=0.04). In total, 204 pulmonologists from six PHs (selected for study in 2009) completed the questionnaires in 2013. The median score of COPD knowledge questionnaire in the intervention group was higher than that of the control group (80 vs 50, respectively, P<0.01). Further, the clinical doubtful diagnostic ratio (15%) and the diagnosis ratio of COPD (3%) in the intervention group were higher than in the control group (4% and 1%, respectively, P<0.05) even after 4 years.

Conclusion

COPD-related health resources allocation improved in the 4 years following intervention at three levels of PHs in the People’s Republic of China. Short-term training combined with spirometry equipment had a sustained effect on improving the physicians’ understanding and diagnosis ability of COPD.

Understanding perception of chronic obstructive pulmonary disease among general practitioners, physicians, and pulmonologists in India: Results from a face-to-face survey

Background:

Challenges exist in the diagnosis, management and follow-up of patients with chronic obstructive pulmonary disease (COPD) in India. Lack of awareness of the disease, its symptoms and its implications may significantly contribute in preventing individuals with symptoms from seeking advice from their primary care physicians or eliminating risk factors. This cross-sectional survey aimed to explore the attitudes, beliefs, and knowledge of doctors (general practitioners [GPs], physicians and pulmonologists) related to COPD recognition, diagnosis, and treatment in India.

Methods:

Data was collated from 91 randomly selected GPs, physicians and pulmonologists through a questionnaire and face-to-face interviews, in 8 cities of India.

Results:

The response rate to the survey was 68% (61 out of 91). Majority of the doctors (90% of GPs-physicians and 82% of pulmonologists) reported that patients with COPD visit them at moderate to severe stages of the disease. 44% of the GPs and physicians reported that they had never performed spirometry to make a diagnosis of COPD. About 35% of doctors reported that COPD occurred only in smokers. The most common reported barriers to the treatment of COPD were difficulty in explaining COPD to the patients, poor patient compliance to the prescribed treatment and the inability of patients to give up smoking. Most doctors agreed that compliance with treatment is a major concern in patients with COPD due to an ageing population, existence of limited therapeutic options and presence of comorbidities.

Conclusion:

The results of this cross-sectional survey of doctors in India, highlighted the need for increasing the awareness about COPD at both doctor and patients level to overcome the prevalent under-diagnosis and under-treatment in COPD.