The Relationship Between Primary Care Physician Burnout and Patient-Reported Care Experiences: a Cross-sectional Study.

BACKGROUND: Primary care physician (PCP) burnout is prevalent and on the rise. Physician burnout may negatively affect patient experience of care. OBJECTIVE: To identify the direct impact of PCP burnout on patient experience in various domains of care. DESIGN: A cross-sectional observational study using physician well-being (PWB) surveys collected in 2016-2017, linked to responses from patient experience of care surveys. Patient demographics and practice characteristics were derived from the electronic health record. Linked data were analyzed at the physician level. SETTING: A large non-profit multi-specialty ambulatory healthcare organization in northern California. PARTICIPANTS: A total of 244 physicians practicing internal medicine or family medicine who responded to the PWB survey (response rate 72%), and 30,701 completed experience surveys from patients seeing these physicians. MEASUREMENTS: Burnout was measured with a validated single-item question with a 5-point scale ranging from (1) enjoy work to (5) completely burned out and seeking help. Patient experience of patient-provider communication, access, and overall rating of provider was measured with Clinician & Group Consumer Assessment of Healthcare Providers & Systems (CG-CAHPS) survey. Patient experience scores (0-100 scale) were adjusted for age, gender, race/ethnicity, and English proficiency. RESULTS: Physician burnout had a negative impact on patient-reported experience of patient-provider communication but not on access or overall rating of providers. A one-level increase in burnout was associated with 0.43 decrease in adjusted patient-provider communication experience score (P < 0.01). LIMITATIONS: Data came from a single large healthcare organization. Patterns may differ for small- and mid-sized practices. CONCLUSION: Physician burnout adversely affects patient-provider communication in primary care visits. Efforts to improve physician work environments could have a meaningful positive impact on patient experience as well as physician well-being.

Frontline Perspectives on Physician Burnout and Strategies to Improve Well-Being: Interviews with Physicians and Health System Leaders.

BACKGROUND: Nationally over 50% of physicians report symptoms of burnout. OBJECTIVE: To understand the perspectives of health system leaders and frontline physicians on contributors to physician burnout and strategies to improve well-being. DESIGN: We conducted in-depth interviews with health system leaders and frontline physicians at a large, predominantly fee-for-service, multispecialty group practice with approximately 1300 physicians. PARTICIPANTS: The 17 participants included 15 physicians, (12 Internal Medicine and Family Medicine physicians and 3 from other specialties), 11 individuals in leadership roles, and 11 women. APPROACH: Interviews included a review of factors associated with burnout at the organization, asking participants which factors they believed contributed to burnout, questions about experiences of burnout, and what specific changes would improve well-being. KEY RESULTS: All 17 participants agreed that organizational factors were key contributors to burnout, while only 9 mentioned the salience of individual factors: "It does not matter how resilient or positive you are, the work environment, especially in primary care will eventually be a problem." An increasing workload associated with the electronic health record (EHR) and a culture focused on productivity were cited as contributing to burnout, especially among physicians in Internal Medicine and Family Medicine (primary care) departments. Physicians in primary care, women, and leaders described multiple barriers to well-being. Participants described responding to increased workloads by reducing clinical work hours. Participants suggested reducing and compensating EHR work, expanding care teams/support staff, reducing use of metrics, providing more support to leaders, changing the business model, and increasing positivity and collegiality, as essential to improving well-being. CONCLUSION: Interviews reveal a variety of interacting factors contributing to physician burnout. Reducing clinical work hours has become a coping strategy. Changes recommended to improve physician well-being include increasing support staff, reducing EHR workload, changing revenue generation and compensation approaches, and shifting organizational culture to place more value on physician wellness.

Physicians' Well-Being Linked To In-Basket Messages Generated By Algorithms In Electronic Health Records.

Despite concerns about physicians' workload associated with electronic health records (EHRs), little attention has been paid to the relationship between physicians' well-being and the in-basket messages physicians receive-specifically, their volume and sources. Analyses of EHR work performed by physicians in a multispecialty practice found that in-basket messages generated by the EHR system accounted for almost half (114) of the 243 weekly in-basket messages received per physician, on average-far exceeding the numbers received from their colleagues (53) and patients (30). In a survey, 36 percent of the physicians reported burnout symptoms, and 29 percent intended to reduce their clinical work time in the upcoming year. Receiving more than the average number of system-generated in-basket messages was associated with 40 percent higher probability of burnout and 38 percent higher probability of intending to reduce clinical work time. Physicians' perceptions of a positive work environment were associated with lower odds of burnout and intention to reduce clinical work time and with greater satisfaction with life. Female physicians had a higher risk of burnout and lower satisfaction with life, compared to males. Meaningful redesign of EHR in-basket workflow and a wellness-enhancing work environment are necessary to effectively improve physicians' well-being.

Domestic goose as a model for West Nile virus vaccine efficacy.

