Week 3: Lab

statistics multi-part question and need an explanation and answer to help me learn.

Part 1:
Your instructor will provide you with a scholarly article. The article will contain at least one graph and/or table. Please reach out to your instructor if you do not receive the article by Monday of Week 3.
Part 2:
Title your paper: “Review of [Name of Article]”
State the Author:
Summarize the article in one paragraph:
Post a screenshot of the article’s frequency table and/or graph.
Example:
Frequency Distribution -OR- Graph
Answer the following questions about your table or graph.
What type of study is used in the article (quantitative or qualitative)?
Explain how you came to that conclusion.
What type of graph or table did you choose for your lab (bar graph, histogram, stem & leaf plot, etc.)?
What characteristics make it this type (you should bring in material that you learned in the course)?
Describe the data displayed in your frequency distribution or graph (consider class size, class width, total frequency, list of frequencies, class consistency, explanatory variables, response variables, shapes of distributions, etc.)
Draw a conclusion about the data from the graph or frequency distribution in the context of the article.
How else might this data have been displayed?
Discuss the pros and cons of 2 other presentation options, such as tables or different graphical displays.
Why do you think those two other presentation options (i.e., tables or different graphs) were not used in this article?
Give the full APA reference of the article you are using for this lab.
Be sure your name is on the Word document, save it, and then submit it under “Assignments” and “Week 3: Lab”.
Week 3 Lab Assignment
Name:________________________ Instructor Name: _______________
Please use this template to help answer the questions listed in the lab instructions. The “parts” below refer to the parts listed in the lab instructions. Type your answers and post your screenshots in the spaces given below. Then, save this document with your name and submit it inside the course room.
Part 1. Read the assigned article.
Please reach out to your instructor if you did not receive the assigned article for the term by Monday of Week 3.
Part 2. Analyze the article.
Title: Review of [Type out name of Article]
Author(s): [Type out names of Author(s) of the Article]
Summarize the article in one paragraph:
Post a screenshot of a graph/chart from the article that you will analyze:
Analysis
(Answer the following questions thoroughly in complete sentences)

What type of study is used in the article (quantitative or qualitative)? Explain how you came to that conclusion. 
What type of graph or table did you choose for your lab (bar graph, histogram, stem & leaf plot, etc.)? What characteristics make it this type (you should bring in material that you learned in the course)?
Describe the data displayed in your frequency distribution or graph (consider class size, class width, total frequency, list of frequencies, class consistency, explanatory variables, response variables, shapes of distributions, etc.)   
Draw a conclusion about the data from the graph or frequency distribution in context of the article. 
How else might this data have been displayed (Pick two different graphs that could have been used to display the same data as your selected graph/table)?
Discuss pros and cons of 2 other presentation options, such as tables or different graphical displays.
Explain how these graphs would be structured to display the data in the article. Why don’t you think those two graphs were not used in this article? 
Give the full APA reference of the article you are using for this lab. 
Be sure your name is on the Word document, save it, and then submit it. In the assignment module, click “start assignment” and then “upload file” and “submit assignment”.

EvidenceRelatingHealthCareProviderBurnoutandQualityofCareASystematicReviewandMeta-analysisDanielS.Tawfik,MD,MS;AnnetteScheid,MD;JochenProfit,MD,MPH;TaitShanafelt,MD;MickeyTrockel,MD,PhD;KathrynC.Adair,PhD;J.BryanSexton,PhD;andJohnP.A.Ioannidis,MD,DScBackground:Whetherhealthcareproviderburnoutcontrib-utestolowerqualityofpatientcareisunclear.Purpose:Toestimatetheoverallrelationshipbetweenburnoutandqualityofcareandtoevaluatewhetherpublishedstudiesprovideexaggeratedestimatesofthisrelationship.DataSources:MEDLINE,PsycINFO,HealthandPsychosocialInstruments(EBSCO),MentalMeasurementsYearbook(EBSCO),EMBASE(Elsevier),andWebofScience(ClarivateAnalytics),withnolanguagerestrictions,frominceptionthrough28May2019.StudySelection:Peer-reviewedpublications,inanylanguage,quantifyinghealthcareproviderburnoutinrelationtoqualityofpatientcare.DataExtraction:2reviewersindependentlyselectedstudies,extractedmeasuresofassociationofburnoutandqualityofcare,andassessedpotentialbiasbyusingtheIoannidis(excesssignif-icance)andEgger(small-studyeffect)tests.DataSynthesis:Atotalof11703citationswereidentified,fromwhich123publicationswith142studypopulationsencompass-ing241553healthcareproviderswereselected.Quality-of-careoutcomesweregroupedinto5categories:bestpractices(n=14),communication(n=5),medicalerrors(n=32),patientout-comes(n=17),andqualityandsafety(n=74).Relationsbe-tweenburnoutandqualityofcarewerehighlyheterogeneous(I2=93.4%to98.8%).Of114uniqueburnout–qualitycombina-tions,58indicatedburnoutrelatedtopoor-qualitycare,6indi-catedburnoutrelatedtohigh-qualitycare,and50showednosignificanteffect.Excesssignificancewasapparent(73%ofstud-iesobservedvs.62%predictedtohavestatisticallysignificantresults;P=0.011).Thisindicatorofpotentialbiaswasmostprominentfortheleast-rigorousqualitymeasuresofbestprac-ticesandqualityandsafety.Limitation:Studieswereprimarilyobservational;neithercausal-itynordirectionalitycouldbedetermined.Conclusion:Burnoutinhealthcareprofessionalsfrequentlyisassociatedwithpoor-qualitycareinthepublishedliterature.Thetrueeffectsizemaybesmallerthanreported.Futurestudiesshouldprespecifyoutcomestoreducetheriskforexaggeratedeffectsizeestimates.PrimaryFundingSource:StanfordMaternalandChildHealthResearchInstitute.AnnInternMed.2019;171:555-567.doi:10.7326/M19-1152Annals.orgForauthoraffiliations,seeendoftext.ThisarticlewaspublishedatAnnals.orgon8October2019.Healthcareprovidersfacearapidlychangingland-scapeoftechnology,caredeliverymethods,andregulationsthatincreasetheriskforprofessionalburn-out.Studiessuggestthatnearlyhalfofhealthcarepro-vidersmayhaveburnoutsymptomsatanygiventime(1).Burnouthasbeenlinkedtoadverseeffects,includ-ingsuicidality,brokenrelationships,decreasedproduc-tivity,unprofessionalbehavior,andemployeeturnover,atboththeproviderandorganizationallevels(2–6).Recentattentionhasbeenfocusedontherelationbetweenhealthcareproviderburnoutandreducedqualityofcare,withagrowingbodyofprimarylitera-tureandsystematicreviewsreportingassociationsbe-tweenburnoutandadherencetopracticeguidelines,communication,medicalerrors,patientoutcomes,andsafetymetrics(7–11).Moststudiesinthisfielduseret-rospectiveobservationaldesignsandapplyawiderangeofburnoutassessmentsandanalytictoolstoevaluatemyriadoutcomesamongdiversepatientpop-ulations(12).Thislackofastandardizedapproachtomeasurementandanalysisincreasesriskofbias,poten-tiallyunderminingscientificprogressinarapidlyex-pandingfieldofresearchbyhamperingtheabilitytodecipherwhichoftheapparentclinicallysignificantre-sultsrepresenttrueeffects(13).Thepresentanalysissoughttoappraisethisbodyofprimaryandreviewlit-erature,developinganunderstandingoftrueeffectswithinthefieldbyusingadetailedevaluationforre-portingbiases.Reportingbiasestakemanyforms,eachcontribut-ingtooverrepresentationof“positive”findingsinthepublishedliterature.Publicationbiasoccurswhenstud-ieswithnegativeresultsarepublishedlessfrequentlyorlessrapidlythanthosewithpositiveresults(14).Se-lectiveoutcomereportingoccurswhenseveralout-comesofpotentialinterestareevaluated,butonlythosewithpositiveresultsarepresentedorempha-sized(13).Selectiveanalysisreportingoccurswhenseveralanalyticstrategiesareused,butthosethatpro-ducethelargesteffectsarepresented.Overall,thesebiasesresultinanexcessofstatisticallysignificantre-sultsinthepublishedliterature,threateningreproduc-ibilityoffindings,promotingmisappropriationofre-sources,andskewingthedesignofstudiesassessinginterventionstoreduceburnoutorimprovequality(13).Seealso:Editorialcomment…………………….589Web-OnlySupplementAnnalsofInternalMedicineREVIEW©2019AmericanCollegeofPhysicians555
