Daniel S. Tawfik, MD, MS; Annette Scheid, MD; Jochen Profit, MD, MPH; Tait Shanafelt, MD; Mickey Trockel, MD, PhD; Kathryn C. Adair, PhD; J. Bryan Sexton, PhD; John P.A. Ioannidis, MD, DSc
Note: The lead author had full access to all data in the study and affirms that the manuscript is an honest, accurate, and transparent account of the study; that no important aspects of the study have been omitted; and that any discrepancies from the study as originally planned have been explained.
Financial Support: By the Stanford Maternal and Child Health Research Institute.
Disclosures: Dr. Tawfik reports grants from Stanford Maternal and Child Health Research Institute during the conduct of the study. Dr. Profit reports grants from the Eunice Kennedy Shriver National Institute of Child Health and Human Development during the conduct of the study and has received honoraria for speaking at scientific meetings on the topic of burnout. Dr. Sexton reports grants from the National Institutes of Health during the conduct of the study. Authors not named here have disclosed no conflicts of interest. Disclosures can also be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M19-1152.
Editors' Disclosures: Christine Laine, MD, MPH, Editor in Chief, reports that her spouse has stock options/holdings with Targeted Diagnostics and Therapeutics. Darren B. Taichman, MD, PhD, Executive Editor, reports that he has no financial relationships or interests to disclose. Cynthia D. Mulrow, MD, MSc, Senior Deputy Editor, reports that she has no relationships or interests to disclose. Jaya K. Rao, MD, MHS, Deputy Editor, reports that she has stock holdings/options in Eli Lilly and Pfizer. Catharine B. Stack, PhD, MS, Deputy Editor, Statistics, reports that she has stock holdings in Pfizer, Johnson & Johnson, and Colgate-Palmolive. Christina C. Wee, MD, MPH, Deputy Editor, reports employment with Beth Israel Deaconess Medical Center. Sankey V. Williams, MD, Deputy Editor, reports that he has no financial relationships or interests to disclose. Yu-Xiao Yang, MD, MSCE, Deputy Editor, reports that he has no financial relationships or interest to disclose.
Reproducible Research Statement: Study protocol, statistical code, and data set: Available from Dr. Tawfik (e-mail, email@example.com).
Corresponding Author: Daniel S. Tawfik, MD, MS, 770 Welch Road, Suite 435, Palo Alto, CA 94304; e-mail, firstname.lastname@example.org.
Current Author Addresses: Dr. Tawfik: 770 Welch Road, Suite 435, Palo Alto, CA 94304.
Dr. Scheid: Office BL341G, 221 Longwood Avenue, Boston, MA 02115.
Dr. Profit: 1265 Welch Road, MSOB x1C07, Stanford, CA 94305.
Dr. Shanafelt: 300 Pasteur Drive, Room H3215, Stanford, CA 94305.
Dr. Trockel: 401 Quarry Road, Room 2303, Stanford, CA 94305.
Drs. Adair and Sexton: 3100 Tower Boulevard, Suite 300, Durham, NC 27707.
Dr. Ioannidis: 1265 Welch Road, MSOB x306, Stanford, CA 94305.
Author Contributions: Conception and design: D.S. Tawfik, J.P.A. Ioannidis.
Analysis and interpretation of the data: D.S. Tawfik, J. Profit, T. Shanafelt.
Drafting of the article: D.S. Tawfik, T. Shanafelt, J.P.A. Ioannidis.
Critical revision for important intellectual content: D.S. Tawfik, A. Scheid, T. Shanafelt, M. Trockel, J.B. Sexton, J.P.A. Ioannidis.
Final approval of the article: D.S. Tawfik, A. Scheid, J. Profit, T. Shanafelt, M. Trockel, K.C. Adair, J.B. Sexton, J.P.A. Ioannidis.
Provision of study materials or patients: D.S. Tawfik.
Statistical expertise: D.S. Tawfik.
Obtaining of funding: D.S. Tawfik.
Administrative, technical, or logistic support: D.S. Tawfik, A. Scheid, J.B. Sexton.
Collection and assembly of data: D.S. Tawfik, A. Scheid, K.C. Adair.
Whether health care provider burnout contributes to lower quality of patient care is unclear.
To estimate the overall relationship between burnout and quality of care and to evaluate whether published studies provide exaggerated estimates of this relationship.
MEDLINE, PsycINFO, Health and Psychosocial Instruments (EBSCO), Mental Measurements Yearbook (EBSCO), EMBASE (Elsevier), and Web of Science (Clarivate Analytics), with no language restrictions, from inception through 28 May 2019.
Peer-reviewed publications, in any language, quantifying health care provider burnout in relation to quality of patient care.
2 reviewers independently selected studies, extracted measures of association of burnout and quality of care, and assessed potential bias by using the Ioannidis (excess significance) and Egger (small-study effect) tests.
A total of 11 703 citations were identified, from which 123 publications with 142 study populations encompassing 241 553 health care providers were selected. Quality-of-care outcomes were grouped into 5 categories: best practices (n = 14), communication (n = 5), medical errors (n = 32), patient outcomes (n = 17), and quality and safety (n = 74). Relations between burnout and quality of care were highly heterogeneous (I2 = 93.4% to 98.8%). Of 114 unique burnout–quality combinations, 58 indicated burnout related to poor-quality care, 6 indicated burnout related to high-quality care, and 50 showed no significant effect. Excess significance was apparent (73% of studies observed vs. 62% predicted to have statistically significant results; P = 0.011). This indicator of potential bias was most prominent for the least-rigorous quality measures of best practices and quality and safety.
Studies were primarily observational; neither causality nor directionality could be determined.
Burnout in health care professionals frequently is associated with poor-quality care in the published literature. The true effect size may be smaller than reported. Future studies should prespecify outcomes to reduce the risk for exaggerated effect size estimates.
Stanford Maternal and Child Health Research Institute.
Tawfik DS, Scheid A, Profit J, et al. Evidence Relating Health Care Provider Burnout and Quality of Care: A Systematic Review and Meta-analysis. Ann Intern Med. 2019;171:555–567. [Epub ahead of print 8 October 2019]. doi: https://doi.org/10.7326/M19-1152
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Published: Ann Intern Med. 2019;171(8):555-567.
Published at www.annals.org on 8 October 2019
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