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Telehealth use, including video visits and secure messages, expanded significantly in Veterans Health Administration (VHA) primary care during the COVID-19 pandemic. However, primary care provider (PCP) burnout also increased during this period. Each modality may have affected primary care workloads differently (either by substituting for or complementing in-person visits) and thereby had varying effects on PCP burnout. This study aims to examine the associations between PCP burnout and the volumes of video visits and secure messages within the health care systems in which the PCPs practiced. This study examined the associations between telehealth modalities (ie, video visits and secure messages) and burnout as reported by 17,034 PCPs in 138 health care systems in VHA from 2020 to 2023. Individual-level data were obtained from annual cross-sectional surveys, and health care system-level data were drawn from administrative data sources. We created logistic regression models using generalized estimating equations to analyze the relationships between individual-level PCP burnout and average volumes of health care system-level video visits and secure messages per 1000 patients, controlling for age, sex, race or ethnicity, and VHA tenure as well as health care system complexity and year. We then predicted the marginal means of PCP burnout by video visit or secure message volume, based on the model results. From 2020 to 2023, average PCP burnout, across repeated, annual cross-sections, increased from 42.1% to 52.7% (survey response rates of 68%-74%). Most survey respondents were aged 50 years and above (9607/17,034, 56.40%), female (10,189/17,034, 59.82%), non-White (9460/17,034, 55.54%), and with less than 10 years of tenure in the VHA (10,990/17,034, 64.52%). Over these 4 years, median annual video visits per 1000 patients in health care systems increased from 15.9 (IQR 8.4-25.5) to 227.6 (IQR 127.1-320.7), and median annual secure messages per 1000 patients increased from 23.4 (IQR 9.4-65.5) to 35.3 (IQR 11.0-87.0). In our fully adjusted models, video visit volumes in a health care system were not related to burnout, but secure message volumes were related to burnout. Burnout was significantly higher among PCPs in health care systems receiving additional secure messages per 1000 patients (odds ratio 1.001, 95% CI 1.000-1.002). On average, PCP burnout increased by 1% point for each additional increase of 43.7 (95% CI 14.0-73.4) secure messages in a health care system. Video visit volumes in a health care system were not associated with PCP burnout, but secure message volumes were associated with PCP burnout. As video visits and secure messages continue to grow, solutions to better manage message volume (eg, automation and provider-led quality improvement) are needed to mitigate the concurrent rise in PCP burnout.

Background The COVID-19 pandemic involved a rapid change to the working conditions of all healthcare workers (HCW), including those in primary care. Organizational responses to the pandemic, including a shift to virtual care, changes in staffing, and reassignments to testing-related work, may have shifted more burden to these HCWs, increasing their burnout and turnover intent, despite their engagement to their organization. Our objectives were (1) to examine changes in burnout and intent to leave rates in VA primary care from 2017–2020 (before and during the pandemic), and (2) to analyze how individual protective factors and organizational context affected burnout and turnover intent among VA primary care HCWs during the early months of the pandemic. Methods We analyzed individual- and healthcare system-level data from 19,894 primary care HCWs in 139 healthcare systems in 2020. We modeled potential relationships between individual-level burnout and turnover intent as outcomes, and individual-level employee engagement, perceptions of workload, leadership, and workgroups. At healthcare system-level, we assessed prior-year levels of burnout and turnover intent, COVID-19 burden (number of tests and deaths), and the extent of virtual care use as potential determinants. We conducted multivariable analyses using logistic regression with standard errors clustered by healthcare system controlled for individual-level demographics and healthcare system complexity. Results In 2020, 37% of primary care HCWs reported burnout, and 31% reported turnover intent. Highly engaged employees were less burned out (OR = 0.57; 95% CI 0.52–0.63) and had lower turnover intent (OR = 0.62; 95% CI 0.57–0.68). Pre-pandemic healthcare system-level burnout was a major predictor of individual-level pandemic burnout ( p  = 0.014). Perceptions of reasonable workload, trustworthy leadership, and strong workgroups were also related to lower burnout and turnover intent ( p  < 0.05 for all). COVID-19 burden, virtual care use, and prior year turnover were not associated with either outcome. Conclusions Employee engagement was associated with a lower likelihood of primary care HCW burnout and turnover intent during the pandemic, suggesting it may have a protective effect during stressful times. COVID-19 burden and virtual care use were not related to either outcome. Future research should focus on understanding the relationship between engagement and burnout and improving well-being in primary care.