METHODSWeconductedasystematicliteraturereviewandmeta-analysistoprovidesummaryestimationsoftherelationbetweenproviderburnoutandqualityofcare,estimatestudyheterogeneity,andexplorethepotentialofreportingbiasinthefield.WefollowedthePRISMA(PreferredReportingItemsforSystematicreviewsandMeta-Analyses)andMOOSE(Meta-analysisofObserva-tionalStudiesinEpidemiology)guidelinesformethod-ologyandreporting(15,16).DataSourcesandSearchesWesearchedMEDLINE,PsycINFO,HealthandPsy-chosocialInstruments(EBSCO),MentalMeasurementsYearbook(EBSCO),EMBASE(Elsevier),andWebofSci-ence(ClarivateAnalytics)frominceptionthrough28May2019,withnolanguagerestrictions.Weusedsearchtermsforburnoutanditssubdomains(emo-tionalexhaustion,depersonalization,andreducedper-sonalaccomplishment),healthcareproviders,andquality-of-caremarkers,asshowninSupplementTa-bles1to3(availableatAnnals.org).StudySelectionWeincludedallpeer-reviewedpublicationsreport-ingoriginalinvestigationsofhealthcareproviderburn-outinrelationtoanassessmentofpatientcarequality.Providersincludedallpaidprofessionalsdeliveringoutpatient,prehospital,emergency,orinpatientcare,includingmedical,surgical,andpsychiatriccare,topa-tientsofanyage.Wechoseaninclusivemethodofidentifyingburnoutstudies,consideringassessmentstoberelatedtoburnoutiftheauthorsdefinedthemassuchandusedanyinventoryintendedtoidentifyburnout,eitherinpartorinfull.Likewise,wechoseaninclusiveapproachtoidentifyquality-of-caremetrics,includinganyassessmentofprocessesoroutcomesindicativeofcarequality.Weincludedobjectivelymeasuredandsubjec-tivelyreportedqualitymetricsoriginatingfromthepro-vider,othersourceswithinthehealthcaresystem,orpa-tientsandtheirsurrogates.Weconsideredmedicalmalpracticeallegationsasubjectivepatient-reportedqualitymetric.Althoughpatientsatisfactionisanimpor-tantoutcome,itisnotconsistentlyindicativeofcarequal-ityorimprovedmedicaloutcomes,suggestingthatitmayberelatedtofactorsoutsidetheprovider’simmediatecontrol,suchasfacilityamenitiesandaccesstocare(17–20).Thus,forthepurposesofthisreview,weexcludedmetricssolelyindicativeofpatientsatisfactiontoreducebiasfromthesenon–provider-relatedfactorsthatmayaf-fectsatisfaction.Weincludedpeer-reviewed,indexedabstractsiftheyreportedastudypopulationnotpreviouslyorsub-sequentlyreportedinafull-lengtharticle.Forstudypopulationsdescribedinmorethan1full-lengtharti-cle,weincludedtheprimaryresultfromthepaperwiththeearliestpublicationdateastheprimaryoutcome,withanyuniqueoutcomesfromsubsequentarticlesassecondaryoutcomes.Wesupplementedthedatabasesearcheswithmanualbibliographyreviewsfromin-cludedstudiesandrelatedliteraturereviews(7–9,21–24).Inlinewithouraimtolookforreportingbias,wedidnotexpandoursearchbeyondpeer-reviewedpub-licationsanddidnotcontactauthorsforunpublisheddata.Ifanarticlepresentedinsufficientdatatocalculateaneffectsize,wesupplementedtheinformationwithdatafromsubsequentpeer-reviewedpublicationswhenavailable;however,westillattributedtheseeffectsizestotheinitialreport.Weexcludedanystudiesthatwerepurelyqualitative.Allinvestigatorscontributedtothedevelopmentofstudyinclusionandexclusioncriteria.Theliteraturere-viewandstudyselectionwereconductedby2inde-pendentreviewersinparallel(D.S.T.andeitherA.S.orK.C.A.),withambiguitiesanddiscrepanciesresolvedbyconsensus.DataExtractionandQualityAssessmentWeextracteddataintoastandardtemplatereflect-ingpublicationcharacteristics,methodsofassessingburnoutandqualitymetrics,andstrengthofthere-portedrelationship.Datawereextractedby2indepen-dentreviewers(D.S.T.andA.S.),withdiscrepanciesre-solvedbyconsensus.WeestimatedeffectsizesandprecisionusingtheHedgesgandSEs,respectively.TheHedgesgestimateseffectsizesimilarlytotheCo-hend,butwithabiascorrectionfactorforsmallsam-ples.Ingeneral,0.2indicatessmalleffect;0.5,mediumeffect;and0.8,largeeffect.Weclassifiedeachassessmentofburnoutasover-allburnout,emotionalexhaustion,depersonalization,orlowpersonalaccomplishment.Wealsoidentifiedburnoutassessmentsasstandardifdefinedasanemo-tionalexhaustionscoreof27orgreateroradeperson-alizationscoreof10orgreaterontheMaslachBurnoutInventory,orasthemidpointandhigheronvalidatedsingle-itemscales.Wecategorizedqualitymetricswithin5groups—bestpractices,communication,medicalerrors,patientoutcomes,andqualityandsafety—andreversecodedany“high-quality”metricssuchthatpositiveeffectsizesindicateburnout’srelationtopoor-qualitycare.Forpublicationswithseveraldistinct(nonover-lapping)studypopulationsreportedseparately,wecon-sideredeachpopulationseparatelyforanalyticpurposes.Forpublicationswithmorethan1outcomeforthesamestudypopulation,wedecidedtoperformanalysesusingonly1outcomeperstudy,ideallythespecifiedprimaryoutcome.Ifnoprimaryoutcomewasclear,wechosethefirst-listedoutcome,consistentwithreportingconventionsofpresentingtheprimaryoutcomefirst.Weconsideredotheroutcomessecondary,excludingthemfromthepri-maryanalysestoavoidbiasfromintercorrelationbutin-cludingtheminselecteddescriptivestatisticsandstrati-fiedanalyseswhenappropriate.DataSynthesisandAnalysisWecalculatedtheHedgesgfromoddsratios(di-chotomizeddata)byusingthetransformationlogOR*3orfromcorrelationcoefficients(unscaledcontinuousdata)byusingthetransformation2*r1r2,REVIEWBurnoutandQualityofCare556AnnalsofInternalMedicine•Vol.171No.8•15October2019Annals.org
bothmultipliedbyabiascorrectionfactorN2Ncon-sistentwithpublishednorms(25,26).FurtherdetailsareprovidedintheSupplement(availableatAnnals.org).Moststudiesreportedburnoutasadichotomousvariableorwithunscaledeffectsizeestimates,facilitat-ingtheaforementionedtransformations.Wescaledef-fectsizesaccordinglyforthe6studiesreportingburn-outonlyasacontinuousvariableinordertomaintaincomparability,adaptingourmethodsfrompublishedguidelines(27,28).Onthebasisofknowndistributionsofburnoutscoresamongproviders(29–31),wecalcu-latedthedifferencebetweenthemeanscoresofpro-viderswithandwithoutburnouttoaverage47.6%ofthespanoftheparticularburnoutscaleused.Wethusconvertedeffectsizesfromcontinuousscalestothecorrespondingeffectsizereflectinga47.6%changeinscalescorewhenneededtoextrapolatetodichoto-mizedburnout.Wealsoperformedsensitivityanalysesexcludingthesefewscaledeffectsizes.DetailsofthisprocessarepresentedintheSupplement.Initially,weintendedtoprimarilyperformarandom-effectsmeta-analysisincludingallprimary(orfirst-listed)effectsizes,withsecondarymeta-analysesstratifiedbyqualitymetriccategoryandbyeachuniqueburnout–qualitymetriccombination.However,becauseofhighheterogeneityinthepooledmeta-analyses,wereportonlysummaryeffectsfromtheuniqueburnout–qualitymetriccombinations.Wealsoperformedsensi-tivityanalyseslimitedtostudieswithstandardburnoutassessmentsandthosewithindependentlyobservedorobjectivelymeasuredquality-of-caremarkers.WeusedtheempiricalBayesmethodwithKnapp–Hartungmod-ificationtoestimatethebetween-studyvariance2(32).WeevaluatedstudyheterogeneityusingI2.Detailsre-gardingthismeta-analyticapproacharepresentedintheSupplement.WeperformedtheIoannidistesttoevaluateforex-cesssignificance(33)byidentifyingthestudypopula-tionwiththehighestprecision(1/SE)amongthosewiththelowestriskofbias(studiesusingafullyvalidatedburnoutinventorywithanobjectivequalitymetric).Wethencalculatedthepowerofallstudiestodetecttheeffectsizeofthisstudyandcomparedtheobservedversusexpectednumberofstudieswithstatisticallysig-nificantresultsbyusingpairedttests.Next,westrati-fiedexcesssignificancetestingbyoutcomecategory.Becausesmallstudiesmaycarryincreasedriskofbias,weperformedtheEggertesttolookforsmall-studyeffects(34).Weregressedstandardnormaldevi-ate(Hedgesg/SE)onprecision(1/SE)byusingrobustSEsduetoclusteringofeffectsizesatthestudypopu-lationlevel.WeusedStata15.0(StataCorp)forallanalyses.Alltestswere2-sided.Forsummaryeffects,weconsidered2differentthresholdsofstatisticalsignificance,P<0.050andthenewlyproposedP<0.005(35,36).Wemadenofurthercorrectionsformultipletesting.ThisstudywasperformedinaccordancewiththeinstitutionalreviewboardrequirementsofStanfordUniversityandwasclassifiedasresearchnotinvolvinghumansubjects.RoleoftheFundingSourceThefundershadnoroleinstudydesign,datacol-lection,analysis,interpretation,orwritingofthereport.Figure1.Evidencesearchandselection.Articles identified in MEDLINEand PsyclNFO (n = 6715)Articles identified in Web ofScience (n = 3116)Articles identified inEMBASE (n = 3871)Duplicate publications (n = 1999)Titles/abstracts screened (n = 11 703)Not relevant (n = 11 390)Selected for full-text review (n = 313)Bibliographic reviews (n = 3)Included in final analysis (n = 123)Excluded (n = 193) No burnout predictor: 123 No quality outcome: 46 Review/repeat population: 16 Not quantitative: 7 Not health care providers: 1BurnoutandQualityofCareREVIEWAnnals.orgAnnalsofInternalMedicine•Vol.171No.8•15October2019557 