Physician Practice Behavior and Practice Guidelines: Using Unannounced Standardized Patients to Gather Data

Krane, N. Kevin; Anderson, Delia; Lazarus, Cathy J.; Termini, Michael; Bowdish, Bruce; Chauvin, Sheila W.; Fonseca, Vivian

doi:10.1007/s11606-008-0826-3

Cited by 17 publications

(13 citation statements)

References 28 publications

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“…Unannounced standardized patients represent the most reliable methodology for studying diagnostic reasoning because the patient scripts are standardized with only the variable of interest carefully controlled and systematically varied [12], because they measure actual performance in the clinical settings rather than potential competence [8], and because their undercover nature makes them resistant to biases associated with artificial testing [1]. We often observed failure to screen for depression, based a concealed audio recording, or to address it in USPs trained to screen positive.…”

Section: Discussionmentioning

confidence: 99%

“…Unannounced standardized patients have been utilized productively in studies of physician performance [5][6][7][8][9]. Luck and Peabody [10] have demonstrated, in the Veterans Affairs system, that USPs are the gold standard for studying quality of care in clinician practice, and they have been used as a standard of comparison for other methods of performance assessment [11], for measurements of quality of diabetes care [12], biomedical decision making [13], and risk communication [14]. Unannounced standardized patients, as "connoisseurs of care" [15], perform more reliable assessments than real patients [15,16].…”

Section: Introductionmentioning

confidence: 99%

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Direct observation of depression screening: identifying diagnostic error and improving accuracy through unannounced standardized patients

Schwartz¹,

Peskin

Spiro³

et al. 2020

Diagnosis

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BackgroundDepression is substantially underdiagnosed in primary care, despite recommendations for screening at every visit. We report a secondary analysis focused on depression of a recently completed study using unannounced standardized patients (USPs) to measure and improve provider behaviors, documentation, and subsequent claims for real patients.MethodsUnannounced standardized patients presented incognito in 217 visits to 59 primary care providers in 22 New Jersey practices. We collected USP checklists, visit audio recordings, and provider notes after visits; provided feedback to practices and providers based on the first two visits per provider; and compared care and documentation behaviors in the visits before and after feedback. We obtained real patient claims from the study practices and a matched comparison group and compared the likelihood of visits including International Classification of Diseases, 10th Revision (ICD-10) codes for depression before and after feedback between the study and comparison groups.ResultsProviders significantly improved in their rate of depression screening following feedback [adjusted odds ratio (AOR), 3.41; 95% confidence interval (CI), 1.52–7.65; p = 0.003]. Sometimes expected behaviors were documented when not performed. The proportion of claims by actual patients with depression-related ICD-10 codes increased significantly more from prefeedback to postfeedback in the study group than in matched control group (interaction AOR, 1.41; 95% CI, 1.32–1.50; p < 0.001).ConclusionsUsing USPs, we found significant performance issues in diagnosis of depression, as well as discrepancies in documentation that may reduce future diagnostic accuracy. Providing feedback based on a small number of USP encounters led to some improvements in clinical performance observed both directly and indirectly via claims.

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Section: Discussionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

Direct observation of depression screening: identifying diagnostic error and improving accuracy through unannounced standardized patients

Schwartz¹,

Peskin

Spiro³

et al. 2020

Diagnosis

View full text Add to dashboard Cite

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“…Unannounced standardized patients (SPs) have been used to assess clinical skills, residents' professionalism, physician compliance with clinical guidelines, response to requests for direct-to-consumer advertised antidepressants, and efficacy of educational interventions. 11,12 Studies have explored the acceptable feasibility and validity of unannounced SPs to assess the quality of care and have shown SPs to be an effective means for obtaining detailed information on practice in context. 13 Since 2009, our institution has used unannounced SPs to unobtrusively assess learners and the clinical microsystem.…”

Section: Introductionmentioning

confidence: 99%

Using Unannounced Standardized Patients to Explore Variation in Care for Patients With Depression

Zabar

Hanley

Watsula-Morley

et al. 2018

Journal of Graduate Medical Education

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“…Unannounced standardized patients are actors trained to enter a clinical setting, portray a patient and evaluate performance, traditionally focusing on the patient/provider interaction. USPs have been used as an innovative research method to assess physicians’ compliance with clinical guidelines, the effects of patients’ requests for direct-to-consumer advertised treatments, and residents’ professionalism in an emergency setting [ 15 - 17 ]. The USP method offers great promise for overcoming many of the methodological limitations of traditional methods of assessing the health care system.…”

Section: Introductionmentioning

confidence: 99%

Unannounced standardized patients: a promising method of assessing patient-centered care in your health care system

Zabar

Hanley

Stevens

et al. 2014

BMC Health Serv Res

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BackgroundWhile unannounced standardized patients (USPs) have been used to assess physicians’ clinical skills in the ambulatory setting, they can also provide valuable information on patients’ experience of the health care setting beyond the physician encounter. This paper explores the use of USPs as a methodology for evaluating patient-centered care in the health care system.MethodsUSPs were trained to complete a behaviorally-anchored assessment of core dimensions of patient-centered care delivered within the clinical microsystem, including: 1) Medical assistants’ safe practices, quality of care, and responsiveness to patients; 2) ease of clinic navigation; and 3) the patient-centeredness of care provided by the physician. Descriptive data is provided on these three levels of patient-centeredness within the targeted clinical microsystem. Chi-square analyses were used to signal whether variations by teams within the clinical microsystem were likely to be due to chance or might reflect true differences in patient-centeredness of specific teams.ResultsSixty USP visits to 11 Primary Care teams were performed over an eight-month period (mean 5 visits/team; range 2–8). No medical assistants reported detecting an USP during the study period. USPs found the clinic easy to navigate and that teams were functioning well in 60% of visits. In 30% to 47% of visits, the physicians could have been more patient-centered. Medical assistants’ patient safety measures were poor: patient identity was confirmed in only 5% of visits and no USPs observed medical assistants wash their hands. Quality of care was relatively high for vital signs (e.g. blood pressure, weight and height), but low for depression screening, occurring in only 15% of visits. In most visits, medical assistants greeted the patient in a timely fashion but took time to fully explain matters in less than half of the visits and rarely introduced themselves. Physicians tried to help patients navigate the system in 62% of visits.ConclusionsUSP assessment captured actionable, critical, behaviorally-specific information on team and system performance in an urban community clinic. This methodology provides unique insight into the patient-centeredness and quality of care in medical settings.

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Physician Practice Behavior and Practice Guidelines: Using Unannounced Standardized Patients to Gather Data

Cited by 17 publications

References 28 publications

Direct observation of depression screening: identifying diagnostic error and improving accuracy through unannounced standardized patients

Direct observation of depression screening: identifying diagnostic error and improving accuracy through unannounced standardized patients

Using Unannounced Standardized Patients to Explore Variation in Care for Patients With Depression

Unannounced standardized patients: a promising method of assessing patient-centered care in your health care system

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