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.