RESULTSThesearchidentified11703citations.Screeningresultedin313potentiallyeligiblepublicationsre-trievedinfulltext—120ofwhichwereincluded—plus3additionalpublicationsidentifiedbybibliographyre-view(Figure1).Overall,weincluded123publicationsfrom1994through2019(37–159),encompassing142distinctstudypopulations,asdetailedinSupplementTable4(availableatAnnals.org).Themediansamplesizewas376(interquartilerange,129to1417).The142studypopulationsincludedphysicians(n=71[50%]),nurses(n=84[59%]),andotherproviders(n=18[13%])foratotalof241553healthcareproviderseval-uated.Qualitymetricscoveredinpatients(n=122[86%]);outpatients(n=62[44%]);andadult(n=134[94%]),pediatric(n=93[65%]),medical(n=135[95%]),andsurgical(n=89[63%])patients.Only4studiesexplicitlyspecifiedaprimaryoutcome.Sixstud-iesdidnotprovidesufficientdatatoderiveaneffectsizefromtheoriginalpublicationbutprovidedusableFigure2.Summaryofallincludedburnout–qualitymetriccombinations,showingfrequencyofeffectsizereporting(count)andvalueofsummaryeffectsize(Hedgesg).Burnout MetricBurnoutEmotional exhaustionDepersonalizationLow personal accomplishmentBurnoutEmotional exhaustionDepersonalizationLow personal accomplishmentQuality MetricQuality and safetyOutcomesErrorsCommunicationBest practices302515Count1075312.01.51.00.5–0.5–1.0–2.0–1.50Hedges g20Inappropriate laboratory testsInappropriate timing of dischargeSuboptimal patient care practicesInappropriate use of patient restraintsPoor adherence to infection controlInappropriate antibiotic prescribingLack of close monitoringLow best practice scoreNeglect of workPoor adherence to management guidelinesPoor communicationLow patient enablement scoreForgetting to convey informationLow attention to patient impactLow physcian empathy scoreNot fully discussing treatment optionsPoor handoff qualityShort consultation lengthSelf-reported medical errorsSelf-reported medication errorsSelf-reported treatment/medication errorsMedical error scoreObserved medical errorsAccident propensityDiagnosis delayDiagnostic errorsObserved medication errorsSelf-reported impairmentAdverse eventsHealth care–associated infectionsPatient fallsLength of stayUrinary tract infectionsMortalityPoor pain controlHIV viral load suppressionMorbidityPosthospitalization recovery timeLow quality of careLow patient safety scoreLow safety climate scoreLow quality during most recent shiftLow work unit safety gradePoor patient care quality scoreMalpractice allegationsLow individual safety gradeLow safety perceptionsNear-miss reportingProlonged emergency department visitREVIEWBurnoutandQualityofCare558AnnalsofInternalMedicine•Vol.171No.8•15October2019Annals.org datapublishedinasubsequentreview(39,66,69,107,115,117).Oneresearchgroupreportedresultsfromasinglestudypopulationin2publications;thefirstpub-lishedeffectwasconsideredprimary,withresultsfromthelaterpublicationconsideredsecondaryeffects(112,160).Overallburnout,emotionalexhaustion,anddeper-sonalizationweretheprimarypredictorsfor56,75,and11studypopulations,respectively,fromavarietyofsur-veyinstruments,asoutlinedinSupplementTable5(availableatAnnals.org).The50distinctqualitymetricsincluded10bestpractices,8communication,10med-icalerrors,10patientoutcomes,and12qualityandsafetymeasures(26measuredproviderperceptionofquality,15usedindependentorobjectivemeasuresofquality,and9includedbothtypesofassessments).AsillustratedinFigure2,38(33%)ofthe114dis-tinctburnout–qualitycombinationswerereported3ormoretimes.Themostfrequentlyreportedeffectre-latedemotionalexhaustiontolowqualityofcare(n=41),withmostofthereportedeffectsizesinthequalityandsafetyandmedicalerrorscategories.Althoughall5categoriesofoutcomeshadestimatesmorefre-quentlyrelatingburnoutinthedirectionofpoorqualityofcare(denotedinredinFigure2),7ofthe16esti-matespointingintheoppositedirectionwerefoundinthecommunicationcategory.Resultsweresimilarwhenlimitedtoprimary(orfirst-listed,whenprimarywasnotspecified)effectsizesonly(SupplementFigure1,avail-ableatAnnals.org).Meta-analysescombiningburnoutandqualitymet-ricswithinqualitycategoriesrevealedI2valuesof93.4%to98.8%,indicatingextremelyhighheterogene-ity;therefore,summaryeffectsareprovidedonlyatthelevelofthe114distinctburnout–qualitycombinations,46ofwhichincludedprimaryeffectsizes.Meta-analysesofthese46combinationsrevealed24(52%)withastatisticallysignificantsummaryeffectgreaterthan0(burnoutrelatedtopoorqualityofcare),1(2%)withstatisticallysignificantsummaryeffectslessthan0(burnoutrelatedtohighqualityofcare),and21(46%)withnodifferenceattheP<0.050threshold.WhentheP<0.005thresholdwasused,therespectivenumberswere18(39%),1(2%),and27(59%).Resultsaresum-marizedinTable1,andprimaryeffectsizesfromallincludedstudiesareshowninSupplementFigure2(availableatAnnals.org).Resultsweresimilarwhensecondaryeffectsizeswereincluded.Ofthe114distinctburnout–qualitymet-riccombinations,58(51%)hadstatisticallysignificantsummaryeffectsgreaterthan0,6(5%)hadstatisticallysignificanteffectslessthan0,and50(44%)showednodifferenceattheP<0.050threshold.WhentheP<0.005thresholdwasused,therespectivenumberswere47(41%),6(5%),and61(54%).Resultsfromallburnout–qualitymetriccombinationsareshowninSup-plementFigure3(availableatAnnals.org).Ourfindingsweresimilarwhenlimitedtostudiesexplicitlyusingstandardburnoutdefinitions,buttheobservedrela-tionshipswereattenuatedwhenlimitedtoindepen-dentorobjectivequalitymetrics,asshowninTable1.Themostprecisestudywithlowriskofbias(143)reportedasmalleffectsize(Hedgesg=0.26,analo-goustoanoddsratioof1.5to1.6).Usingthisestimate,theIoannidistestfoundanexcessofobservedversuspredictedstatisticallysignificantstudies(73%observedvs.62%predictedatthe0.050significancethreshold,P=0.011)(Table2).Whenstratifiedbyqualitymetriccategory,anexcessofstatisticallysignificantstudieswasseeninthecategoriesofbestpracticesandqualityandsafety.ResultsweresimilarfortheP<0.005threshold.TheEggertestdidnotshowsmall-studyeffects(inter-cept,1.32[95%CI,3.48to0.85]),indicatingthatsmallerstudiesdidnotsystematicallyoverestimateeffectsizes(Figure3).AfunnelplotrelatingeffectsizetoSEisshowninSupplementFigure4(availableatAnnals.org).DISCUSSIONThisoverviewextendspreviousworkinthefieldbyincludingacomprehensiveevaluationforreportingbi-asesinthehealthcareproviderburnoutliterature,en-compassing145publishedstudypopulationsthatquantifiedtherelationbetweenburnoutandqualityofcareover25yearsfor241553healthcareprofession-als.Mostoftheevidencesuggestsarelationshipbe-tweenproviderburnoutandimpairedqualityofcare,consistentwithrecentreviewsofvariousdimensions(7–10,22).Althoughtheeffectsizesinthepublishedliter-aturearemodestlystrong,ourfindingofexcesssignif-icanceimpliesthatthetruemagnitudemaybesmallerthanreported,andthestudiesthatattemptedtolowertheriskofbiasdemonstratefewersignificantassocia-tionsthanthefullevidencebase.Thatonly4studiesTable1.NumberandDirectionofSummaryEffectSizesforEachCombinationofBurnoutandQualityMetric*CriteriaforInclusionBurnout–QualityCombinations,n†P<0.050Threshold,n(%)P<0.005Threshold,n(%)Hedgesg>0‡Hedgesg<0§NoEffectHedgesg>0‡Hedgesg<0§NoEffectPrimaryeffectsonly4624(52)1(2)21(46)18(39)1(2)27(59)Primaryandsecondaryeffects11458(51)6(5)50(44)47(41)6(5)61(54)Standardburnoutdefinitions2415(62)1(4)8(33)14(58)1(4)9(38)Independent/objectivequalitymetrics4814(29)2(4)32(67)9(19)2(4)37(77)*SummaryeffectsizesobtainedviaempiricalBayesmeta-analysis.†Numberofdistinctburnout–qualitycombinationsrepresented.‡Indicatesburnoutrelatedtopoor-qualitycare.§Indicatesburnoutrelatedtohigh-qualitycare.Notsignificantlydifferentfrom0atthespecifiedPvaluethreshold.BurnoutandQualityofCareREVIEWAnnals.orgAnnalsofInternalMedicine•Vol.171No.8•15October2019559 specifiedprimaryoutcomesfurthersupportsthepossi-bilityofreportingbiascausingexaggeratedeffects.Froma2015searchofMEDLINE,WebofScience,andCINAHL(EBSCO),Salyersandcolleagues(9)re-portedeffectsizesofr=0.26(Hedgesg=0.54)andr=0.23(Hedgesg=0.47)fortherelationshipbe-tweenburnoutandqualityandsafetyoutcomes,re-spectively.Theseeffectsizesaresomewhatlargerthanthoseobservedinthepresentstudy.However,thepre-viousmeta-analysisalsoincludedmarkersofpatientsatisfactionandincludedonly82studiesthroughMarch2015.Morerecently,a2017all-languagesearchofMEDLINE,EMBASE,andCINAHLbyPanagiotiandcolleagues(10)identified47physicianstudiesandre-portedamoresimilarsummaryoddsratioof1.96forpatientsafetyincidents(approximateHedgesg=0.37).However,thatreviewincluded42473physicians(lessthan20%ofthenumberofprovidersrepresentedhere)anddidnotincludediversehealthcareprofessionals.Theobservedrelationshipsbetweenburnoutandqualityofcareareprobablymultifactorial.Providerswhohaveburnoutmayhavelesstimeorcommitmenttooptimizethecareoftheirpatients,maytakemoreunnecessaryrisks,ormaybeunabletopayattentiontonecessarydetailsorrecognizetheconsequencesoftheiractions(71).Conversely,exposuretoadversepa-tienteventsorrecognitionofpoor-qualitycaremayre-sultinemotionalorotherpsychologicaldistressamongproviders.Thisphenomenonoftenisreferredtoassec-ondarytrauma,particularlyinrelationtosentineleventsorimportantsafetyincidents,butitmightalsoarisefromrepeatedminorincidents(161).Thetrueeffectsizesrelatingburnoutandqualityofcareinbothdirec-tionsareimportanttounderstandinordertomakesounddecisionsregardingresourceallocationandstudydesignofinterventions,bothtoimprovequalityofcareandtodiminishburnout.Recentconcernshavearisenregardingvariabilityinburnoutassessmentmethods,andthisinconsistencywasevidentinthebodyofliteraturecompiledhere(12).Inthisregard,thesubsetofstudiesinouranalysisthatusedthemostwidelyaccepted“standard”burnoutassessmentmethodsdemonstratedasimilartoslightlyincreasedfrequencyofsignificantassociationscom-paredwiththefullevidencebase.Thisfindingsuggeststhattherelationshipbetweenburnoutandqualityofcareinthepublishedliteratureisnotaresultofsubop-timalmeasuresorvariabilityinthedefinitionofburn-out.Excesssignificanceinthepublishedliteraturewasnotedspecificallyforadherencetobestpracticeguide-linesandforqualityandsafetymetrics.Investigationsofburnoutinrelationtotheseoutcomesaretypicallyret-rospectivestudiesofroutinelycollectedoutcomemet-ricsinexistingdatasets,withoutpreregisteredproto-cols.Therelativeeaseofdefiningandevaluatingmanyoutcomesinmanywayswiththesedatasetsincreasestheriskforselectiveoutcomeandselectiveanalysisre-porting,whichmayhavecontributedtoexcesssignifi-cance.Wefoundslightlylowereffectsizes,butwithoutexcesssignificance,forthepatientoutcomessub-group,possiblyreflectingthemorecommonusebythesestudiesofqualitymetricswithlittleornoflexibilityintheirdefinitionandmeasurement(suchasmortalityorlengthofstay).Indirectassessment,studiesusingindependentorobjectivequalitymetricsdemonstratedlessfrequentsignificanteffects.Thisfindingisnotsurprising,be-causepreviousresearchsuggeststhatcurrentmethodsofobjectivelymeasuringqualityofcarecannotreliablyidentifycertainevents,suchaserrorsinjudgment,technicalproceduralmistakes,ornearmisses(10,162).Objectivemetricsalsoarecostlytomeasureanddiffi-culttoconnecttoanindividualproviderbecauseoftheteam-basednatureofmostclinicalcare,limitingappli-cationtosmallerstudiesandthoseinwhichaqualitymetriccanbeconnectedreliablytoaprovider.Ontheotherhand,subjectivequalitymetricsmaybemoresensitiveandcomprehensivebutmorepronetobias(forexample,havingburnoutmaycreaterecallbias).Furtherresearchisneededtodeterminetheappropri-atebalancebetweeninsensitivityofobjectivequalitymetricsandpotentialforrecallbiaswithsubjectivequalitymetrics.Ouranalysisfoundnoevidencespecificallyforsmall-studyeffects,thatis,small(moreimprecise)stud-iesreportinglargereffectsthanlargestudies.Thesefindingsareconsistentwiththoseofpreviousmeta-analyses,whichtraditionallyevaluatedforsmall-studyeffectsasasurrogateforallformsofreportingbias(9,10).Thediscrepancybetweenourfindingsofoverallexcesssignificancewithoutevidenceofsmall-studyef-Table2.PredictedVersusObservedSignificanceforPrimary*EffectSizes,AmongAllIncludedStudiesandStratifiedbyQualityMetricCategoryCategoryStudies,nP<0.050ThresholdP<0.005ThresholdPredictedSignificance,%ObservedSignificance,n(%)PValuePredictedSignificance,%ObservedSignificance,n(%)PValueFullcohort14262104(73)0.0114696(68)<0.001Bestpractices14129(64)0.00128(57)0.001Communication5433(60)0.67403(60)0.63Medicalerrors325020(62)0.1693315(47)0.182Patientoutcomes17649(53)NP549(53)NPQualityandsafety746562(84)<0.0015060(81)<0.001NP=notpertinent(observedsmallerthanpredicted).*Orfirstlisted,whentheprimaryeffectsizewasnotspecified.REVIEWBurnoutandQualityofCare560AnnalsofInternalMedicine•Vol.171No.8•15October2019Annals.org fectsmayhighlighttheinsensitivityofthelattertestasamarkerofallformsofbias.Moreover,smallerstudiesinthisfieldaremorelikelytohaveobjectivemeasure-ments,whereaslargerstudiesaremorelikelytohavesubjectivemeasurements.Thiswoulddilutetheabilityofthesmall-studyeffecttesttoshowatypicalbiaspattern.Ourstudyshouldbeviewedinlightofitsdesign.Althoughmostincludedstudieswerecross-sectional,observational,andunabletodeterminethedirectional-ityofacausalrelationship,longitudinalstudiessuggestbidirectionalcausality(62,149,151,152).Although2independentreviewersconductedextensivesearches,theymayhavemissedsomerelevantstudies.Burnouthasseveralimportantoutcomesbeyonditseffectsonqualityofcarethatwerenotthefocusofouranalysis(2–6).Finally,excesssignificancemaybearesultofgenuineheterogeneityofeffectsacrossstudiesratherthanreportingbias(33).Theeffectsreportedhererep-resenttheresultsofheterogeneousstudies;therefore,wedonotreportasinglesummaryeffectsize.Rather,wereportfrequenciesofsignificantsummaryeffectsizeswithinburnout–qualitymetriccombinationstoprovideaquantitativeframeworkforinterpretationwhileacknowledgingthatadistributionoftrueeffectsizesisexpectedinthisfield-wideassessment,incon-trasttoatraditionalmeta-analysis(163).Weavoidedscoringqualityassessmentsofthein-cludedstudies,choosinginsteadtoanalyzekeyaspectsofstudyquality,assuggestedbytheproposedreport-ingguidelinesformeta-analysesofobservationalstud-ies(16).Judgingthequalityofmostlycross-sectionalobservationalstudiesisnotoriouslydifficult,andnowidelyacceptedtoolsexist.Salyersandcolleagues(9)createda10-itemtooltoassessqualityaspectsin82burnoutandquality-of-carestudiesanddidnotidentifyanyrelationshipbetweenstudyqualityscoreandeffectsize.Ourfindingscarryseveralimportantimplicationsforfutureinterventiontrialsandobservationalstudies.Forinterventiontrials,thepotentialforexaggeratedpublishedeffectsshouldbeconsideredinpowercalcu-lationstolowertheriskforfalse-negativeresults(typeIIerror).Inaddition,futurestudiesshouldattempttore-ducetheriskofreportingbiases.Standardizationandconsensusoncoreoutcomesmaybeusefulforfuturestudiesifappropriatetargetscanbeidentified(164).Suchstandardizationmayimprovecomparabilityamongstudies,facilitatingtraditionalmeta-analysises-timatesoftherelevanteffectsizes.Someoutcomes,suchasself-reportedmedicalerrors,lowqualityofcare,andlowpatientsafetyscore,areparticularlyprev-alentintheliterature,suggestingthatresearchersal-readyconsidertheseoutcomeseitherimportantorfea-sibletomeasure.However,ifcoreoutcomesaretobewidelyaccepted,theymustbebothimportantandfea-sibletomeasure.Thus,inadditiontothis“popularvote”approach,expertconsensusisneededtocurateanappropriatelistofcoreoutcomesforthisfield.Otheroutcomeevaluationsmightthenbediscouragedunlessauniquejustificationispresent.Studyregistrationmayfurtherreducetheriskofstudypublicationbiasandincreasetransparencyofun-publishedstudies.Byregisteringastudypubliclyatitsoutset,researcherscanreducethelikelihoodthatastudywasconceivedandconductedbutremainsun-Figure3.Standardnormaldeviate(Hedgesg/SE)inrelationtoprecision(1/SE).Standard Normal DeviateRobustSEParameterEstimate–3.48 to 0.850.33 to 0.751.100.100.23<0.001–1.320.54InterceptSlopeP Value95% CIPrecision95% CIFitted values002020–20404060608080BurnoutandQualityofCareREVIEWAnnals.orgAnnalsofInternalMedicine•Vol.171No.8•15October2019561 publishedbecauseofundesirableorlacklusterresults(165).Inasimilarmanner,protocolprespecificationmayreducetheriskforselectiveoutcomeandselectiveanalysisreportingwithinpublishedstudies,allowingeasieridentificationofanyposthocanalyses.Publishedanalysesthatdeviatefromtheprespecifiedprotocolwouldrequirejustificationfromtheauthors,andthisapproachwouldalertthereadersthatthoseresultsmaybemoresusceptibletobias.Currently,thesemechanismsareusedrarelyinanyfieldofmedicineoutsideclinicaltrials,buttheycouldbecomewidelyad-optedwithsufficientadvocacybyresearchers,publish-ers,funders,andotherstakeholders.Inconclusion,burnoutamonghealthcareprovid-ersisfrequentlyassociatedwithreducedqualityofcareinthepublishedliterature.However,fewrigorousstud-iesexist,andtheeffectsizemaybesmallerthanreport-ed—andmaybeparticularlysmallerforobjectivequalitymeasures.Whethercurtailingburnoutimprovesqualityofcare,orwhetherimprovingqualityofcarereducesburnout,isnotyetknown,andadequatelypoweredanddesignedrandomizedtrials(91,166,167)willbeindispensableinansweringthesequestions.FromStanfordUniversitySchoolofMedicine,Stanford,Cali-fornia(D.S.T.,T.S.,M.T.);BrighamandWomen'sHospitalandHarvardMedicalSchool,Boston,Massachusetts(A.S.);Stan-fordUniversitySchoolofMedicine,Stanford,California,andCaliforniaPerinatalQualityCareCollaborative,PaloAlto,Cal-ifornia(J.P.);DukeUniversitySchoolofMedicine,DukeUni-versityHealthSystem,andDukePatientSafetyCenter,Dur-ham,NorthCarolina(K.C.A.,J.B.S.);andStanfordUniversitySchoolofMedicine,StanfordUniversitySchoolofHumanitiesandSciences,andMeta-ResearchInnovationCenteratStan-ford(METRICS),Stanford,California(J.P.I.).Note:Theleadauthorhadfullaccesstoalldatainthestudyandaffirmsthatthemanuscriptisanhonest,accurate,andtransparentaccountofthestudy;thatnoimportantaspectsofthestudyhavebeenomitted;andthatanydiscrepanciesfromthestudyasoriginallyplannedhavebeenexplained.FinancialSupport:BytheStanfordMaternalandChildHealthResearchInstitute.Disclosures:Dr.TawfikreportsgrantsfromStanfordMaternalandChildHealthResearchInstituteduringtheconductofthestudy.Dr.ProfitreportsgrantsfromtheEuniceKennedyShriverNationalInstituteofChildHealthandHumanDevelop-mentduringtheconductofthestudyandhasreceivedhon-orariaforspeakingatscientificmeetingsonthetopicofburn-out.Dr.SextonreportsgrantsfromtheNationalInstitutesofHealthduringtheconductofthestudy.Authorsnotnamedherehavedisclosednoconflictsofinterest.Disclosurescanalsobeviewedatwww.