IMPORTANCE: Burnout is prevalent in physicians and can have a negative influence on performance, career continuation and patient care. Existing evidence does not allow clear recommendations for the management of burnout in physicians. OBJECTIVE: To evaluate the effectiveness of interventions to reduce burnout in physicians. We also examined whether different types of interventions (physician-directed or organization-directed interventions), physician characteristics (length of experience) and healthcare setting characteristics (primary or secondary care) were associated with improved effects. DATA SOURCES: Medline, Embase, PsycINFO, Cinahl, and Central, were searched from inception to May 2016. The reference lists of eligible studies and other relevant systematic reviews were hand-searched. STUDY SELECTION: Randomized controlled trials and controlled before-after studies of interventions targeting burnout in physicians. DATA EXTRACTION AND SYNTHESIS: Two independent reviewers extracted data and assessed the risk of bias. The main meta-analysis was followed by a number of pre-specified subgroup and sensitivity analyses. All analyses were performed using random-effects models and heterogeneity was quantified using I 2. MAIN OUTCOME AND MEASURES: The core outcome was burnout scores focused on emotional exhaustion, reported as standardized mean differences and their 95% confidence intervals. RESULTS: Twenty independent comparisons from 19 studies were included in the metaanalysis (n=1,550 physicians). Interventions were associated with small significant reductions in burnout (SMD=-0.29, 95% CI=-0.42 to-0.16; equal to a drop of 3-points on the emotional exhaustion domain of the Maslach Burnout Inventory above change in the controls). Subgroup analyses suggested significantly improved effects for organization-5 directed interventions (SMD=-0.45, 95% CI=-0.62 to-0.28) compared to physician-directed interventions (SMD=-0.18, 95% CI=-0.32 to-0.03). Interventions delivered in experienced physicians and in primary care were associated with higher effects compared to interventions delivered in inexperienced physicians and in secondary care, but these differences were not significant. The results were not influenced by the risk of bias ratings. CONCLUSION: Evidence from this meta-analysis suggests that current intervention programs for burnout in physicians are associated with small benefits which may be boosted by adoption of organization-directed approaches. This finding provides support for the view that burnout is a problem of the whole healthcare organization, rather than individuals.

Background The emergence of patient and public involvement (PPI) in healthcare in the UK can be traced as far back as the 1970s. More recently, campaigns by harmed patients have led to a renewed focus on strengthening PPI. There is a growing awareness of the benefits of PPI in research as well as a need to address power inequities and a lack of diversity and inclusion. This review was undertaken to look at evidence for theories, barriers and enablers in PPI across health, social care and patient safety that could be used to strengthen PPI and address a perceived knowledge and theory gap with PPI in patient safety. Methods We searched MEDLINE, EMBASE and PsycINFO from inception to August 2018, using both MeSH and free-text terms to identify published empirical literature. Protocols in PROSPERO were also searched to identify any systematic reviews in progress. The extracted information was analysed using a narrative approach, which synthesises data using a descriptive method. Results Forty-two reviews were identified and grouped by key outcomes. Twenty-two papers mentioned theory in some form, 31 mentioned equality and diversity (although with no theory mentioned in this area), and only 19 cited equality and diversity as a barrier or enabler. Thirty-four reviews identified barriers and enablers at different organisational levels: personal/individual; attitudes; health professional; roles and expectations; knowledge, information and communication; financing and resourcing; training; general support; recruitment and representation, PPI methods and working with communities and addressing power dynamics. Conclusions The review findings suggest that a commitment to PPI and partnership working is dependent on taking a whole system approach. This needs to consider the complex individual and organisational enablers and constraints to this process and address imbalances of power experienced by different groups. Addressing equality and diversity and use of a theory-driven approach to guide PPI are neglected areas. The long tradition of involvement across health and social care can provide considerable expertise in thinking about ways to strengthen approaches to PPI. This is especially important in patient safety, with a much newer tradition of developing PPI than other areas of healthcare.

BackgroundImplementation of self-management support in traditional primary care settings has proved difficult, encouraging the development of alternative models which actively link to community resources. Chronic kidney disease (CKD) is a common condition usually diagnosed in the presence of other co-morbidities. This trial aimed to determine the effectiveness of an intervention to provide information and telephone-guided access to community support versus usual care for patients with stage 3 CKD.Methods and FindingsIn a pragmatic, two-arm, patient level randomised controlled trial 436 patients with a diagnosis of stage 3 CKD were recruited from 24 general practices in Greater Manchester. Patients were randomised to intervention (215) or usual care (221). Primary outcome measures were health related quality of life (EQ-5D health questionnaire), blood pressure control, and positive and active engagement in life (heiQ) at 6 months. At 6 months, mean health related quality of life was significantly higher for the intervention group (adjusted mean difference = 0.05; 95% CI = 0.01, 0.08) and blood pressure was controlled for a significantly greater proportion of patients in the intervention group (adjusted odds-ratio = 1.85; 95% CI = 1.25, 2.72). Patients did not differ significantly in positive and active engagement in life. The intervention group reported a reduction in costs compared with control.ConclusionsAn intervention to provide tailored information and telephone-guided access to community resources was associated with modest but significant improvements in health related quality of life and better maintenance of blood pressure control for patients with stage 3 CKD compared with usual care. However, further research is required to identify the mechanisms of action of the intervention.Trial RegistrationControlled-Trials.com ISRCTN45433299