PURPOSE Although patient-centered communication is associated with improved health and patient trust, information about the impact of patient-centered communication on health care costs is limited. We studied the relationship between patient-centered communication and diagnostic testing expenditures. METHODSWe undertook an observational cross-sectional study using covert standardized patient visits to study physician interaction style and its relationship to diagnostic testing costs. Participants were 100 primary care physicians in the Rochester, NY, area participating in a large managed care organization (MCO). Audio recordings of 2 standardized patient encounters for each physician were rated using the Measure of Patient-Centered Communication (MPCC). Standardized diagnostic testing and other expenditures, adjusted for patient demographics and case-mix, were derived from the MCO claims database. Analyses were adjusted for demographics and standardized patient detection. RESULTSCompared with other physicians, those who had MPCC scores in the lowest tercile had greater standardized diagnostic testing expenditures (11.0% higher, 95% confi dence interval [CI], 4.5%-17.8%) and greater total standardized expenditures (3.5% higher, 95% CI, 1.0%-6.1%). Whereas lower MPCC scores were associated with shorter visits, adjustment for visit length and standardized patient detection did not affect the relationship with expenditures. Total (testing, ambulatory and hospital care) expenditures were also greater for physicians who had lower MPCC scores, an effect primarily associated with the effect on testing expenditures.CONCLUSIONS Patient-centered communication is associated with fewer diagnostic testing expenditures but also with increased visit length. Because costs and visit length may affect physicians' and health systems' willingness to endorse and practice a patient-centered approach, these results should be confi rmed in future randomized trials. INTRODUCTIONP atient-centered communication is based on a moral philosophy that calls for physicians to expand upon the biomedical approach to care by (1) helping patients feel understood through inquiry into patients' needs, perspectives, and expectations; (2) attending to the psychosocial context; and (3) expanding patients' involvement in understanding their illnesses and in decisions that affect their health.1-3 Patient-centered communication is a complex construct, aspects of which have differential associations with such outcomes as patient satisfaction 4 and control of chronic disease. [5][6][7][8] Most physicians tend to use a biomedical rather than a patientcentered communication style, 9 whereas most patients prefer a patient-centered approach. 10,11 Although patient-centered communication should not be advocated on the basis of cost considerations alone, it is important to understand the cost implications of such an approach from a health policy perspec- 12,13 Even though both studies reported that elements of patient-centered communication are associated ...

Therapeutic Level II. See Instructions to Authors for a complete description of level of evidence.

Objective. To examine the prevalence, predictors, and consequences of physician detection of unannounced standardized patients (SPs) in a study of the impact of direct-to-consumer advertising on treatment for depression. Data Sources. Eighteen trained SPs were randomly assigned to conduct 298 unannounced audio-recorded visits with 152 primary care physicians in three U.S. cities between May 2003 and May 2004. Study Design. Randomized controlled trial using SPs. SPs portrayed six roles, created by crossing two clinical conditions (major depression or adjustment disorder) with three medication request scripts (brand-specific request, general request for an antidepressant, or no request). Data Collection. Within 2 weeks following the visit, physicians completed a form asking whether they "suspected" conducting an office visit with an SP during the past 2 weeks; 296 (99 percent) detection forms were returned. Physicians provided contextual data, a Clinician Background Questionnaire. SPs filled in a Standardized Patient Reporting Form for each visit and returned all written prescriptions and medication samples to the laboratory. Principal Findings. Depending on the definition, detection rates ranged from 5 percent (unambiguous detection) to 23.6 percent (any degree of suspicion) of SP visits. In 12.8 percent of encounters, physicians accurately detected the SP before or during the visit but they only rarely believed their suspicions affected their clinical behavior. In random effects logistic regression analyses controlling for role, actor, physician, and practice factors, suspected visits occurred less frequently in HMO settings than in solo practice settings (p<.05). Physicians more frequently referred SPs to mental health professionals when visits aroused high suspicion (p<.05). Conclusions. Trained actors portrayed patient roles conveying mood disorders at low levels of detection. There was some evidence for differential treatment of detected standardized patients by physicians with regard to referrals but not antidepressant prescribing or follow-up recommendations. Systematic assessment of detection is recommended when SPs are used in studies of clinical process and quality of care.

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