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M19-1152.ReproducibleResearchStatement:Studyprotocol,statisticalcode,anddataset:AvailablefromDr.Tawfik(e-mail,dtawfik@stanford.edu).CorrespondingAuthor:DanielS.Tawfik,MD,MS,770WelchRoad,Suite435,PaloAlto,CA94304;e-mail,dtawfik@stanford.edu.Currentauthoraddressesandauthorcontributionsareavail-ableatAnnals.org.References1.ShanafeltTD,WestCP,SinskyC,etal.Changesinburnoutandsatisfactionwithwork-lifeintegrationinphysiciansandthegeneralUSworkingpopulationbetween2011and2017.MayoClinProc.2019.[PMID:30803733]doi:10.1016/j.mayocp.2018.10.0232.ShanafeltTD,BooneSL,DyrbyeLN,etal.Themedicalmarriage:anationalsurveyofthespouses/partnersofUSphysicians.MayoClinProc.2013;88:216-25.[PMID:23489448]doi:10.1016/j.mayocp.2012.11.0213.ShanafeltTD,MungoM,SchmitgenJ,etal.Longitudinalstudyevaluatingtheassociationbetweenphysicianburnoutandchangesinprofessionalworkeffort.MayoClinProc.2016;91:422-31.[PMID:27046522]doi:10.1016/j.mayocp.2016.02.0014.WindoverAK,MartinezK,MercerMB,etal.Correlatesandout-comesofphysicianburnoutwithinalargeacademicmedicalcenter.JAMAInternMed.2018;178:856-858.[PMID:29459945]doi:10.1001/jamainternmed.2018.00195.HamidiMS,BohmanB,SandborgC,etal.Estimatinginstitutionalphysicianturnoverattributabletoself-reportedburnoutandassoci-atedfinancialburden:acasestudy.BMCHealthServRes.2018;18:851.[PMID:30477483]doi:10.1186/s12913-018-3663-z6.vanderHeijdenF,DillinghG,BakkerA,etal.Suicidalthoughtsamongmedicalresidentswithburnout.ArchSuicideRes.2008;12:344-6.[PMID:18828037]doi:10.1080/138111108023253497.DewaCS,LoongD,BonatoS,etal.Therelationshipbetweenphysicianburnoutandqualityofhealthcareintermsofsafetyandacceptability:asystematicreview.BMJOpen.2017;7:e015141.[PMID:28637730]doi:10.1136/bmjopen-2016-0151418.HallLH,JohnsonJ,WattI,etal.Healthcarestaffwellbeing,burn-out,andpatientsafety:asystematicreview.PLoSOne.2016;11:e0159015.[PMID:27391946]doi:10.1371/journal.pone.01590159.SalyersMP,BonfilsKA,LutherL,etal.Therelationshipbetweenprofessionalburnoutandqualityandsafetyinhealthcare:ameta-analysis.JGenInternMed.2017;32:475-482.[PMID:27785668]doi:10.1007/s11606-016-3886-910.PanagiotiM,GeraghtyK,JohnsonJ,etal.Associationbetweenphysicianburnoutandpatientsafety,professionalism,andpatientsatisfaction:asystematicreviewandmeta-analysis.JAMAIn-ternMed.2018;178:1317-1330.[PMID:30193239]doi:10.1001/jamainternmed.2018.371311.RathertC,WilliamsES,LinhartH.Evidenceforthequadrupleaim:asystematicreviewoftheliteratureonphysicianburnoutandpatientoutcomes.MedCare.2018;56:976-984.[PMID:30339573]doi:10.1097/MLR.000000000000099912.RotensteinLS,TorreM,RamosMA,etal.Prevalenceofburnoutamongphysicians:asystematicreview.JAMA.2018;320:1131-1150.[PMID:30326495]doi:10.1001/jama.2018.1277713.IoannidisJP,Munafo`MR,Fusar-PoliP,etal.Publicationandotherreportingbiasesincognitivesciences:detection,prevalence,andprevention.TrendsCognSci.2014;18:235-41.[PMID:24656991]doi:10.1016/j.tics.2014.02.01014.DwanK,GambleC,WilliamsonPR,etal;ReportingBiasGroup.Systematicreviewoftheempiricalevidenceofstudypublicationbiasandoutcomereportingbias-anupdatedreview.PLoSOne.2013;8:e66844.[PMID:23861749]doi:10.1371/journal.pone.006684415.MoherD,LiberatiA,TetzlaffJ,etal;PRISMAGroup.Preferredreportingitemsforsystematicreviewsandmeta-analyses:thePRISMAstatement.AnnInternMed.2009;151:264-9,W64.[PMID:19622511]REVIEWBurnoutandQualityofCare562AnnalsofInternalMedicine•Vol.171No.8•15October2019Annals.org 16.StroupDF,BerlinJA,MortonSC,etal.Meta-analysisofobserva-tionalstudiesinepidemiology:aproposalforreporting.Meta-analysisOfObservationalStudiesinEpidemiology(MOOSE)group.JAMA.2000;283:2008-12.[PMID:10789670]17.ChangJT,HaysRD,ShekellePG,etal.Patients'globalratingsoftheirhealthcarearenotassociatedwiththetechnicalqualityoftheircare.AnnInternMed.2006;144:665-72.[PMID:16670136]18.KennedyGD,TevisSE,KentKC.Istherearelationshipbetweenpatientsatisfactionandfavorableoutcomes?AnnSurg.2014;260:592-8;discussion598-600.[PMID:25203875]doi:10.1097/SLA.000000000000093219.RaoM,ClarkeA,SandersonC,etal.Patients'ownassessmentsofqualityofprimarycarecomparedwithobjectiverecordsbasedmeasuresoftechnicalqualityofcare:crosssectionalstudy.BMJ.2006;333:19.[PMID:16793783]20.SchmockerRK,CherneyStaffordLM,WinslowER.SatisfactionwithsurgeoncareasmeasuredbytheSurgery-CAHPSsurveyisnotrelatedtoNSQIPoutcomes.Surgery.2019;165:510-515.[PMID:30322662]doi:10.1016/j.surg.2018.08.02821.ChuangCH,TsengPC,LinCY,etal.Burnoutintheintensivecareunitprofessionals:asystematicreview.Medicine(Baltimore).2016;95:e5629.[PMID:27977605]22.DewaCS,LoongD,BonatoS,etal.Therelationshipbetweenresidentburnoutandsafety-relatedandacceptability-relatedqualityofhealthcare:asystematicliteraturereview.BMCMedEduc.2017;17:195.[PMID:29121895]doi:10.1186/s12909-017-1040-y23.ScheepersRA,BoerebachBC,ArahOA,etal.Asystematicre-viewoftheimpactofphysicians'occupationalwell-beingonthequalityofpatientcare.IntJBehavMed.2015;22:683-98.[PMID:25733349]doi:10.1007/s12529-015-9473-324.WestCP,DyrbyeLN,ErwinPJ,etal.Interventionstopreventandreducephysicianburnout:asystematicreviewandmeta-analysis.Lancet.2016;388:2272-2281.[PMID:27692469]doi:10.1016/S0140-6736(16)31279-X25.ChinnS.Asimplemethodforconvertinganoddsratiotoeffectsizeforuseinmeta-analysis.StatMed.2000;19:3127-31.[PMID:11113947]26.LajeunesseM.RecoveringMissingorPartialDatafromStudies:ASurveyofConversionsandImputationsforMeta-analysis.Princeton:PrincetonUnivPr;2013.27.GuyattGH,ThorlundK,OxmanAD,etal.GRADEguidelines:13.Preparingsummaryoffindingstablesandevidenceprofiles-continuousoutcomes.JClinEpidemiol.2013;66:173-83.[PMID:23116689]doi:10.1016/j.jclinepi.2012.08.00128.HasselbladV,HedgesLV.Meta-analysisofscreeninganddiag-nostictests.PsycholBull.1995;117:167-78.[PMID:7870860]29.ShanafeltTD,BooneS,TanL,etal.Burnoutandsatisfactionwithwork-lifebalanceamongUSphysiciansrelativetothegeneralUSpopulation.ArchInternMed.2012;172:1377-85.[PMID:22911330]30.TawfikDS,PhibbsCS,SextonJB,etal.FactorsassociatedwithproviderburnoutintheNICU.Pediatrics.2017;139.[PMID:28557756]doi:10.1542/peds.2016-413431.WestCP,ShanafeltTD,KolarsJC.Qualityoflife,burnout,edu-cationaldebt,andmedicalknowledgeamonginternalmedicineres-idents.JAMA.2011;306:952-60.[PMID:21900135]doi:10.1001/jama.2011.124732.KnappG,HartungJ.Improvedtestsforarandomeffectsmeta-regressionwithasinglecovariate.StatMed.2003;22:2693-710.[PMID:12939780]33.IoannidisJP,TrikalinosTA.Anexploratorytestforanexcessofsignificantfindings.ClinTrials.2007;4:245-53.[PMID:17715249]34.SterneJA,SuttonAJ,IoannidisJP,etal.Recommendationsforexaminingandinterpretingfunnelplotasymmetryinmeta-analysesofrandomisedcontrolledtrials.BMJ.2011;343:d4002.[PMID:21784880]doi:10.1136/bmj.d400235.BenjaminDJ,BergerJO,JohannessonM,etal.Redefinestatis-ticalsignificance.NatHumBehav.2018;2:6-10.[PMID:30980045]doi:10.1038/s41562-017-0189-z36.IoannidisJPA.TheproposaltolowerPvaluethresholdsto.005.JAMA.2018;319:1429-1430.[PMID:29566133]doi:10.1001/jama.2018.153637.AbeK,OhashiA.Developmentandtestingofastaffquestion-naireforevaluatingthequalityofservicesatnursinghomesinJapan.JAmMedDirAssoc.2009;10:189-95.[PMID:19233059]doi:10.1016/j.jamda.2008.10.00438.Ozˇvacˇic´Adzˇic´Z,Katic´M,KernJ,etal.Isburnoutinfamilyphy-siciansinCroatiarelatedtointerpersonalqualityofcare?ArhHigRadaToksikol.2013;64:255-64.[PMID:23819934]doi:10.2478/10004-1254-64-2013-230739.AikenLH,SermeusW,VandenHeedeK,etal.Patientsafety,satisfaction,andqualityofhospitalcare:crosssectionalsurveysofnursesandpatientsin12countriesinEuropeandtheUnitedStates.BMJ.2012;344:e1717.[PMID:22434089]doi:10.1136/bmj.e171740.AngermeierI,DunfordBB,BossAD,etal.Theimpactofpartic-ipativemanagementperceptionsoncustomerservice,medicaler-rors,burnout,andturnoverintentions.JHealthcManag.2009;54:127-40;discussion141.[PMID:19413167]41.BaerTE,FeracoAM,TuysuzogluSagalowskyS,etal.Pediatricresidentburnoutandattitudestowardpatients.Pediatrics.2017;139.[PMID:28232639]doi:10.1542/peds.2016-216342.BaierN,RothK,FelgnerS,etal.Burnoutandsafetyoutcomes-across-sectionalnationwidesurveyofEMS-workersinGermany.BMCEmergMed.2018;18:24.[PMID:30126358]doi:10.1186/s12873-018-0177-243.BalchCM,OreskovichMR,DyrbyeLN,etal.Personalconse-quencesofmalpracticelawsuitsonAmericansurgeons.JAmCollSurg.2011;213:657-67.