West Nile virus (WNV) is an emergent pathogen in the Americas, first reported in New York during 1999, and has since spread across the USA, Central and South America causing neurological disease in humans, horses and some bird species, including domestic geese. No WNV vaccines are licensed in the USA for use in geese. This study reports the development of a domestic goose vaccine efficacy model, based on utilizing multiple parameters to determine protection. To test the model, 47 geese were divided in two experiments, testing five different vaccine groups and two sham groups (challenged and unchallenged). Based on the broad range of results for individual metrics between the Challenged-Sham and Unchallenged-Sham groups, the best parameters to measure protection were Clinical Pathogenicity Index (CPI), plasma virus positive geese on days 1-4 post-inoculation and plasma virus titers, and brain histological lesion rates and severity scores. Compared to the Challenged-Sham group, the fowlpox virus vectored vaccine with inserts of WNV prM and E proteins (vFP2000) provided the best protection with significant differences in all five metrics, followed by the canarypox virus vectored vaccine with inserts of WNV prM and E proteins (vCP2018) with four metrics of protection, recombinant vCP2017 with three metrics and WNV E protein with one. These data indicate that domestic geese can be used in an efficacy model for vaccine protection studies using clinical, plasma virological and brain histopathological parameters to evaluate protection against WNV challenge.

Protective immunization of horses with a recombinant canarypox virus vectored vaccine co-expressing genes encoding the outer capsid proteins of African horse sickness virus.

We describe the development and preliminary characterization of a recombinant canarypox virus vectored (ALVAC) vaccine for protective immunization of equids against African horse sickness virus (AHSV) infection. Horses (n=8) immunized with either of two concentrations of recombinant canarypox virus vector (ALVAC-AHSV) co-expressing synthetic genes encoding the outer capsid proteins (VP2 and VP5) of AHSV serotype 4 (AHSV-4) developed variable titres (<10-80) of virus-specific neutralizing antibodies and were completely resistant to challenge infection with a virulent strain of AHSV-4. In contrast, a horse immunized with a commercial recombinant canarypox virus vectored vaccine expressing the haemagglutinin genes of two equine influenza H3N8 viruses was seronegative to AHSV and following infection with virulent AHSV-4 developed pyrexia, thrombocytopenia and marked oedema of the supraorbital fossae typical of the "dikkop" or cardiac form of African horse sickness. AHSV was detected by virus isolation and quantitative reverse transcriptase polymerase chain reaction in the blood of the control horse from 8 days onwards after challenge infection whereas AHSV was not detected at any time in the blood of the ALVAC-AHSV vaccinated horses. The control horse seroconverted to AHSV by 2 weeks after challenge infection as determined by both virus neutralization and ELISA assays, whereas six of eight of the ALVAC-AHSV vaccinated horses did not seroconvert by either assay following challenge infection with virulent AHSV-4. These data confirm that the ALVAC-AHSV vaccine will be useful for the protective immunization of equids against African horse sickness, and avoids many of the problems inherent to live-attenuated AHSV vaccines.

Evaluation of the ability of canarypox-vectored equine influenza virus vaccines to induce humoral immune responses against canine influenza viruses in dogs.

OBJECTIVE: To evaluate canarypox-vectored equine influenza virus (EIV) vaccines expressing hemagglutinins of A/equine/Kentucky/94 (vCP1529) and A2/equine/Ohio /03 (vCP2242) for induction of antibody responses against canine influenza virus (CIV) in dogs. ANIMALS: 35 dogs. PROCEDURES: Dogs were randomly allocated into 4 groups; group 1 (n = 8) and group 2 (9) were inoculated SC on days 0 and 28 with 1.0 mL (approx 10(5.7) TCID(50)) of vCP1529 and vCP2242, respectively. Dogs in group 3 (n = 9) were inoculated twice with 0.25 mL (approx 10(5.7) TCID(50)) of vCP2242 via the transdermal route. The 9 dogs of group 4 were control animals. All dogs were examined for adverse reactions. Sera, collected on days -1, 7, 13, 21, 28, 35, and 42, were tested by hemagglutination inhibition (HI) and virus neutralization (VN) assays for antibodies against CIV antigens A/Canine/FL/43/04-PR and A/Canine/NY/115809/05, respectively. RESULTS: Inoculations were tolerated well. The HI and VN antibodies were detected by 7 days after primary inoculation. Most dogs of groups 1 and 2 and all dogs of group 3 had detectable antibodies by 14 days after initial inoculation. The second inoculation induced an anamnestic response, yielding geometric mean HI titers of 139, 276, and 1,505 and VN titers of 335, 937, and 3,288 by day 42 (14 days after booster inoculation) in groups 1, 2, and 3, respectively. CONCLUSIONS AND CLINICAL RELEVANCE: Canarypox-vectored EIV vaccines induce biologically important antibodies and may substantially impact CIV transmission within a community and be of great value in protecting dogs against CIV-induced disease.

Recombinant canarypox virus vaccine co-expressing genes encoding the VP2 and VP5 outer capsid proteins of bluetongue virus induces high level protection in sheep.

