Correlates of Burnout in Small Independent Primary Care Practices in an Urban Setting

Batel Blechter; Nan Jiang; Charles Cleland; Carolyn Berry; Olugbenga Ogedegbe; Donna Shelley

doi:10.3122/jabfm.2018.04.170360

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Table 1.

Characteristics of Small Independent Primary Care Practices and Providers

			n	(%)
Practice characteristics (N = 174)	Categorical variables	Number of providers
		Solo provider	113	(66.9%)
		≥2 providers	56	(33.1%)
		MUA designation^*
		Yes	75	(43.1%)
		No	99	(56.9%)
		PCMH recognition
		Yes	81	(46.5%)
		No	93	(53.5%)
			Mean	(SD)
	Continuous variables	CPCQ	0.78	(0.19)
		Patient panel size	2207	(2252)
		% of non-Hispanic white patients	19	(26.8)
		Adaptive reserve	0.78	(0.17)
			n	(%)
Provider characteristics (N = 235)	Categorical variable	Burnout
		Yes	29	(13.5%)
		No	185	(86.5%)
			Mean	(SD)
	Continuous variables	Working hours per week	36.9	(13.4)
	Continuous variables	Years in practice	12.4	(8.2)

↵* Data extracted from Health Resources and Service Administration website.
MUA, medically underserved area; PCMH, patient-centered medical home; CPCQ, Change Process Capability Questionnaire; SD, standard deviation.

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Table 2.

Bivariate Analysis of the Factors Associated with Provider Burnout

	OR (95% CI)	P
Practice characteristics (N = 174)
Number of providers (solo)	0.88 (0.39–1.97)	.752
MUA designation^* (yes)	0.56 (0.25–1.30)	.177
PMCH recognition (yes)	1.44 (0.64–3.25)	.379
CPCQ	0.12 (0.01–1.16)	.067
Patient panel size	1.04 (0.70–1.55)	.854
% of non-Hispanic white patients	1.01 (0.99–1.02)	.287
Adaptive reserve	0.12 (0.02–0.85)	.034
Provider characteristics (N = 235)
Working hours per week	1.02 (0.99–1.04)	.220
Years in practice	0.99 (0.95–1.05)	.825

↵* Data extracted from Health Resources and Service Administration website
CI, confidential interval; OR, odds ratio; MUA, Medically underserved area; PCMH, patient-centered medical home; CPCQ, Change Process Capability Questionnaire.

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Appendix A.

