Development of the Provider Co-Management Index: Measuring Nurse Practitioner-Physician Co-Management

Background: Primary care provider (PCP) workforce deficits have yielded larger patient panel sizes and have created a challenge for individual providers to manage all recommended care independently. As a result, different PCP disciplines, such as nurse practitioners (NPs) and physicians, are increasingly co-managing patients. Co-management is defined as two independent providers that must interact and share care delivery tasks to effectively manage the same patient. There is existing evidence of the impact of two physicians co-managing patients, or a physician and a pharmacist, yet little to no literature has investigated nurse practitioner-physician co-management. To further investigate the effectiveness of this emerging care delivery model, especially given the increase of NPs that independently practice free of physician oversight, nurse practitioner-physician co-management needs to be measured; yet, no instruments currently exist to do so. The purpose of this study was to develop a novel instrument, the Provider Co-Management Index (PCMI) and test its initial psychometric properties.

Methods: We developed a pool of 30 items from the collective evidence of a systematic review, concept analysis, and qualitative study. Subscales were based on three theoretical dimensions of co-management: effective communication; mutual respect/trust; and shared philosophy of care. A 4-point response scale (strongly agree-strongly disagree) was used. We conducted face and content validity testing through in-person interviews with primary care experts. We asked each expert to rate each item for clarity and relevance and we calculated a content validity index for items (I-CVI) and subscales (S-CVI). Next, pilot testing was conducted with a convenience sample of PCPs (n=40 nurse practitioners and physicians). Data analysis included descriptive statistics, inter-item correlations, corrected item-total correlations, and Cronbach’s alpha to test internal consistency reliability.

Results: Items, instructions, and subscales were reviewed by the research team and nine items were removed for lack of clarity. During face/content validity testing 2 items were removed due to disagreement of experts about item relevancy (I-CVI=.5) and 4 items were revised. Each subscale demonstrated high content validity: Effective Communication (S-CVI=.952); Mutual Respect/Trust (S-CVI=.944); and Shared Philosophy of Care (S-CVI=.899). Corrected item-total correlations ranged from .288 to .782. Subscales demonstrated high internal consistency reliability: Effective Communication (r=.811); Mutual Respect/Trust (r=.746); and Shared Philosophy of Care (r=.779).

Conclusions: PCMI is the first instrument that measures nurse practitioner-physician co-management and can be used in research and clinical practice to examine the impact of co-management on patient, practice, and provider outcomes. Construct validity testing is underway and recommended prior to wide spread use.