Advocates for Evidence-Based Health Policy Speakers
Evidence for the Quadruple Aim
Many superstitious medical providers firmly believe that things come in sets of three. In the context of revamping the U.S. healthcare system, they might point to the Triple Aim, a framework put forward by Donald Berwick. It posits that improving health care in the U.S. requires simultaneous efforts directed at patient experiences, population health, and cost control. The numerically superstitious might be dismayed to hear that there is talk of extending the Triple Aim into a Quadruple Aim, folding in an emphasis on improving working conditions in health care.
This mooted expansion is driven by concerns that increasing physician burnout imperils the achievement of the original Triple Aim goals. As some studies have found more than 50% of physicians are burned-out, reducing burnout may be a necessary condition for physicians to provide high value care. Work stress leads to burnout, which is understood has having three dimensions: emotional exhaustion, depersonalization, and reduced perception of personal accomplishment. The highlighted review seeks to assess the available research evidence on the effects of burnout on patient outcomes.
Fascinatingly, research looking at physician perceptions consistently linked burnout to worse quality of care and increased medical errors, but the five studies based on chart review were not able to bear out those relationships. Despite finding no effect from burnout, one of those five studies found that depressed residents made six times as many errors (as identified in the medical record) compared to those who were not depressed. Patient perceptions of care received from burned-out physicians were complex, with burnout leading to lower overall satisfaction but having neutral or even positive effects when evaluating specific physician attributes such as empathy and interpersonal skills.
Thus, clear and compelling evidence linking burnout to worse patient outcomes is lacking. This may be due to limitations in the relatively small number of studies available or it may reflect that burned-out physicians are able to continue delivering high quality care despite personal turmoil. Burnout has also been correlated with depression, which has been definitively linked to more medical errors. More research is needed, but for now, adding burnout prevention to the Triple Aim lacks evidence.
Abstract
BACKGROUND: Experts express concern that attaining of the Triple Aim of reducing health care costs, improving patient experiences and ultimately population health, may be compromised by high levels of burnout among physicians. Some have called for a fourth aim of improving the work environment for care providers.
OBJECTIVES: Burnout has been linked to poor outcomes in many occupational settings. This study’s aim was to investigate linkages between physician burnout and patient outcomes through a systematic review of the literature.
RESEARCH DESIGN: Systematic search of 3 databases using Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) guidelines. In total, 1201 articles were reviewed, and 28 were included in the final analysis. Studies needed to be empirical, measure physician burnout as a predictor, and include patient outcome measures.
MEASURES: The majority of studies were cross-sectional and measured patient outcomes via physician perception self-reports (n=14). Five studies reported clinical measures (quality, errors), and 9 included patient ratings of their care.
RESULTS: Studies using self-reports of suboptimal quality and errors found that physicians higher in burnout consistently reported worse quality, yet studies linking burnout to independent clinical outcomes found no relationships. Similarly, burnout was related to lower patient ratings of care, but when specific behaviors were rated there was no relationship.
PMID: 30339573
CONCLUSIONS: Although the interest in burnout’s effects is strong, the lack of rigorous empirical studies examining patient outcomes is problematic. Future research should develop and test causal models to better understand which domains of patient care are influenced by physician burnout.
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