Background Enhanced recovery after surgery (ERAS) interventions aim to improve patient outcomes. Vascular surgery patients have unique requirements and it is unclear which ERAS interventions are supported by an evidence base. Methods We conducted a scoping review to identify ERAS randomized controlled trials (RCTs) published in the biomedical or nursing literature. We assessed interventions for applicability to vascular surgery and differentiated interventions given at preadmission, preoperative, intraoperative, and postoperative surgery stages. We documented the research in an evidence map. Results We identified 76 relevant RCTs. Interventions were mostly administered in preoperative (23 RCTs; 30%) or intraoperative surgery stages (35 RCTs; 46%). The majority of studies reported mortality outcomes (44 RCTs; 58%), but hospital (27 RCTs; 35%) and intensive care unit (9 RCTs; 12%) length of stay outcomes were less consistently described. Conclusion The ERAS evidence base is growing but contains gaps. Research on preadmission interventions and more consistent reporting of key outcomes is needed.

Background The scope of care coordination in VA primary care increased with the launch of the Veterans Choice Act, which aimed to increase access through greater use of non-VA Community Care. These changes may have overburdened already busy providers with additional administrative tasks, contributing to provider burnout. Our objective was to understand the role of challenges with care coordination in burnout. We analyzed relationships between care coordination challenges with Community Care reported by VA primary care providers (PCPs) and VA PCP burnout. Methods Our cross-sectional survey contained five questions about challenges with care coordination. We assessed whether care coordination challenges were associated with two measures of provider burnout, adjusted for provider and facility characteristics. Models were also adjusted for survey nonresponse and clustered by facility. Trainee and executive respondents were excluded. 1,543 PCPs in 129 VA facilities nationwide responded to our survey (13 % response rate). Results 51 % of our sample reported some level of burnout overall, and 46 % reported feeling burned out at least once a week. PCPs were more likely to be burned out overall if they reported more than average challenges with care coordination (odds ratio [OR] 2.04, 95 % confidence interval [CI] 1.58 to 2.63). These challenges include managing patients with outside prescriptions or obtaining outside tests or records. Conclusions VA primary care providers who reported greater than average care coordination challenges were more likely to be burned out. Interventions to improve care coordination could help improve VA provider experience.

Background The Veterans Health Administration (VA) serves Veterans in the nation’s largest integrated healthcare system. VA seeks to provide high quality of healthcare to Veterans, but due to the VA Choice and MISSION Acts, VA increasingly pays for care outside of its system in the community. This systematic review compares care provided in VA and non-VA settings, and includes published studies from 2015 to 2023, updating 2 prior systematic reviews on this topic. Methods We searched PubMed, Web of Science, and PsychINFO from 2015 to 2023 for published literature comparing VA and non-VA care, including VA-paid community care. Records were included at the abstract or full-text level if they compared VA medical care with care provided in other healthcare systems, and included clinical quality, safety, access, patient experience, efficiency (cost), or equity outcomes. Data from included studies was abstracted by two independent reviewers, with disagreements resolved by consensus. Results were synthesized narratively and via graphical evidence maps. Results Thirty-seven studies were included after screening 2415 titles. Twelve studies compared VA and VA-paid community care. Most studies assessed clinical quality and safety, and studies of access were second most common. Only six studies assessed patient experience and six assessed cost or efficiency. Clinical quality and safety of VA care was better than or equal to non-VA care in most studies. Patient experience in VA care was better than or equal to experience in non-VA care in all studies, but access and cost/efficiency outcomes were mixed. Discussion VA care is consistently as good as or better than non-VA care in terms of clinical quality and safety. Access, cost/efficiency, and patient experience between the two systems are not well studied. Further research is needed on these outcomes and on services widely used by Veterans in VA-paid community care, like physical medicine and rehabilitation.

Many Clinical and Translational Science Awards (CTSAs) focus their energy on operational aspects of running their hub, but may not devote enough energy and resources toward branding and effective communication. However, CTSAs have an important mission when it comes to communicating effectively with their stakeholders through social media. Using framing theory as the underpinning, the purpose of this content analysis is to investigate the ways in which CTSAs use Twitter to communicate with their various stakeholders, the type of content they post, and the type of engagement their tweets garner. We examined 349 tweets posted from January 2019 to January 2020 from 19 CTSA Twitter accounts (sampled from a total of 35 CTSA accounts). A thematic codebook was generated using tweets randomly chosen from the sample. Content analysis was performed on the entire tweet sample by four coders using the codebook (alpha = 0.89). CTSAs tweeted the most about events (29.8%), and the least about study recruitment (2.01%). Most tweets included images (59.31%) and hashtags (51.29%), but received little user engagement on the average post (average: 4.38 likes and 1.94 retweets). CTSAs tweeted most from 10 a.m. to 12 p.m. PST and received the most engagement. Most CTSAs had a dedicated person (e.g., manager, coordinator) handling their communications. Our analysis shows multiple opportunities for CTSAs to engage with stakeholders and the public, as well as standardize and improve their Twitter communications to effectively reach a broader audience.