[PMID:21890381]doi:10.1016/j.jamcollsurg.2011.08.00544.BaoY,VedinaR,MoodieS,etal.Therelationshipbetweenvalueincongruenceandindividualandorganizationalwell-beingout-comes:anexploratorystudyamongCatalannurses.JAdvNurs.2013;69:631-41.[PMID:22632178]doi:10.1111/j.1365-2648.2012.06045.x45.BasarU,BasimN.Across-sectionalsurveyonconsequencesofnurses'burnout:moderatingroleoforganizationalpolitics.JAdvNurs.2016;72:1838-50.[PMID:26988276]doi:10.1111/jan.1295846.BeckmanTJ,ReedDA,ShanafeltTD,etal.Residentphysicianwell-beingandassessmentsoftheirknowledgeandclinicalperfor-mance.JGenInternMed.2012;27:325-30.[PMID:21948207]doi:10.1007/s11606-011-1891-647.BlockL,WuAW,FeldmanL,etal.Residencyschedule,burnoutandpatientcareamongfirst-yearresidents.PostgradMedJ.2013;89:495-500.[PMID:23852828]doi:10.1136/postgradmedj-2012-13174348.BoamahSA,ReadEA,SpenceLaschingerHK.Factorsinfluenc-ingnewgraduatenurseburnoutdevelopment,jobsatisfactionandpatientcarequality:atime-laggedstudy.JAdvNurs.2017;73:1182-1195.[PMID:27878844]doi:10.1111/jan.1321549.BronkhorstB,VermeerenB.Safetyclimate,workerhealthandorganizationalhealthperformance:testingaphysical,psychosocialandcombinedpathway.InternationalJournalofWorkplaceHealthManagement.2016;9:270-89.50.BrunsbergKA,LandriganCP,GarciaBM,etal.Associationofpediatricresidentphysiciandepressionandburnoutwithharmfulmedicalerrorsoninpatientservices.AcadMed.2019;94:1150-1156.[PMID:31045601]doi:10.1097/ACM.000000000000277851.ChaoM,ShihCT,HsuSF.Nurseoccupationalburnoutandpatient-ratedqualityofcare:theboundaryconditionsofemotionalintelligenceanddemographicprofiles.JpnJNursSci.2016;13:156-65.[PMID:26542752]doi:10.1111/jjns.1210052.ChenKY,YangCM,LienCH,etal.Burnout,jobsatisfaction,andmedicalmalpracticeamongphysicians.IntJMedSci.2013;10:1471-8.[PMID:24046520]doi:10.7150/ijms.674353.ChengC,BartramT,KarimiL,etal.Theroleofteamclimateinthemanagementofemotionallabour:implicationsfornursereten-tion.JAdvNurs.2013;69:2812-25.[PMID:23834619]doi:10.1111/jan.12202BurnoutandQualityofCareREVIEWAnnals.orgAnnalsofInternalMedicine•Vol.171No.8•15October2019563 54.CimiottiJP,AikenLH,SloaneDM,etal.Nursestaffing,burnout,andhealthcare-associatedinfection.AmJInfectControl.2012;40:486-90.[PMID:22854376]doi:10.1016/j.ajic.2012.02.02955.ColindresCV,BryceE,Coral-RoseroP,etal.Effectofeffort-rewardimbalanceandburnoutoninfectioncontrolamongEcuador-iannurses.IntNursRev.2018;65:190-199.[PMID:29114886]doi:10.1111/inr.1240956.CummingsGG,EstabrooksCA,MidodziWK,etal.Influenceoforganizationalcharacteristicsandcontextonresearchutilization.NursRes.2007;56:S24-39.[PMID:17625471]57.DavenportDL,HendersonWG,MoscaCL,etal.Risk-adjustedmorbidityinteachinghospitalscorrelateswithreportedlevelsofcommunicationandcollaborationonsurgicalteamsbutnotwithscalemeasuresofteamworkclimate,safetyclimate,orworkingcon-ditions.JAmCollSurg.2007;205:778-84.[PMID:18035261]58.deOliveiraGSJr,ChangR,FitzgeraldPC,etal.Theprevalenceofburnoutanddepressionandtheirassociationwithadherencetosafetyandpracticestandards:asurveyofUnitedStatesanesthesiol-ogytrainees.AnesthAnalg.2013;117:182-93.[PMID:23687232]doi:10.1213/ANE.0b013e3182917da959.DeStefanoC,PhilipponAL,KrastinovaE,etal.Effectofemer-gencyphysicianburnoutonpatientwaitingtimes.InternEmergMed.2018;13:421-428.[PMID:28677043]doi:10.1007/s11739-017-1706-960.DeckardG,MeterkoM,FieldD.Physicianburnout:anexamina-tionofpersonal,professional,andorganizationalrelationships.MedCare.1994;32:745-54.[PMID:8028408]61.DoriganGH,GuirardelloEB.Effectofthepracticeenvironmentofnursesonjoboutcomesandsafetyclimate.RevLatAmEnferma-gem.2018;26:e3056.[PMID:30379243]doi:10.1590/1518-8345.2633.305662.FahrenkopfAM,SectishTC,BargerLK,etal.Ratesofmedicationerrorsamongdepressedandburntoutresidents:prospectiveco-hortstudy.BMJ.2008;336:488-91.[PMID:18258931]doi:10.1136/bmj.39469.763218.BE63.FaivreG,KielwasserH,BourgeoisM,etal.BurnoutsyndromeinorthopaedicandtraumasurgeryresidentsinFrance:anationwidesurvey.OrthopTraumatolSurgRes.2018;104:1291-1295.[PMID:30341030]doi:10.1016/j.otsr.2018.08.01664.GallettaM,PortogheseI,D’AlojaE,etal.Relationshipbetweenjobburnout,psychosocialfactorsandhealthcare-associatedinfec-tionsincriticalcareunits.IntensiveCritCareNurs.2016;34:51-8.[PMID:26961918]doi:10.1016/j.iccn.2015.11.00465.Garrouste-OrgeasM,PerrinM,SoufirL,etal.TheIatrorefstudy:medicalerrorsareassociatedwithsymptomsofdepressioninICUstaffbutnotburnoutorsafetyculture.IntensiveCareMed.2015;41:273-84.[PMID:25576157]doi:10.1007/s00134-014-3601-466.GasparinoRC,GuirardelloEdeB,AikenLH.Validationofthebrazilianversionofthenursingworkindex-revised(B-NWI-r).JClinNurs.2011;20:3494-501.[PMID:21749511]doi:10.1111/j.1365-2702.2011.03776.x67.GopalR,GlasheenJJ,MiyoshiTJ,etal.Burnoutandinternalmedicineresidentwork-hourrestrictions.ArchInternMed.2005;165:2595-600.[PMID:16344416]68.GuirardelloEB.Impactofcriticalcareenvironmentonburnout,perceivedqualityofcareandsafetyattitudeofthenursingteam.RevLatAmEnfermagem.2017;25:e2884.[PMID:28591294]doi:10.1590/1518-8345.1472.288469.Gunnarsdo´ttirS,ClarkeSP,RaffertyAM,etal.Front-linemanage-ment,staffingandnurse-doctorrelationshipsaspredictorsofnurseandpatientoutcomes.asurveyofIcelandichospitalnurses.IntJNursStud.2009;46:920-7.[PMID:17229425]70.GuptaK,LiskerS,RivadeneiraNA,etal.Decisionsandrepercus-sionsofsecondvictimexperiencesformothersinmedicine(SAVEDRMoM).BMJQualSaf.2019;28:564-573.[PMID:30718333]doi:10.1136/bmjqs-2018-00837271.HalbeslebenJR,RathertC.Linkingphysicianburnoutandpatientoutcomes:exploringthedyadicrelationshipbetweenphysiciansandpatients.HealthCareManageRev.2008;33:29-39.[PMID:18091442]72.HalbeslebenJR,WakefieldBJ,WakefieldDS,etal.Nurseburnoutandpatientsafetyoutcomes:nursesafetyperceptionversusreportingbehavior.WestJNursRes.2008;30:560-77.[PMID:18187408]doi:10.1177/019394590731132273.HansenRP,VedstedP,SokolowskiI,etal.Generalpractitionercharacteristicsanddelayincancerdiagnosis.apopulation-basedco-hortstudy.BMCFamPract.2011;12:100.[PMID:21943310]doi:10.1186/1471-2296-12-10074.HayashinoY,Utsugi-OzakiM,FeldmanMD,etal.Hopemodifiedtheassociationbetweendistressandincidenceofself-perceivedmedicalerrorsamongpracticingphysicians:prospectivecohortstudy.PLoSOne.2012;7:e35585.[PMID:22530055]doi:10.1371/journal.pone.003558575.HoldenRJ,PatelNR,ScanlonMC,etal.Effectsofmentalde-mandsduringdispensingonperceivedmedicationsafetyandem-ployeewell-being:astudyofworkloadinpediatrichospitalpharma-cies.ResSocialAdmPharm.2010;6:293-306.[PMID:21111387]doi:10.1016/j.sapharm.2009.10.00176.HoldenRJ,ScanlonMC,PatelNR,etal.Ahumanfactorsframe-workandstudyoftheeffectofnursingworkloadonpatientsafetyandemployeequalityofworkinglife.BMJQualSaf.2011;20:15-24.[PMID:21228071]doi:10.1136/bmjqs.2008.02838177.HuangCH,WuHH,ChouCY,etal.Theperceptionsofphysiciansandnursesregardingtheestablishmentofpatientsafetyinare-gionalteachinghospitalinTaiwan.IranJPublicHealth.2018;47:852-860.[PMID:30087871]78.HuangCH,WuHH,LeeYC.Theperceptionsofpatientsafetyculture:adifferencebetweenphysiciansandnursesinTaiwan.ApplNursRes.2018;40:39-44.[PMID:29579497]doi:10.1016/j.apnr.2017.12.01079.HuangEC,PuC,HuangN,etal.ResidentburnoutinTaiwanHospitals-anditsrelationtophysicianfelttrustfrompatients.JFor-mosMedAssoc.2019.[PMID:30626545]doi:10.1016/j.jfma.2018.12.01580.JohnsonJ,LouchG,DunningA,etal.Burnoutmediatestheassociationbetweendepressionandpatientsafetyperceptions:across-sectionalstudyinhospitalnurses.JAdvNurs.2017;73:1667-1680.[PMID:28072469]doi:10.1111/jan.1325181.KangEK,LihmHS,KongEH.Associationofinternandresidentburnoutwithself-reportedmedicalerrors.KoreanJFamMed.2013;34:36-42.[PMID:23372904]doi:10.4082/kjfm.2013.34.1.3682.KimMH,MazengaAC,SimonK,etal.Burnoutandself-reportedsuboptimalpatientcareamongsthealthcareworkersprovidingHIVcareinMalawi.PLoSOne.2018;13:e0192983.[PMID:29466443]doi:10.1371/journal.pone.019298383.KirwanM,MatthewsA,ScottPA.Theimpactoftheworkenvi-ronmentofnursesonpatientsafetyoutcomes:amulti-levelmodel-lingapproach.IntJNursStud.2013;50:253-63.[PMID:23116681]doi:10.1016/j.ijnurstu.2012.08.02084.KleinJ,GrosseFrieK,BlumK,etal.BurnoutandperceivedqualityofcareamongGermancliniciansinsurgery.IntJQualHealthCare.2010;22:525-30.[PMID:20935011]doi:10.1093/intqhc/mzq05685.KwahJ,FallarR,WeintraubJP,RippJ.Theimpactofjobburnoutonmeasuresofprofessionalisminfirst-yearinternalmedicineresi-dentsatalargeurbanacademicmedicalcenter.JGenInternMed.2014;29:S228.86.LafreniereJP,RiosR,PackerH,etal.Burnedoutatthebedside:patientperceptionsofphysicianburnoutinaninternalmedicineres-identcontinuityclinic.JGenInternMed.2016;31:203-208.[PMID:26340808]doi:10.1007/s11606-015-3503-387.SpenceLaschingerHK,LeiterMP.Theimpactofnursingworkenvironmentsonpatientsafetyoutcomes:themediatingroleofburnout/engagement.JNursAdm.2006;36:259-67.