Related Experiment Videos
Impact of Unannounced Standardized Patient Audit and Feedback on Care, Documentation, and Costs: an Experiment and
Alan Schwartz1, Steven Peskin2,3, Alan Spiro4
1Institute for Practice and Provider Performance Improvement, Inc., 3712 N. Broadway #460, Chicago, IL, 60613, USA. alanschwartz@i3pi.com.
Background:
Meaningful variations in physician performance are not always discernible from the medical record.
Objective:
We used unannounced standardized patients to measure and provide feedback on care quality and fidelity of documentation, and examined downstream effects on reimbursement claims.
Design:
Static group pre-post comparison study conducted between 2017 and 2019.
Setting:
Fourteen New Jersey primary care practice groups (22 practices) enrolled in Horizon BCBS's value-based program received the intervention. For claims analyses, we identified 14 additional comparison practice groups matched on county, practice size, and claims activity.
Participants:
Fifty-nine of 64 providers volunteered to participate.
Intervention:
Unannounced standardized patients (USPs) made 217 visits portraying patients with 1-2 focal conditions (diabetes, depression, back pain, smoking, or preventive cancer screening). After two baseline visits to a provider, we delivered feedback and conducted two follow-up visits.
Measurements:
USP-completed checklists of guideline-based provider care behaviors, visit audio recordings, and provider notes were used to measure behaviors performed and documentation errors pre- and post-feedback. We also compared changes in 3-month office-based claims by actual patients between the intervention and comparison practice groups before and after feedback.
Results:
Expected clinical behaviors increased from 46% to 56% (OR = 1.53, 95% CI 1.29-1.83, p < 0.0001), with significant improvements in smoking cessation, back pain, and depression screening. Providers were less likely to document unperformed tasks after (16%) than before feedback (18%; OR = 0.74, 95% CI 0.62 to 0.90, p = 0.002). Actual claim costs increased significantly less in the study than comparison group for diabetes and depression but significantly more for smoking cessation, cancer screening, and low back pain.
Limitations:
Self-selection of participating practices and lack of access to prescription claims.
Conclusion:
Direct observation of care identifies hidden deficits in practice and documentation, and with feedback can improve both, with concomitant effects on costs.