We describe the development and preliminary characterization of a recombinant canarypox virus vectored vaccine for protective immunization of ruminants against bluetongue virus (BTV) infection. Sheep (n=6) immunized with recombinant canarypox virus vector (BTV-CP) co-expressing synthetic genes encoding the two outer capsid proteins (VP2 and VP5) of BTV serotype 17 (BTV-17) developed high titers (40-160) of virus-specific neutralizing antibodies and were resistant to challenge with a field strain of BTV-17. In contrast, sheep (n=5) immunized with a commercial recombinant canarypox virus vector expressing the E and preM genes of West Nile virus were seronegative to BTV and developed pyrexia, lymphopenia, and extended, high-titered viremias following challenge exposure to the field strain of BTV-17. These data confirm that the BTV-CP vaccine may be useful for the protective immunization of ruminants against bluetongue, and it may avoid the problems inherent to live-attenuated (LA) BTV vaccines.

Evaluation of the efficacy provided by a Recombinant Canarypox-Vectored Equine West Nile Virus vaccine against an experimental West Nile Virus intrathecal challenge in horses.

Efficacy of the Recombitek Equine West Nile Virus (WNV) vaccine was evaluated against a WNV intrathecal challenge model that results in WNV-induced clinical disease. Ten vaccinated (twice at days 0 and 35) and 10 control horses were challenged 2 weeks after administration of the second vaccine with a virulent WNV by intrathecal administration. After the challenge, eight of 10 controls developed clinical signs of encephalomyelitis whereas one vaccinate exhibited muscle fasciculation only once. Nine controls and one vaccinate developed a fever. Histopathology revealed mild to moderate nonsuppurative encephalitis in eight controls and one vaccinate. None of the vaccinates and all of the controls developed WNV viremia after challenge. All vaccinated horses developed antibodies to WNV after vaccination. These and results of previous studies demonstrate efficacy of the Recombitek WNV vaccine against WNV-induced clinical disease and natural challenge with WNV-infected mosquitoes.

Pathogenesis of West Nile virus infection in dogs treated with glucocorticoids.

Control and glucocorticoid-treated dogs were infected with West Nile virus (WNV) through the bites of infected mosquitoes to study the effect of a commonly used immunomodulator on the magnitude and duration of viremia and on development of clinical disease. All dogs became viremic after challenge. The peak viremia and integrated magnitude of viremia were approximately 40 and 50 times higher, respectively, in the five dogs treated with methyl-prednisolone for 1 month compared with untreated dogs. None of the five control or treated dogs developed signs of clinical disease, nor was histopathologic evidence of neuroinvasion observed in any case. Neutralizing antibodies to WNV were produced in all dogs, with no apparent effect of glucocorticoid treatment. Considering the dramatic effect of glucocorticoid treatment on magnitude of viremia, it is likely that this therapy had suppressive effects on some aspect of innate immunity or T cell function.

Immunogenicity of fowlpox virus expressing the avian influenza virus H5 gene (TROVAC AIV-H5) in cats.

Vaccination of cats with fowlpox virus expressing the avian influenza (AI) virus H5 hemagglutinin gene (TROVAC AI) resulted in detectable hemagglutination inhibition (HI) antibody responses to the homologous A/Turkey/Ireland/1378/83 (H5N8) (A/tky/Ire/83) AI virus antigen. The HI antibody responses to heterologous A/Chicken/Indonesia/7/03 (H5N1) (A/ck/Indonesia/03) AI virus antigen were also detected in all vaccinated cats, but only after booster vaccinations. The vaccine described in this study and other poxvirus-vectored vaccines may be of value for the prophylaxis of AI virus-associated morbidity and mortality in mammals.

Assessment of the efficacy of a single dose of a recombinant vaccine against West Nile virus in response to natural challenge with West Nile virus-infected mosquitoes in horses.

OBJECTIVE: To determine the onset of immunity after IM administration of a single dose of a recombinant canarypox virus vaccine against West Nile virus (WNV) in horses in a blind challenge trial. ANIMALS: 20 mixed-breed horses. PROCEDURE: Horses with no prior exposure to WNV were randomly assigned to 1 of 2 groups (10 horses/group). In 1 group, a recombinant canarypox virus vaccine against WNV was administered to each horse once (day 0). The other 10 control horses were untreated. On day 26, 9 treated and 10 control horses were challenged via the bites of mosquitoes (Aedes albopictus) infected with WNV. Clinical responses and WNV isolation were monitored for 14 days after challenge exposure; antibody responses against WNV after administration of the vaccine and challenge were also assessed in both groups. RESULTS: Following challenge via WNV-infected mosquitoes, 1 of 9 treated horses developed viremia. In contrast, 8 of 10 control horses developed viremia after challenge exposure to WNV-infected mosquitoes. All horses seroconverted after WNV challenge; compared with control horses, antibody responses in the horses that received the vaccine were detected earlier. CONCLUSIONS AND CLINICAL RELEVANCE: In horses, a single dose of the recombinant canarypox virus-WNV vaccine appears to provide early protection against development of viremia after challenge with WNV-infected mosquitoes, even in the absence of measurable antibody titers in some horses. This vaccine may provide veterinarians with an important tool in controlling WNV infection during a natural outbreak or under conditions in which a rapid onset of protection is required.