Helfrich Christian D, Dolan Emily D, Simonetti Joseph, Reid Robert J, Joos Sandra, Wakefield Bonnie J, Schectman Gordon, Stark Richard, Fihn Stephan D, Harvey Henry B, Nelson Karin
VA Puget Sound Health Services Research & Development Center of Excellence, US Department of Veterans Affairs, Seattle, WA, USA,
J Gen Intern Med. 2014 Jul;29 Suppl 2(Suppl 2):S659-66. doi: 10.1007/s11606-013-2702-z.
A high proportion of the US primary care workforce reports burnout, which is associated with negative consequences for clinicians and patients. Many protective factors from burnout are characteristics of patient-centered medical home (PCMH) models, though even positive organizational transformation is often stressful. The existing literature on the effects of PCMH on burnout is limited, with most findings based on small-scale demonstration projects with data collected only among physicians, and the results are mixed.
To determine if components of PCMH related to team-based care were associated with lower burnout among primary care team members participating in a national medical home transformation, the VA Patient Aligned Care Team (PACT).
Web-based, cross-sectional survey and administrative data from May 2012.
A total of 4,539 VA primary care personnel from 588 VA primary care clinics.
The dependent variable was burnout, and the independent variables were measures of team-based care: team functioning, time spent in huddles, team staffing, delegation of clinical responsibilities, working to top of competency, and collective self-efficacy. We also included administrative measures of workload and patient comorbidity.
Overall, 39 % of respondents reported burnout. Participatory decision making (OR 0.65, 95 % CI 0.57, 0.74) and having a fully staffed PACT (OR 0.79, 95 % CI 0.68, 0.93) were associated with lower burnout, while being assigned to a PACT (OR 1.46, 95 % CI 1.11, 1.93), spending time on work someone with less training could do (OR 1.29, 95 % CI 1.07, 1.57) and a stressful, fast-moving work environment (OR 4.33, 95 % CI 3.78, 4.96) were associated with higher burnout. Longer tenure and occupation were also correlated with burnout.
Lower burnout may be achieved by medical home models that are appropriately staffed, emphasize participatory decision making, and increase the proportion of time team members spend working to the top of their competency level.
美国大部分基层医疗工作者都有职业倦怠的情况，这对临床医生和患者都会产生负面影响。许多预防职业倦怠的保护因素都体现在以患者为中心的医疗之家（PCMH）模式中，不过即使是积极的组织变革往往也会带来压力。关于PCMH对职业倦怠影响的现有文献有限，大多数研究结果基于小规模示范项目，且数据仅收集自医生，结果也不一致。
确定参与全国医疗之家转型项目“退伍军人事务部患者协作医疗团队（PACT）”的基层医疗团队成员中，与团队协作式医疗相关的PCMH组成部分是否与较低的职业倦怠相关。
基于网络的横断面调查以及2012年5月的行政数据。
来自588家退伍军人事务部基层医疗诊所的4539名退伍军人事务部基层医疗人员。
因变量为职业倦怠，自变量为团队协作式医疗的测量指标：团队功能、小组讨论时间、团队人员配备、临床职责委派、按能力上限工作以及集体自我效能感。我们还纳入了工作量和患者合并症的行政测量指标。
总体而言，39%的受访者表示有职业倦怠。参与式决策（比值比0.65，95%置信区间0.57，0.74）以及拥有人员配备齐全的PACT（比值比0.79，95%置信区间0.68，0.93）与较低的职业倦怠相关，而被分配到PACT（比值比1.46，95%置信区间1.11，1.93）、花费时间做未经充分培训人员也能做的工作（比值比1.29，95%置信区间1.07，1.57）以及压力大、节奏快的工作环境（比值比4.33，95%置信区间3.78，4.96）与较高的职业倦怠相关。任职时间长和特定职业也与职业倦怠相关。
人员配备合理、强调参与式决策并增加团队成员按能力上限工作时间比例的医疗之家模式，可能会降低职业倦怠。
