key: cord-0931404-5v6evc8c authors: Dugani, Sagar B.; Fischer, Karen M.; Schroeder, Darrell R.; Geyer, Holly L.; Maniaci, Michael J.; Croghan, Ivana T.; Kashani, Daniel; Burton, M. Caroline title: Wellness of hospitalists and hospital medicine advanced practice providers during the COVID‐19 pandemic, 2020–2021 date: 2022-03-24 journal: J Hosp Med DOI: 10.1002/jhm.12812 sha: 24e9deb50214e0acf7b59336c00bbc9fbb30e80b doc_id: 931404 cord_uid: 5v6evc8c BACKGROUND: The early phase of the coronavirus disease 2019 (COVID‐19) pandemic had a negative impact on the wellness of hospitalists and hospital medicine advanced practice providers (APPs). However, the burden of the pandemic has evolved and the change in hospitalist and hospital medicine APP wellness is unknown. OBJECTIVE: To evaluate the longitudinal trend in wellness of hospitalists and hospital medicine APPs during the COVID‐19 pandemic and guide wellness interventions. DESIGN, SETTING AND PARTICIPANTS: Between May 4, 2020, and June 6, 2021, we administered three surveys to Internal Medicine hospitalists (physicians) and hospital medicine APPs (nurse practitioners and physician assistants) at 16 Mayo Clinic hospitals in four U.S. states. MEASUREMENTS: We evaluated the association of hospitalist and hospital medicine APP characteristics with PROMIS® measures of global wellbeing‐mental health, global wellbeing‐social activities and relationships, anxiety, social isolation, and emotional support, using logistic and linear regression models. RESULTS: The response rates were 52.2% (n=154/295; May 2020), 37.1% (n=111/299; October 2020) and 35.5% (n=114/321; May 2021). In mixed models that included hospitalist and hospital medicine APP characteristics and survey period, APPs, compared with physicians, had lower odds of top global wellbeing‐social activities and relationships (adjusted odds ratio 0.42 [0.22–0.82]; p = .01), whereas survey period showed no association. The survey period showed an independent association with higher anxiety (May 2020 vs. others) and higher social isolation (October 2020 vs. others), whereas profession showed no association. Concern about contracting COVID‐19 at work was significantly associated with lower odds of top global wellbeing‐mental health and global wellbeing‐social activities and relationships, and with higher anxiety and social isolation. Hospitalist and hospital medicine APP characteristics showed no association with levels of emotional support. CONCLUSIONS: In this longitudinal assessment of hospitalists and hospital medicine APPs, concern about contracting COVID‐19 at work remained a determinant of wellness. The trend for global wellbeing, anxiety, and social isolation may guide wellness interventions. Hospitalists and hospital medicine advanced practice providers (APPs) are integral to the management of adults hospitalized with coronavirus disease 2019 . Compared to the prepandemic period, hospitalists and hospital medicine APPs early in the pandemic (May 2020) reported lower global well-being, higher anxiety, and higher social isolation. 1 The COVID-19 pandemic has since progressed with improved prevention, diagnostics, and therapeutics. However, it is unknown if the wellness of hospitalists and hospital medicine APPs has concomitantly changed, which could inform wellness efforts. Early in the pandemic, limited knowledge on COVID-19 led to substantial stress among healthcare providers. A survey of 20,947 workers at 42 organizations, from May to October 2020, revealed a fear of exposure or transmission to COVID-19 (61%), anxiety/depression (38%), and burnout (49%). 2 Similarly, surveys of physician assistants and nurse practitioners highlighted their level of stress, suboptimal access to personal protective equipment, and concern about contracting COVID-19 infection. 3, 4 Since then, the COVID-19 burden has changed, notably, from the increased availability of COVID-19 vaccines. 5, 6 However, the varied public uptake of COVID-19 vaccines and the emergence of COVID-19 variants have led to increased hospitalizations and stress on healthcare providers. [7] [8] [9] Given these changes, it is unclear if the wellness of hospitalists and hospital medicine APPs has changed, which has implications for burnout and attrition, and for the care of hospitalized patients. To address these knowledge gaps, we surveyed hospitalists and hospital medicine APPs at an academic institution's 16 hospitals in four US states during three periods in the COVID-19 pandemic. We evaluated trends in wellness to identify areas for improvement and intervention. The study was conducted by the Hospital Experiences to Advance Goals and Outcomes Network (HEXAGON) group. 10 HEXAGON focuses on generating knowledge, improving efficiency, and fostering innovation in hospital care through internal and external partnerships. 10 The study was deemed Exempt by the Mayo Clinic Institutional Review Board. We conducted three surveys. The first survey (May 2020) pertained to two periods: before March 15, 2020 (prior to pandemic) and March 15-April 30, 2020 (during pandemic Deidentified responses were exported from REDCap ® . Participant characteristics were analyzed by survey period and using descriptive statistics. Scores for anxiety, social isolation, and emotional support were calculated as described. 