BackgroundPrevious studies have documented income differences between male and female physicians. However, the implications of these differences are unclear, since previous studies have lacked detailed data on the quantity and composition of work hours. We sought to identify the sources of these income differences using data from a novel survey of physician work and income.ObjectiveTo compare differences in income between male and female physicians.DesignWe estimated unadjusted income differences between male and female physicians. We then adjusted these differences for total hours worked, composition of work hours, percent of patient care time spent providing procedures, specialty, compensation type, age, years in practice, race, ethnicity, and state and practice random effects.ParticipantsWe surveyed 656 physicians in 30 practices in six states and received 439 responses (67% response rate): 263 from males and 176 from females.Main measureSelf-reported annual income.Key resultsMale physicians had significantly higher annual incomes than female physicians (mean $297,641 vs. $206,751; difference $90,890, 95% CI $27,769 to $154,011) and worked significantly more total hours (mean 2470 vs. 2074; difference 396, 95% CI 250 to 542) and more patient care hours (mean 2203 vs. 1845; difference 358, 95% CI 212 to 505) per year. Male physicians were less likely than female physicians to specialize in primary care (49.1 vs. 70.5%), but more likely to perform procedures with (33.1 vs. 15.5%) or without general anesthesia (84.3 vs. 73.1%). After adjustment, male physicians’ incomes were $27,404 (95% CI $3120 to $51,688) greater than female physicians’ incomes.ConclusionsAdjustment for multiple possible confounders, including the number and composition of work hours, can explain approximately 70% of unadjusted income differences between male and female physicians; 30% remains unexplained. Additional study and dedicated efforts might be necessary to identify and address the causes of these unexplained differences.

BackgroundCivility, or politeness, is an important part of the healthcare workplace, and its absence can lead to healthcare provider and staff burnout. Lack of civility is well-documented among mostly female nurses, but is not well-described among the gender-mixed primary care provider (PCP) workforce. Understanding civility and its relationship to burnout among male and female PCPs could help lead to tailored interventions to improve civility and reduce burnout in primary care.ObjectiveTo analyze gender differences in civility, burnout, and the relationship between civility and burnout among male and female PCPs.DesignMulti-level logistic regression analysis of a cross-sectional national survey.ParticipantsA total of 3216 PCP respondents (1946 women and 1270 men) in 135 medical centers from a 2019 national Veterans Health Administration (VA) survey.Main MeasuresOutcomes: burnout; predictors: workplace civility and gender; controls: race, ethnicity, VA tenure, and supervisory status.Key ResultsWorkplace civility was rated higher (p<0.001) among male (mean = 4.07, standard deviation [SD] = 0.36, range 1–5) compared to female (mean = 3.88, SD = 0.33) PCPs. Almost half of the sample reported burnout (47.6%), but this difference was not significant (p = 0.73) between the genders. Higher workplace civility was significantly related to lower burnout among female PCPs (odds ratio [OR] = 0.46, 95% confidence interval [CI] = 0.31 to 0.69), but not among male PCPs (OR = 0.71, 95% CI = 0.42 to 1.22). Interactions between civility and other demographic variables (race, ethnicity, VA tenure, or supervisory status) were not significantly related to burnout.ConclusionFemale PCPs report lower workplace civility than male PCPs. An inverse relationship between civility and burnout is present for women but not men. More research is needed on this phenomenon. Interventions tailored to gender- and primary care-specific needs should be employed to increase civility and reduce burnout among PCPs.

BackgroundThe patient-centered medical home (PCMH) model is intended to improve primary care, but evidence of its effects on provider well-being is mixed. Investigating the relationships between specific PCMH components and provider burnout and potential attrition may help improve the efficacy of the care model.ObjectiveWe analyzed provider attitudes toward specific components of PCMH in the Veterans Health Administration (VA) and their relation to emotional exhaustion (EE)—a central component of burnout—and intent to remain in VA primary care.DesignLogistic regression analysis of a cross-sectional survey.Subjects116 providers (physicians; nurse practitioners; physician assistants) in 21 practices between September 2015 and January 2016 in one VA region.Main MeasuresOutcomes: burnout as measured with the emotional exhaustion (EE) subscale of the Maslach Burnout Inventory and intent to remain in VA primary care for the next 2 years; predictors: difficulties with components of PCMH, demographic characteristics.Key ResultsForty percent of providers reported high EE (≥ 27 points) and 63% reported an intent to remain in VA primary care for the next 2 years. Providers reporting high difficultly with PCMH elements were more likely to report high EE, for example, coordinating with specialists (odds ratio [OR] 8.32, 95% confidence interval [CI] 3.58–19.33), responding to EHR alerts (OR 6.88; 95% CI 1.93–24.43), and managing unscheduled visits (OR 7.53, 95% CI 2.01–28.23). Providers who reported high EE were also 87% less likely to intend to remain in VA primary care.ConclusionsTo reduce EE and turnover in PCMH, primary care providers may need additional support and training to address challenges with specific aspects of the model.