[PMID:16705307]88.LaschingerH,ShamianJ,ThomsonD.Impactofmagnethospitalcharacteristicsonnurses'perceptionsoftrust,burnout,qualityofcare,andworksatisfaction.NursingEconomic$.2001;19(5):209-19.REVIEWBurnoutandQualityofCare564AnnalsofInternalMedicine•Vol.171No.8•15October2019Annals.org 89.LewisEJ,BaernholdtMB,YanG,etal.RelationshipofadverseeventsandsupporttoRNburnout.JNursCareQual.2015;30:144-52.[PMID:25148522]doi:10.1097/NCQ.000000000000008490.LinzerM,ManwellLB,WilliamsES,etal;MEMO(MinimizingError,MaximizingOutcome)Investigators.Workingconditionsinprimarycare:physicianreactionsandcarequality.AnnInternMed.2009;151:28-36,W6-9.[PMID:19581644]91.LinzerM,PoplauS,BrownR,etal.Doworkconditioninterven-tionsaffectqualityanderrorsinprimarycare?resultsfromthehealthyworkplacestudy.JGenInternMed.2017;32:56-61.[PMID:27612486]doi:10.1007/s11606-016-3856-292.LiuX,ZhengJ,LiuK,etal.Hospitalnursingorganizationalfac-tors,nursingcareleftundone,andnurseburnoutaspredictorsofpatientsafety:astructuralequationmodelinganalysis.IntJNursStud.2018;86:82-89.[PMID:29966828]doi:10.1016/j.ijnurstu.2018.05.00593.LiuY,AungsurochY.Factorsinfluencingnurse-assessedqualitynursingcare:across-sectionalstudyinhospitals.JAdvNurs.2018;74:935-945.[PMID:29148146]doi:10.1111/jan.1350794.LoerbroksA,GlaserJ,Vu-EickmannP,etal.Physicianburnout,workengagementandthequalityofpatientcare.OccupMed(Lond).2017;67:356-362.[PMID:28510762]doi:10.1093/occmed/kqx05195.LorenzVR,SabinoMO,CorreˆaFilhoHR.Professionalexhaustion,qualityandintentionsamongfamilyhealthnurses.RevBrasEnferm.2018;71:2295-2301.[PMID:30365797]doi:10.1590/0034-7167-2016-051096.LuDW,DresdenS,McCloskeyC,etal.Impactofburnoutonself-reportedpatientcareamongemergencyphysicians.WestJEmergMed.2015;16:996-1001.[PMID:26759643]doi:10.5811/westjem.2015.9.2794597.MacPheeM,DahintenVS,HavaeiF.Theimpactofheavyper-ceivednurseworkloadsonpatientandnurseoutcomes.Administra-tiveSciences.2017;7:7.98.MartinussenM,KaiserS,AdolfsenF,etal.Reorganisationofhealthcareservicesforchildrenandfamilies:improvingcollabora-tion,servicequality,andworkerwell-being.JInterprofCare.2017;31:487-496.[PMID:28481168]doi:10.1080/13561820.2017.131624999.MazurkiewiczRA,SmithKL,KorensteinD,RippJ.Theimpactofresidentphysicianburnoutonthequalityofcareofhospitalizedpa-tients.JGenInternMed.2012;27:S323-S4.100.MionG,LibertN,JournoisD.[Burnout-associatedfactorsinanesthesiaandintensivecaremedicine.2009surveyoftheFrenchSocietyofAnesthesiologyandIntensiveCare].AnnFrAnesthRe-anim.2013;32:175-88.[PMID:23395149]doi:10.1016/j.annfar.2012.12.004101.MohrDC,EatonJL,MeterkoM,etal.FactorsassociatedwithinternalmedicinephysicianjobattitudesintheVeteransHealthAd-ministration.BMCHealthServRes.2018;18:244.[PMID:29622008]doi:10.1186/s12913-018-3015-z102.MolinaSigueroA,Garcı´aPe´rezMA,AlonsoGonza´lezM,etal.[PrevalenceofworkerburnoutandpsychiatricillnessinprimarycarephysiciansinahealthcareareainMadrid].AtenPrimaria.2003;31:564-71.[PMID:12783745]103.NantsupawatA,NantsupawatR,KunaviktikulW,etal.Nurseburnout,nurse-reportedqualityofcare,andpatientoutcomesinthaihospitals.JNursScholarsh.2016;48:83-90.[PMID:26650339]doi:10.1111/jnu.12187104.O’ConnorP,LydonS,O’DeaA,etal.AlongitudinalandmulticentrestudyofburnoutanderrorinIrishjuniordoctors.PostgradMedJ.2017;93:660-664.[PMID:28600343]doi:10.1136/postgradmedj-2016-134626105.PanuntoMR,GuirardelloEdeB.Professionalnursingpractice:environmentandemotionalexhaustionamongintensivecarenurses.RevLatAmEnfermagem.2013;21:765-72.[PMID:23918023]doi:10.1590/S0104-11692013000300016106.PassalacquaSA,SegrinC.Theeffectofresidentphysicianstress,burnout,andempathyonpatient-centeredcommunicationduringthelong-callshift.HealthCommun.2012;27:449-56.[PMID:21970629]doi:10.1080/10410236.2011.606527107.PatricianPA,ShangJ,LakeET.OrganizationaldeterminantsofworkoutcomesandqualitycareratingsamongArmyMedicalDe-partmentregisterednurses.ResNursHealth.2010;33:99-110.[PMID:20151409]doi:10.1002/nur.20370108.PedersenAF,CarlsenAH,VedstedP.AssociationofGPs'riskattitudes,levelofempathy,andburnoutstatuswithPSAtestinginprimarycare.BrJGenPract.2015;65:e845-51.[PMID:26541183]doi:10.3399/bjgp15X687649109.PoghosyanL,ClarkeSP,FinlaysonM,etal.Nurseburnoutandqualityofcare:cross-nationalinvestigationinsixcountries.ResNursHealth.2010;33:288-98.[PMID:20645421]doi:10.1002/nur.20383110.PrattM,KerrM,WongC.TheimpactofERI,burnout,andcar-ingforSARSpatientsonhospitalnurses'self-reportedcompliancewithinfectioncontrol.CanJInfectControl.2009;24:167-72,174.[PMID:19891170]111.PrinsJT,vanderHeijdenFM,Hoekstra-WeebersJE,etal.Burn-out,engagementandresidentphysicians'self-reportederrors.Psy-cholHealthMed.2009;14:654-66.[PMID:20183538]doi:10.1080/13548500903311554112.ProfitJ,SharekPJ,AmspokerAB,etal.BurnoutintheNICUsettinganditsrelationtosafetyculture.BMJQualSaf.2014;23:806-13.[PMID:24742780]doi:10.1136/bmjqs-2014-002831113.QureshiHA,RawlaniR,MiotonLM,etal.BurnoutphenomenoninU.S.plasticsurgeons:riskfactorsandimpactonqualityoflife.PlastReconstrSurg.2015;135:619-26.[PMID:25357156]doi:10.1097/PRS.0000000000000855114.RaffertyAM,BallJ,AikenLH.Areteamworkandprofessionalautonomycompatible,anddotheyresultinimprovedhospitalcare?QualHealthCare.2001;10Suppl2:ii32-7.[PMID:11700377]115.RidleyJ,WilsonB,HarwoodL,etal.Workenvironment,healthoutcomesandmagnethospitaltraitsintheCanadiannephrologynursingscene.CANNTJ.2009;19:28-35.[PMID:19354155]116.RiquelmeI,Chaco´nJI,Ga´ndaraAV,etal;PAINBOStudyGroup.Prevalenceofburnoutamongpainmedicinephysiciansanditspotentialeffectuponclinicaloutcomesinpatientswithoncologicpainorchronicpainofnononcologicorigin.PainMed.2018;19:2398-2407.[PMID:29361180]doi:10.1093/pm/pnx335117.RochefortCM,ClarkeSP.Nurses'workenvironments,carera-tioning,joboutcomes,andqualityofcareonneonatalunits.JAdvNurs.2010;66:2213-24.[PMID:20626479]doi:10.1111/j.1365-2648.2010.05376.x118.SalyersMP,FukuiS,RollinsAL,etal.Burnoutandself-reportedqualityofcareincommunitymentalhealth.AdmPolicyMentHealth.2015;42:61-9.[PMID:24659446]119.SchmidtSG,DichterMN,BartholomeyczikS,etal.Thesatisfac-tionwiththequalityofdementiacareandthehealth,burnoutandworkabilityofnurses:alongitudinalanalysisof50Germannursinghomes.GeriatrNurs.2014;35:42-6.[PMID:24131899]doi:10.1016/j.gerinurse.2013.09.006120.SchwartzSP,AdairKC,BaeJ,etal.Work-lifebalancebehav-ioursclusterinworksettingsandrelatetoburnoutandsafetyculture:across-sectionalsurveyanalysis.BMJQualSaf.2019;28:142-150.[PMID:30309912]doi:10.1136/bmjqs-2018-007933121.ShanafeltTD,BalchCM,BechampsG,etal.Burnoutandmed-icalerrorsamongAmericansurgeons.AnnSurg.2010;251:995-1000.[PMID:19934755]doi:10.1097/SLA.0b013e3181bfdab3122.ShanafeltTD,BradleyKA,WipfJE,etal.Burnoutandself-reportedpatientcareinaninternalmedicineresidencyprogram.AnnInternMed.2002;136:358-67.[PMID:11874308]123.ShieldsCG,FuzzellLN,ChristSL,etal.Patientandprovidercharacteristicsassociatedwithcommunicationaboutopioids:anob-servationalstudy.PatientEducCouns.2019;102:888-894.[PMID:30552013]doi:10.1016/j.pec.2018.12.005124.ShiromA,NirelN,VinokurAD.Overload,autonomy,andburn-outaspredictorsofphysicians'qualityofcare.JOccupHealthPsy-chol.2006;11:328-42.[PMID:17059297]125.Sillero-SilleroA,ZabaleguiA.Safetyandsatisfactionofpatientswithnurse'scareintheperioperative.RevLatAmEnfermagem.BurnoutandQualityofCareREVIEWAnnals.orgAnnalsofInternalMedicine•Vol.171No.8•15October2019565 2019;27:e3142.[PMID:31038636]doi:10.1590/1518-8345.2646.3142126.SokolovaO,PogosovaN,IsakovaS,etal.ImpactofprimarycarephysiciansburnoutontheiradherencetonationalguidelinesforcommonCVD.GlobalHeart.2018;13:486.127.SquiresM,TourangeauA,SpenceLaschingerHK,etal.Thelinkbetweenleadershipandsafetyoutcomesinhospitals.JNursManag.2010;18:914-25.[PMID:21073565]doi:10.1111/j.1365-2834.2010.01181.x128.SturmH,RiegerMA,MartusP,etal;WorkSafeMedConsortium.Doperceivedworkingconditionsandpatientsafetyculturecorrelatewithobjectiveworkloadandpatientoutcomes:across-sectionalex-plorativestudyfromaGermanuniversityhospital.PLoSOne.2019;14:e0209487.[PMID:30608945]doi:10.1371/journal.pone.0209487129.SulaimanCFC,HennP,SmithS,etal.Burnoutsyndromeamongnon-consultanthospitaldoctorsinIreland:relationshipwithself-reportedpatientcare.IntJQualHealthCare.2017;29:679-684.[PMID:28992145]doi:10.1093/intqhc/mzx087130.SunBZ,ChaitoffA,HuB,etal.Empathy,burnout,andantibioticprescribingforacuterespiratoryinfections:across-sectionalprimarycarestudyintheUS.BrJGenPract.2017;67:e565-e571.[PMID:28717000]doi:10.3399/bjgp17X691901131.TawfikDS,ProfitJ,MorgenthalerTI,etal.Physicianburnout,well-being,andworkunitsafetygradesinrelationshiptoreportedmedicalerrors.MayoClinProc.2018;93:1571-1580.[PMID:30001832]doi:10.1016/j.mayocp.2018.05.014132.TengCI,ShyuYI,ChiouWK,etal.Interactiveeffectsofnurse-experiencedtimepressureandburnoutonpatientsafety:across-sectionalsurvey.IntJNursStud.2010;47:1442-50.