10, 11, 13 To compare emotional support across surveys, we used multiple imputations for two questions in the May 2020 survey. For each survey period, we used separate logistic regression models for global well-being. We used a binary dependent variable for "top" category on the Likert scale and reported results of "top category" (excellent or very good) versus "lower category" (good, fair, poor) as odds ratio (95% confidence interval). For each survey period, we used linear regression models for anxiety, social isolation, and emotional support, and reported results as an estimate (standard error). The models included age (<40 years; ≥40 years), gender (women/other; men), profession (hospital medicine APPs; hospitalists), concern about contracting COVID-19 at work (strongly agree or agree; other [neutral, disagree, or strongly disagree]), and survey We used PROMIS surveys for anxiety, social isolation, and emotional support (Supporting Information Appendix 1). In linear mixed models that included all surveys, survey period and concern about contracting COVID-19 at work were associated with a higher level of anxiety ( Table 2) . When analyzed by individual survey period, in May 2020, women, compared to men, had a higher level of anxiety (p = .01) ( Figure 1 and Table S1 ). In all survey periods, concern about contracting COVID-19 at work was associated with a higher level of anxiety. In linear mixed models that included all surveys, concern about contracting COVID-19 at work was associated with a higher level of social isolation (Table 2) . Generally similar results were obtained when analyzed by individual survey periods ( Figure 1 and Table S1 ). In all survey periods, we did not observe an association between characteristics and levels of emotional support (Table 2, Figure 1 , and Table S1 ). PROMIS has one question on global well-being-mental health. In mixed logistic regression models that included all surveys, concern about contracting COVID-19 at work was associated with lower odds Analysis by individual survey period revealed generally consistent results ( Figure S1 ). In October 2020, respondents <40 years, compared with age ≥40 years, had 72% lower odds of top global wellbeing-mental health, which was similar to the 77% lower odds associated with concern about contracting COVID-19 at work (both, p < .01). 1 Data missing for age (n = 1), gender (n = 3), primary source for COVID-19 information (n = 2), cared for patients with known or suspected COVID-19 (n = 5), changed where you lived due to fear of transmitting COVID-19 to family members (n = 2), global well-being-mental health (n = 1), and global well-being-social activities and relationships (n = 4). P value from χ 2 test. The characteristics of respondents to all and individual surveys were generally similar (compare Table 1 and Table S2 ). In linear mixed models, survey period was associated with higher anxiety (May 2020) and higher social isolation (May 2020 and October 2020) (Table S3 ). In mixed logistic regression models that included all surveys, the survey period was associated with odds of top well-being-mental health and odds of top well-being-social activities and relationships ( 26 In that study, the psychological well-being of women, compared to men, was more affected by the pandemic, and partially mitigated by job autonomy and partner support. 26 1 Higher score indicates higher anxiety and higher social isolation, but higher emotional support. APP refers to nurse practitioners and physician assistants. For "concern about contracting COVID-19 at work," other refers to neutral, disagree, or strongly disagree. *p < .05; **p < .01. Abbreviations: APP, advanced practice provider; COVID-19, coronavirus disease 2019 due to severe acute respiratory syndrome coronavirus 2 social isolation. Although not evaluated in the study, the availability of medications, vaccines, and other protective measures for COVID-19 may have alleviated, but did not abrogate, concern about con- Although we examined several personal and professional characteristics, the contribution of unmeasured factors (e.g., work experience) to wellness is unknown. The study has several strengths. It surveyed hospitalists and hospital medicine APPs in four US states at distinct periods in the pandemic (early, mid, and late). Although the survey sites were within the same institution, the heterogeneity in providers, patients, state-level burden of COVID-19 and healthcare policies, increases generalizability to other institutions. 1, 39 The study provides a foundation to characterize system-and profession-specific factors that influence wellness. In summary, this longitudinal study of wellness of hospitalists and hospital medicine APPs revealed that concern for contracting COVID-19 at work was an independent determinant of global wellbeing, anxiety, and social isolation. In addition, compared to hospitalists, hospital medicine APPs had lower top global well-beingsocial activities and relationships. These findings do not establish causality but provide a strong foundation for ongoing wellness efforts. This is particularly relevant because hospital medicine is the predominant service line to manage COVID-19 patients on general medical wards. In this longitudinal assessment of hospitalists and hospital medicine APPs in an academic institution's 16 hospitals across four US states, concern about contracting COVID-19 at work was an independent determinant of global well-being, anxiety, and social isolation. The long-term effects of chronically unwell hospitalists and hospital medicine APPs are unknown but may weaken institutions' ability to care for hospitalized patients. There is an urgent need for ongoing wellness efforts to support hospitalists and hospital medicine APPs and build a stronger workforce. 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