Measures of Independent Variables

Variable (Data Source)	Survey Item	Coding Method
Practice characteristics
Number of provider (practice survey)	Which of the following best describes your practice site size?	1 = “Solo provider” (Answer option A) 0 = “≥2 providers” (Other than answer option A)
	A. Solo practice
	B. 2 to 5 clinicians (medical doctor, doctor of osteopathic medicine, nurse practitioner, physician's assistant)
	C. 6 to 10 clinicians
	D. 11 to 15 clinicians
	E. 16 or more clinicians
MUA designation (HRSA website)	Has your practice site been designated as a MUA or medically underserved population by the HRSA?	1 = “Yes” 0 = “No
MUA designation (HRSA website)	A. Yes B. No	1 = “Yes” 0 = “No
PCMH recognition (PCIP)	Is your practice site recognized or accredited as a PCMH?	1 = “Yes” 0 = “No”
PCMH recognition (PCIP)	A. Yes B. No	1 = “Yes” 0 = “No”
Patient panel size (PCIP)	Please estimate the average patient panel size for a full-time clinician in your practice site.
% of non-Hispanic white patients (PCIP)	Please give the percentage of your patients in the following categories.
	A. White
	B. Black/African American
	C. American Indian or Alaska Native
	D. Asian
	E. Native Hawaiian or other Pacific Islander
	F. Some Other Race/Mixed Race
	G. Percent unknown
Adaptive reserve (practice member survey)	1. Mistakes have led to positive changes here	Each item was scored on a 1 (“strongly disagree”) to 5 (“strongly agree”) scale. To obtain the mean adaptive reserve score, we converted the score for each item to a 0 to 1 scale and then summed up all the nonmissing values and divided by the total number of nonmissing items.
	2. I have many opportunities to grow in my work
	3. People in our practice actively seek new ways to improve how we do things
	4. People at all levels in this office openly talk about what is and isn't working
	5. Leadership strongly supports practice change efforts
	6. After trying something new, we take time to think about how it worked
	7. Most of the people who work in our practice seem to enjoy their work
	8. It is hard to get things to change in our practice
	9. This practice is a place of joy and hope
	10. This practice learns from its mistakes
	11. Practice leadership promotes an environment that is an enjoyable place to work
	12. People in this practice operate as a real team
	13. When we experience a problem in the practice, we make a serious effort to figure out what's really going on
	14. Leadership in this practice creates an environment where things can be accomplished
	Each item is offered a 5-point Likert scale as below.
	A. Strongly disagree
	B. Disagree
	C. Neutral
	D. Agree
	E. Strongly agree
CPCQ (practice survey)	Indicate the extent to which you agree or disagree that your practice site has used the following strategies to improve cardiovascular preventive care:	Each item was scored on a 1 (“strongly disagree”) to 5 (“strongly agree”) scale. To obtain the mean CPCQ score, we converted the score for each item to a 0 to 1 scale, and then summed up all the nonmissing values and divided by the total number of nonmissing items.
	1. Providing information and skills training
	2. Using opinion leaders, role modeling. Or other vehicles to encourage support for change
	3. Changing or creating systems in the practice that make it easier to provide high quality care
	4. Removal or reduction of barriers to better quality of care
	5. Using teams focused on accomplishing the change process for improved care
	6. Delegating to nonclinician staff the responsibility to carry out aspects of care that are normally the responsibility of physicians
	7. Providing to those who are charged with implementing improved care the power to authorize and make the desired changes
	8. Periodic measurements of care quality for assessing compliance with any new approach to care
	9. Reporting measurements of practice performance on cardiovascular disease prevention measures (such as aspirin for patients at risk for ischemic vascular disease) for compassion with their peers
	10. Setting goals and benchmarking rates of performance quality on cardiovascular disease prevention measures at least yearly
	11. Customizing the implementation of cardiovascular disease prevention care changes to the practice
	12. Using rapid cycling, piloting, pretesting, or other vehicles for reducing the risk of negative results for introducing organization-wide change in care
	13. Deliberately designing care improvements so as to make clinician participation less work than before
	14. Deliberately designing care improvements to make the care process more beneficial to the patient
	Each item is offered a 5-point Likert scale as below.
	A. Strongly disagree
	B. Disagree
	C. Neutral
	D. Agree
	E. Strongly agree
	F. NA
Provider characteristics
Hours worked per week (Practice Member Survey)	How many hours per week do you work at this practice site?
Years in practice (Practice Member Survey)	How many years have you worked in this practice site?
Burnout (Practice Member Survey)	Using your own definition of burnout, please indicate which of the following statements best describes how you feel about your situation at work	1 = “Burnout” (Answer options C-E) 0 = “Not burned out” (Answer options A or B)
	A. I enjoy my work. I have no symptoms of burnout
	B. Occasionally I am under stress, and I don't always have as much energy as I once did, but I don't feel burned out
	C. I am definitely burning out and have one or more symptoms of burnout, such as physical and emotional exhaustion
	D. The symptoms of burnout that I'm experiencing won't go away. I think about frustrations at work a lot
	E. I feel completely burned out and often wonder if I can go on practicing. I am at the point where I may need some changes

MUA: medically underserved area, PCMH, patient-centered medical home; CPCQ, Change Process Capability Questionnaire; HRSA, Health Resources and Service Administration; PCIP, Primary Care Incentive Payment Program.