title: Effort-reward imbalance and perceived quality of patient care: a cross-sectional study among physicians in Germany.
abstract: BACKGROUND
  Work stress may impair physicians' ability to provide high quality patient care. Prior research remains however sparse and has insufficiently explored explanations for this relationship. It has been suggested that physicians' poor mental health is one potential explanatory factor. We drew on a well-established model to measure work stress (the effort-reward imbalance [ERI] model) in order to test this hypothesis. Further, to address another research gap and to potentially inform the development of better-targeted interventions, we aimed to examine associations of individual ERI constructs with the quality of care.
  
  
  METHODS
  We used cross-sectional data, which had been collected in 2014 among 416 physicians in Germany. ERI constructs (i.e. effort, reward, the ERI ratio, and overcommitment) were measured by the established 23-item questionnaire. Physicians' perceptions of quality of care were assessed by a six-item instrument inquiring after poor care practices or attitudes. Physicians' mental health was operationalized by the state scale of the Spielberger's State-Trait Depression Scales. We used both continuous and categorized dependent and independent variables in multivariable linear and logistic regression analyses.
  
  
  RESULTS
  Both an increasing ERI ratio and increasing effort were associated with poorer quality of care while increasing rewards were related to better care. Physicians' depressive symptoms did not affect these associations substantially. Associations with overcommitment were weak and attenuated to non-significant levels by correction for depressive symptoms. The level of overcommitment did not modify associations between the ERI ratio and quality of care.
  
  
  CONCLUSIONS
  Our study suggests that high work-related efforts and low rewards are associated with reports of poorer patient care among physicians, irrespectively of physicians' depressive symptoms. Quality of patient care may thus be improved by concurrently reducing effort and increasing rewards among physicians.
authors.affiliation: Institute of Occupational and Social Medicine, Centre for Health and Society, Faculty of Medicine, University of Düsseldorf, Universitätsstraße 1, 40225, Düsseldorf, Germany. Adrian.Loerbroks@uni-duesseldorf.de.
authors.forename: Adrian
authors.initials: A
authors.lastname: Loerbroks
authors.affiliation: Institute and Outpatient Clinic for Occupational, Social, and Environmental Medicine, Ludwig-Maximilians-University, Ziemssenstrasse 1, 80336, Munich, Germany.
authors.forename: Matthias
authors.initials: M
authors.lastname: Weigl
authors.affiliation: Institute of Occupational and Social Medicine, Centre for Health and Society, Faculty of Medicine, University of Düsseldorf, Universitätsstraße 1, 40225, Düsseldorf, Germany.
authors.forename: Jian
authors.initials: J
authors.lastname: Li
authors.affiliation: Institute of Occupational and Social Medicine, Centre for Health and Society, Faculty of Medicine, University of Düsseldorf, Universitätsstraße 1, 40225, Düsseldorf, Germany.
authors.forename: Peter
authors.initials: P
authors.lastname: Angerer
mesh_terms: D000328:Adult; D001291:Attitude of Health Personnel; D003430:Cross-Sectional Studies; D003863:Depression / Q000453:epidemiology; D005260:Female; D005858:Germany / Q000453:epidemiology; D006801:Humans; D008297:Male; D010820:Physicians / Q000523:psychology* / Q000706:statistics & numerical data; D011787:Quality of Health Care; D012201:Reward; D013315:Stress, Psychological / Q000523:psychology*; D011795:Surveys and Questionnaires; D014937:Work / Q000523:psychology*
keywords: Effort-reward imbalance; Health services; Physicians; Quality of care; Work stress