Physicians’ perceptions of autonomy support during transition to value-based reimbursement: A multi-center psychometric evaluation of six-item and three-item measures

Background: Successive health system reforms have steadily eroded physician autonomy. Escalating accountability demands placed on physicians concurrent with diminishing autonomy plus widespread “cost cutting” endanger clinical work-life quality and, in turn, threaten patient-care quality, safety, and continuity. This has engendered a renewed emphasis on bettering physician work-life to safeguard patient care. Research indicates that autonomy support could be an effective intervention point in this dynamic, and that improving healthcare practitioners’ experience of autonomy can promote better patient outcomes. New measures of autonomy support towards physicians during systemic/organizational transformation are thus needed. Objective: We investigated the validity and reliability of two versions of a brief measure of physicians’ perceptions of autonomy support. Design: Psychometric evaluation of practitioners’ responses to a theory-based, pilot-tested, multi-center, cross-sectional survey-questionnaire. Participants: Physicians serving in California, Massachusetts, or upstate New York clinical practices implementing pay-for-performance incentives were eligible. We obtained responses from 1,534 (35.14%) of 4,365 physicians surveyed. Analysis: We randomly partitioned the study sample equitably into derivation and validation subsamples. We conducted parallel analysis, inter-item/point-biserial correlations, and item-response-theory-based graded response modeling on six autonomy support items. Three items with the highest (a) point-biserial correlations, (b) item-level discrimination and (c) information capture were used to construct a short-form (3-item) version of the full (6-item) autonomy scale. We utilized exploratory structural equation modeling and confirmatory factor analysis to establish the factor structure and construct validity of the full-length and short-form scales before comparing their factor invariance, reliability and interrater agreement across physician subgroups. Findings: All six autonomy support items loaded highly onto one factor accounting for the majority of variance and demonstrating good data fit. The three most discriminating and informative items loaded equally well onto a single factor with similar goodness-of-fit to the data. The three-item scale correlated highly with its six-item parent, showing equally high sensitivity and specificity in discriminating high autonomy support. Variability in scores nested predominantly at within- rather than between-subgroup levels. Conclusions and implications: Our data supported the factor structure, construct validity, internal consistency, and reliability of six- and three-item autonomy support scales. These brief tools are easily incorporated into multi-dimensional questionnaires at relatively low cost.