Introduction
Primary care workforce shortages, rising healthcare spending, limited
patient access to care, and the epidemic of chronic diseases have
imposed a strain on the U.S. primary care system. 1-3As of 2021, it is estimated that more than half of Americans are living
with at least one chronic disease and need timely and high-quality
primary care to manage their conditions.4 Further
increasing care delivery complexity, one study estimates that upward of
26% of Americans have multiple chronic conditions.5Increased demand for primary care services is complicated by a workforce
supply deficit that is expected to worsen substantially by
2030.3 A lack of providers to meet the demand for
primary care creates additional workload for existing PCPs by expanding
the number of patients each PCP is expected to manage. For over a
decade, some researchers estimate that an individual PCP would require
an unrealistic amount of time (~21.7 hours each day) to
deliver all recommended care to patients in an average size patient
panel.6 As PCP supply and time spent with a patient
during a clinical encounter decreases, the increased risk of omitting
important care management tasks jeopardizes patient safety and may
reduce the quality of care.7 Consequently, primary
care delivery is a rapidly changing landscape of technology, regulatory
policies, and care delivery models that some suggest have exacerbated
the incidence of PCP burnout.8, 9
Burnout is a condition in which extended periods of workplace stress
lead to feeling emotionally exhausted, exhibiting negative thought
patterns, and increased unhappiness with work.10 Prior
to the current COVID-19 pandemic, nearly half of PCPs report burnout
symptoms with higher burnout rates in primary care compared to other
medical specialties.11 A recent systematic review
found that burnout is prevalent among PCPs, up to 60% in one study,
across the health continuum including small community practices and
Veteran Affairs (VA) clinics.12 Historically,
literature about burnout has focused predominantly on the physician
workforce and the impact of physician burnout can lead to suboptimal
quality of care and patient clinical outcomes.13, 14Current literature fails to capture burnout in other types of
interdisciplinary primary care workforce including nurse practitioners
(NPs) and physician assistants (PAs). New evidence is slowly emerging
with one recent study of NP burnout that found prevalence rates as high
as 25%, and comparable to physicians.15 Evidence
about PA burnout in primary care is scarce.
The deleterious effects of burnout are not however limited to patient
outcomes. There is increased evidence that burnout yields adverse
provider-level effects including suicidality, depression, limited
self-care, decreased productivity, unprofessional behavior and low
workforce retention rates.12, 16 At the
organizational- and system-level, there are financial consequences as
well with burnout noted as the largest factor contributing to whether or
not physicians would leave their current practice.17Medical systems are then left with the burden of cost to replace these
physicians; and recent reports estimate that replacing a physician can
cost up to $1 million.18, 19 In response, policy
makers, clinicians, and researchers have called for novel strategies and
care delivery models to combat burnout and improve clinician
wellness.20 One promising approach is the increase of
team-based, shared care, where multiple disciplines work together to
meet the demand for high quality and efficient primary care services.
Provider co-management is one proposed team-based model to improve
primary care delivery outcomes 21 and is defined as
two or more providers (interdisciplinary dyads) sharing the
responsibility of care management tasks for the same
patient.22, 23 In this model, providers perform tasks
autonomously but collectively contribute care demands needed to manage
the same patient’s diagnoses, care management needs, and plan of care.
The earliest evidence of the effectiveness of provider co-management
emerged from acute care settings. One study found that co-management
improved the clinical outcomes of surgical patients co-managed by
surgeons and medical attending physicians.24Co-management has also been found to improve clinical patient outcomes
and increase provider adherence to recommended care
guidelines.25 Given that the largest number of patient
encounters occur in a primary care setting, and with the increase in
patients living with at least one chronic condition, an investigation of
the impact of provider co-management in primary care is warranted.
Further, with the rise of interdisciplinary PCPs, including NPs and PAs,
working alongside physician colleagues, interdisciplinary provider teams
that co-manage patients may be a feasible strategy to alleviate burnout
and improve job satisfaction.26
As more primary care practices are adopting an interdisciplinary team
model, where two types of disciplines (e.g., physicians and NPs) are
co-managing patient care demands, the interaction between providers may
influence and potentially mitigate some aspects of burnout and job
dissatisfaction. Thus, the purpose of this study was to explore the
impact of interdisciplinary PCP co-management, and related attributes,
on provider outcomes including burnout, job satisfaction, and intention
to leave current position.