Linzer Mark, Poplau Sara, Brown Roger, Grossman Ellie, Varkey Anita, Yale Steven, Williams Eric S, Hicks Lanis, Wallock Jill, Kohnhorst Diane, Barbouche Michael
Hennepin County Medical Center, Minneapolis, MN, USA.
Minneapolis Medical Research Foundation, Minneapolis, MN, USA.
J Gen Intern Med. 2017 Jan;32(1):56-61. doi: 10.1007/s11606-016-3856-2. Epub 2016 Sep 9.
While primary care work conditions are associated with adverse clinician outcomes, little is known about the effect of work condition interventions on quality or safety.
A cluster randomized controlled trial of 34 clinics in the upper Midwest and New York City.
Primary care clinicians and their diabetic and hypertensive patients.
Quality improvement projects to improve communication between providers, workflow design, and chronic disease management. Intervention clinics received brief summaries of their clinician and patient outcome data at baseline.
We measured work conditions and clinician and patient outcomes both at baseline and 6-12 months post-intervention. Multilevel regression analyses assessed the impact of work condition changes on outcomes. Subgroup analyses assessed impact by intervention category.
There were no significant differences in error reduction (19 % vs. 11 %, OR of improvement 1.84, 95 % CI 0.70, 4.82, p = 0.21) or quality of care improvement (19 % improved vs. 44 %, OR 0.62, 95 % CI 0.58, 1.21, p = 0.42) between intervention and control clinics. The conceptual model linking work conditions, provider outcomes, and error reduction showed significant relationships between work conditions and provider outcomes (p ≤ 0.001) and a trend toward a reduced error rate in providers with lower burnout (OR 1.44, 95 % CI 0.94, 2.23, p = 0.09).
Few quality metrics, short time span, fewer clinicians recruited than anticipated.
Work-life interventions improving clinician satisfaction and well-being do not necessarily reduce errors or improve quality. Longer, more focused interventions may be needed to produce meaningful improvements in patient care.
ClinicalTrials.gov # NCT02542995.
虽然基层医疗工作条件与临床医生的不良结局相关，但对于工作条件干预对质量或安全性的影响知之甚少。
对美国中西部上游地区和纽约市的34家诊所进行整群随机对照试验。
基层医疗临床医生及其糖尿病和高血压患者。
开展质量改进项目，以改善医疗服务提供者之间的沟通、工作流程设计和慢性病管理。干预诊所收到了其临床医生和患者基线结局数据的简要总结。
我们在基线时以及干预后6至12个月测量了工作条件以及临床医生和患者的结局。多层次回归分析评估了工作条件变化对结局的影响。亚组分析按干预类别评估影响。
干预诊所与对照诊所在减少差错方面（19% 对11%，改善的比值比为1.84，95% 置信区间为0.70至4.82，p = 0.21）或改善护理质量方面（改善的比例为19% 对44%，比值比为0.62，95% 置信区间为0.58至1.21，p = 0.42）均无显著差异。将工作条件、医疗服务提供者结局和减少差错联系起来的概念模型显示，工作条件与医疗服务提供者结局之间存在显著关系（p≤0.001），并且倦怠程度较低的医疗服务提供者的差错率有降低趋势（比值比为1.44，95% 置信区间为0.94至2.23，p = 0.09）。
质量指标较少、时间跨度短、招募的临床医生比预期少。
改善临床医生满意度和幸福感的工作生活干预措施不一定能减少差错或提高质量。可能需要更长时间、更有针对性的干预措施才能在患者护理方面产生有意义的改善。
ClinicalTrials.gov # NCT02542995
