Physician Burnout, Quality of Care Relationship may be Exaggerated

Daniel Tawfik, MD

The relationship between physician burnout and quality of care may be misleading, according to a new, comprehensive literature review.

A team led by Daniel Tawfik, MD, Stanford University School of Medicine, set out to estimate the relationship between burnout and quality of care, while evaluating whether published studies provide exaggerated estimates on this association from 11,703 citations using 142 studies.

They grouped quality-of-care outcomes into 5 different categories—best practices (n=14), communication (n=5), medical errors (n=32), patient outcomes (n=17), and quality and safety (n=74).

In the past, studies have suggested that almost 50% of health care providers may have burnout symptoms at any given time. Burnout is associated with adverse effects, including suicidality, broken relationships, decreased productivity, unprofessional behavior, and employee turnover, both at the provider and organizational levels.

The majority of recent studies have focused on the links between burnout and adherence to practice guidelines, communication, medical errors, patient outcomes, and safety metrics. Most of these studies use a retrospective, observational design and apply a wide range of burnout assessments and analytic tools to evaluate the different outcomes among diverse patient populations.

However, the investigators believe a lack of a standardized approach to measurement and analysis increase the risk of bias and potentially undermine the scientific progress by hampering the ability to identify which of the apparent clinically significant results representing true effects.

Some of the biases plaguing past studies including overrepresentation of positive findings in published literature, resulting in an excess of statistically significant results and threatening reproducibility of findings, promoting misappropriation of resources, and skewing the design of studies assessing interventions to reduce burnout or improve quality.

The investigators chose an inclusive method of identifying burnout studies by considering assessments to be related to burnout if the authors defined them as such and used any inventory intended to identify burnout, either in part or in full.

They also chose an inclusive approach to identify quality-of-care metrics, including any assessment of processes or outcomes indicative of care quality, including objectively measures and subjectively reported quality metrics originating from the provider, other sources within the health care system, or patients and their surrogates.

In an interview with MD Magazine®, Tawfik explained how the study results ultimately surprised him.

“I think the first thing that surprised us was we expected to find a wide variation of how people are studying burnout and quality of care and which combinations they're studying,” Tawfik said. “But I don't think any of us actually expected to find the degree of variation that we did find. There was just a huge variety of different quality of care outcomes, and burnout measures that were being used in this study, probably even more so than what we expected.”

The team characterized each assessment of burnout as overall burnout, emotional exhaustion , depersonalization, or low personal accomplishment. They also categorized quality metrics within 5 groups—best practices, communication, medical errors, patient outcomes, and quality and safety.

“Most studies reported burnout as a dichotomous variable or with unscaled effect size estimates, facilitating the aforementioned transformations,” the authors wrote. “We scaled effect sizes accordingly for the 6 studies reporting burn- out only as a continuous variable in order to maintain comparability, adapting our methods from published guidelines.”

When calculating the difference between the mean scores of providers with and without burnout, they found a 47.6% change in scale score when needed to extrapolate to dichotomized burnout.

The relationship between burnout and quality of care were highly heterogeneous (I² = 93.4-98.8%), with 114 burnout-quality combinations, 58 of which indicate burnout is related to poor-quality care while 6 indicate burnout is related to high-quality care and 50 showing no significant effect.

Overall burnout, emotional exhaustion, and depersonalization were the primary predictors for 56, 75, and 11 study populations.

Also, 38 (33%) of the 114-distinct burnout—quality combinations were reported 3 or more times and the most frequently reported effect related emotional exhaustion to low quality of care with most of the reported effect sizes in the quality and safety and medical errors categories.

The investigators ultimately concluded that the true effect size of the relationship between burnout in health care professionals and poor quality-of-care might be smaller than reported and future studies should prespecify outcomes to reduce the risk for effect size estimates.

“Ultimately what we want to do is reduce provider burnout, and improve quality of care, and knowing how strong that relationship is," Tawfik said. "Then also figuring out which direction that relationship is moving, is going to really help us then design interventions."

The study, “Evidence Relating Health Care Provider Burnout and Quality of Care: A Systematic Review and Meta-analysis,” was published online in the Annals of Internal Medicine.