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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.

Although psychological services might benefit from the adoption of the stepped care model, a substantial research agenda needs to be fulfilled before a judgement can be made as to whether stepped care might be an efficient method of delivering psychological services.

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BackgroundTelehealth (TH) and telecare (TC) interventions are increasingly valued for supporting self-care in ageing populations; however, evaluation studies often report high rates of non-participation that are not well understood. This paper reports from a qualitative study nested within a large randomised controlled trial in the UK: the Whole System Demonstrator (WSD) project. It explores barriers to participation and adoption of TH and TC from the perspective of people who declined to participate or withdrew from the trial.MethodsQualitative semi-structured interviews were conducted with 22 people who declined to participate in the trial following explanations of the intervention (n = 19), or who withdrew from the intervention arm (n = 3). Participants were recruited from the four trial groups (with diabetes, chronic obstructive pulmonary disease, heart failure, or social care needs); and all came from the three trial areas (Cornwall, Kent, east London). Observations of home visits where the trial and interventions were first explained were also conducted by shadowing 8 members of health and social care staff visiting 23 people at home. Field notes were made of observational visits and explored alongside interview transcripts to elicit key themes.ResultsBarriers to adoption of TH and TC associated with non-participation and withdrawal from the trial were identified within the following themes: requirements for technical competence and operation of equipment; threats to identity, independence and self-care; expectations and experiences of disruption to services. Respondents held concerns that special skills were needed to operate equipment but these were often based on misunderstandings. Respondents’ views were often explained in terms of potential threats to identity associated with positive ageing and self-reliance, and views that interventions could undermine self-care and coping. Finally, participants were reluctant to risk potentially disruptive changes to existing services that were often highly valued.ConclusionsThese findings regarding perceptions of potential disruption of interventions to identity and services go beyond more common expectations that concerns about privacy and dislike of technology deter uptake. These insights have implications for health and social care staff indicating that more detailed information and time for discussion could be valuable especially on introduction. It seems especially important for potential recipients to have the opportunity to discuss their expectations and such views might usefully feed back into design and implementation.

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SummaryBackgroundThe management of people with multiple chronic conditions challenges health-care systems designed around single conditions. There is international consensus that care for multimorbidity should be patient-centred, focus on quality of life, and promote self-management towards agreed goals. However, there is little evidence about the effectiveness of this approach. Our hypothesis was that the patient-centred, so-called 3D approach (based on dimensions of health, depression, and drugs) for patients with multimorbidity would improve their health-related quality of life, which is the ultimate aim of the 3D intervention.MethodsWe did this pragmatic cluster-randomised trial in general practices in England and Scotland. Practices were randomly allocated to continue usual care (17 practices) or to provide 6-monthly comprehensive 3D reviews, incorporating patient-centred strategies that reflected international consensus on best care (16 practices). Randomisation was computer-generated, stratified by area, and minimised by practice deprivation and list size. Adults with three or more chronic conditions were recruited. The primary outcome was quality of life (assessed with EQ-5D-5L) after 15 months' follow-up. Participants were not masked to group assignment, but analysis of outcomes was blinded. We analysed the primary outcome in the intention-to-treat population, with missing data being multiply imputed. This trial is registered as an International Standard Randomised Controlled Trial, number ISRCTN06180958.FindingsBetween May 20, 2015, and Dec 31, 2015, we recruited 1546 patients from 33 practices and randomly assigned them to receive the intervention (n=797) or usual care (n=749). In our intention-to-treat analysis, there was no difference between trial groups in the primary outcome of quality of life (adjusted difference in mean EQ-5D-5L 0·00, 95% CI −0·02 to 0·02; p=0·93). 78 patients died, and the deaths were not considered as related to the intervention.InterpretationTo our knowledge, this trial is the largest investigation of the international consensus about optimal management of multimorbidity. The 3D intervention did not improve patients' quality of life.FundingNational Institute for Health Research.

Background. Although self-help interventions are effective in treating depression, less is known about the factors that determine effectiveness (i.e. moderators of effect). This study sought to determine whether the content of self-help interventions, the study populations or aspects of study design were the most important moderators.