[PMID:20472237]doi:10.1016/j.ijnurstu.2010.04.005133.Toral-VillanuevaR,Aguilar-MadridG,Jua´rez-Pe´rezCA.BurnoutandpatientcareinjuniordoctorsinMexicoCity.OccupMed(Lond).2009;59:8-13.[PMID:18796698]doi:10.1093/occmed/kqn122134.TrockelM,BohmanB,LesureE,etal.Abriefinstrumenttoassessbothburnoutandprofessionalfulfillmentinphysicians:reli-abilityandvalidity,includingcorrelationwithself-reportedmedicalerrors,inasampleofresidentandpracticingphysicians.AcadPsy-chiatry.2018;42:11-24.[PMID:29196982]doi:10.1007/s40596-017-0849-3135.TsigaE,PanagopoulouE,MontgomeryA.Examiningthelinkbetweenburnoutandmedicalerror:achecklistapproach.BurnoutResearch.2017;6:1-8.136.VanBogaertP,ClarkeS,RoelantE,etal.Impactsofunit-levelnursepracticeenvironmentandburnoutonnurse-reportedout-comes:amultilevelmodellingapproach.JClinNurs.2010;19:1664-74.[PMID:20579204]doi:10.1111/j.1365-2702.2009.03128.x137.VanBogaertP,ClarkeS,WoutersK,etal.Impactsofunit-levelnursepracticeenvironment,workloadandburnoutonnurse-reportedoutcomesinpsychiatrichospitals:amultilevelmodellingapproach.IntJNursStud.2013;50:357-65.[PMID:22695484]doi:10.1016/j.ijnurstu.2012.05.006138.VanBogaertP,DillesT,WoutersK,etal.Practiceenvironment,workcharacteristicsandlevelsofburnoutaspredictorsofnursere-portedjoboutcomes,qualityofcareandpatientadverseevents:astudyacrossresidentialagedcareservices.OpenJournalofNurs-ing.2014;4:343-55.139.VanBogaertP,KowalskiC,WeeksSM,etal.Therelationshipbetweennursepracticeenvironment,nurseworkcharacteristics,burnoutandjoboutcomeandqualityofnursingcare:across-sectionalsurvey.IntJNursStud.2013;50:1667-77.[PMID:23777786]doi:10.1016/j.ijnurstu.2013.05.010140.VanBogaertP,MeulemansH,ClarkeS,etal.Hospitalnursepracticeenvironment,burnout,joboutcomesandqualityofcare:testofastructuralequationmodel.JAdvNurs.2009;65:2175-85.[PMID:20568322]141.VanBogaertP,TimmermansO,WeeksSM,etal.Nursingunitteamsmatter:impactofunit-levelnursepracticeenvironment,nurseworkcharacteristics,andburnoutonnursereportedjoboutcomes,andqualityofcare,andpatientadverseevents—across-sectionalsur-vey.IntJNursStud.2014;51:1123-34.[PMID:24444772]doi:10.1016/j.ijnurstu.2013.12.009142.BogaertPV,HeusdenDV,SlootmansS,etal.Staffempower-mentandengagementinamagnet®recognizedandjointcommis-sioninternationalaccreditedacademiccentreinBelgium:across-sectionalsurvey.BMCHealthServRes.2018;18:756.[PMID:30285735]doi:10.1186/s12913-018-3562-3143.VanGervenE,VanderElstT,VandenbroeckS,etal.Increasedriskofburnoutforphysiciansandnursesinvolvedinapatientsafetyincident.MedCare.2016;54:937-43.[PMID:27213542]doi:10.1097/MLR.0000000000000582144.VifladtA,SimonsenBO,LydersenS,etal.Theassociationbe-tweenpatientsafetycultureandburnoutandsenseofcoherence:across-sectionalstudyinrestructuredandnotrestructuredintensivecareunits.IntensiveCritCareNurs.2016;36:26-34.[PMID:27212614]doi:10.1016/j.iccn.2016.03.004145.VogusTJ,CooilB,SitterdingM,etal.Safetyorganizing,emotionalexhaustion,andturnoverinhospitalnursingunits.MedCare.2014;52:870-6.[PMID:25222533]doi:10.1097/MLR.0000000000000169146.WawrzyniakAJ,RodriguezAE.Theassociationbetweenphysi-cianburnoutandsatisfactiononhealthoutcomesinHIV-infectedoutpatients.PsychosomaticMedicine.2017;79:A102.147.WeiglM,SchneiderA,HoffmannF,etal.Workstress,burnout,andperceivedqualityofcare:across-sectionalstudyamonghospi-talpediatricians.EurJPediatr.2015;174:1237-46.[PMID:25846697]doi:10.1007/s00431-015-2529-1148.WelpA,MeierLL,ManserT.Emotionalexhaustionandwork-loadpredictclinician-ratedandobjectivepatientsafety.FrontPsy-chol.2014;5:1573.[PMID:25657627]doi:10.3389/fpsyg.2014.01573149.WelpA,MeierLL,ManserT.Theinterplaybetweenteamwork,clinicians'emotionalexhaustion,andclinician-ratedpatientsafety:alongitudinalstudy.CritCare.2016;20:110.[PMID:27095501]doi:10.1186/s13054-016-1282-9150.WenJ,ChengY,HuX,etal.Workload,burnout,andmedicalmistakesamongphysiciansinChina:across-sectionalstudy.BiosciTrends.2016;10:27-33.[PMID:26961213]doi:10.5582/bst.2015.01175151.WestCP,HuschkaMM,NovotnyPJ,etal.Associationofper-ceivedmedicalerrorswithresidentdistressandempathy:aprospec-tivelongitudinalstudy.JAMA.2006;296:1071-8.[PMID:16954486]152.WestCP,TanAD,HabermannTM,etal.Associationofresidentfatigueanddistresswithperceivedmedicalerrors.JAMA.2009;302:1294-300.[PMID:19773564]doi:10.1001/jama.2009.1389153.WilliamsES,ManwellLB,KonradTR,etal.Therelationshipoforganizationalculture,stress,satisfaction,andburnoutwithphysician-reportederrorandsuboptimalpatientcare:resultsfromtheMEMOstudy.HealthCareManageRev.2007;32:203-12.[PMID:17666991]154.WinningAM,MerandiJM,LeweD,etal.TheemotionalimpactoferrorsoradverseeventsonhealthcareprovidersintheNICU:theprotectiveroleofcoworkersupport.JAdvNurs.2018;74:172-180.[PMID:28746750]doi:10.1111/jan.13403155.YanosPT,VayshenkerB,DeLucaJS,etal.Developmentandvalidationofascaleassessingmentalhealthclinicians'experiencesofassociativestigma.PsychiatrServ.2017;68:1053-1060.[PMID:28617207]doi:10.1176/appi.ps.201600553156.YassiA,CohenM,CvitkovichY,etal.FactorsassociatedwithstaffinjuriesinintermediatecarefacilitiesinBritishColumbia,Can-ada.NursRes.2004;53:87-98.[PMID:15084993]157.YouLM,AikenLH,SloaneDM,etal.Hospitalnursing,carequality,andpatientsatisfaction:cross-sectionalsurveysofnursesandpatientsinhospitalsinChinaandEurope.IntJNursStud.2013;50:154-61.[PMID:22658468]doi:10.1016/j.ijnurstu.2012.05.003158.YugueroO,MarsalJR,ButiM,etal.Descriptivestudyofasso-ciationbetweenqualityofcareandempathyandburnoutinprimarycare.BMCMedEthics.2017;18:54.[PMID:28950853]doi:10.1186/s12910-017-0214-9REVIEWBurnoutandQualityofCare566AnnalsofInternalMedicine•Vol.171No.8•15October2019Annals.org 159.ZareiE,KhakzadN,ReniersG,etal.Ontherelationshipbe-tweensafetyclimateandoccupationalburnoutinhealthcareorgani-zations.SafetyScience.2016;89:1-10.160.TawfikDS,SextonJB,KanP,etal.Burnoutintheneonatalintensivecareunitanditsrelationtohealthcare-associatedinfec-tions.JPerinatol.2017;37:315-320.[PMID:27853320]doi:10.1038/jp.2016.211161.VanGervenE,VanderElstT,VandenbroeckS,etal.Increasedriskofburnoutforphysiciansandnursesinvolvedinapatientsafetyincident.MedCare.2016;54:937-43.[PMID:27213542]doi:10.1097/MLR.0000000000000582162.SariAB,SheldonTA,CracknellA,etal.SensitivityofroutinesystemforreportingpatientsafetyincidentsinanNHShospital:ret-rospectivepatientcasenotereview.BMJ.2007;334:79.[PMID:17175566]163.IoannidisJP,PatsopoulosNA,RothsteinHR.Reasonsorex-cusesforavoidingmeta-analysisinforestplots.BMJ.2008;336:1413-5.[PMID:18566080]doi:10.1136/bmj.a117164.DoddS,ClarkeM,BeckerL,etal.Ataxonomyhasbeendevel-opedforoutcomesinmedicalresearchtohelpimproveknowledgediscovery.JClinEpidemiol.2018;96:84-92.[PMID:29288712]doi:10.1016/j.jclinepi.2017.12.020165.Dal-Re´R,IoannidisJP,BrackenMB,etal.Makingprospectiveregistrationofobservationalresearchareality.SciTranslMed.2014;6:224cm1.[PMID:24553383]doi:10.1126/scitranslmed.3007513166.ParshuramCS,AmaralAC,FergusonND,etal;CanadianCrit-icalCareTrialsGroup.Patientsafety,residentwell-beingandconti-nuityofcarewithdifferentresidentdutyschedulesintheintensivecareunit:arandomizedtrial.CMAJ.2015;187:321-9.[PMID:25667258]doi:10.1503/cmaj.140752167.WestCP,DyrbyeL,SateleD,etal.ArandomizedcontrolledtrialevaluatingtheeffectofCompass(ColleaguesMeetingtoPromoteandSustainSatisfaction)smallgroupsessionsonphysicianwell-being,meaning,andjobsatisfaction.JGenInternMed.2015;30:S89.INFORMATIONFORAUTHORSTheAnnalsInformationforAuthorssectionisavailableatwww.annals.org/aim/pages/authors.Allmanuscriptsmustbesubmittedelectronicallyus-ingthemanuscriptsubmissionoptionatAnnals.org.BurnoutandQualityofCareREVIEWAnnals.orgAnnalsofInternalMedicine•Vol.171No.8•15October2019567 CurrentAuthorAddresses:Dr.Tawfik:770WelchRoad,Suite435,PaloAlto,CA94304.Dr.Scheid:OfficeBL341G,221LongwoodAvenue,Boston,MA02115.Dr.Profit:1265WelchRoad,MSOBx1C07,Stanford,CA94305.Dr.Shanafelt:300PasteurDrive,RoomH3215,Stanford,CA94305.Dr.Trockel:401QuarryRoad,Room2303,Stanford,CA94305.Drs.AdairandSexton:3100TowerBoulevard,Suite300,Dur-ham,NC27707.Dr.Ioannidis:1265WelchRoad,MSOBx306,Stanford,CA94305.AuthorContributions:Conceptionanddesign:D.S.Tawfik,J.P.A.Ioannidis.Analysisandinterpretationofthedata:D.S.Tawfik,J.Profit,T.Shanafelt.Draftingofthearticle:D.S.Tawfik,T.Shanafelt,J.P.A.Ioannidis.Criticalrevisionforimportantintellectualcontent:D.S.Tawfik,A.Scheid,T.Shanafelt,M.Trockel,J.B.Sexton,J.P.A.Ioannidis.Finalapprovalofthearticle:D.S.Tawfik,A.Scheid,J.Profit,T.Shanafelt,M.Trockel,K.C.Adair,J.B.Sexton,J.P.A.Ioannidis.Provisionofstudymaterialsorpatients:D.S.Tawfik.Statisticalexpertise:D.S.Tawfik.Obtainingoffunding:D.S.Tawfik.Administrative,technical,orlogisticsupport:D.S.Tawfik,A.Scheid,J.B.Sexton.Collectionandassemblyofdata:D.S.Tawfik,A.Scheid,K.C.Adair.Annals.orgAnnalsofInternalMedicine•Vol.171No.8•15October2019 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