Use of standardized patients to assess between-physician variations in resource utilization.

CONTEXT As medical costs are increasingly being scrutinized, there is heightened interest in defining variations in physician behavior in clinical settings. OBJECTIVE To evaluate if standardized patient (SP) technology is a reliable and feasible method of studying interphysician variations in test ordering, referral requests, prescribing behavior, and visit costs. DESIGN The study was conducted with blinded SP visits to family medicine and internal medicine residents, university-affiliated family physicians, and community-based family physicians. Resource utilization and visit costs were assessed using test requisitions, consult requests, and prescriptions that were collected by the SPs. SETTING Physicians' offices in ambulatory care, hospital-based clinics and in the community. PARTICIPANTS Four persons (aged 57-77 years) trained to simulate having osteoarthritis of the hip. In one simulation, the patient had gastropathy due to nonsteroidal anti-inflammatory drug use, and in the other, the patient sought therapy for hip discomfort. MAIN OUTCOME MEASURES Reliability of cost estimates of physician services, tests, consultations, prescriptions, and total visits and test-ordering behavior for nonsteroidal anti-inflammatory gastropathy. RESULTS Overall, 112 (63%) of the physicians who were sent invitations to the study agreed to participate. Of 312 total SP visits conducted over a 1-year period, unblinding due to SP detection occurred on 36 occasions (11.5%). Reliable cost estimates of physician services, tests, and consultations, and moderately reliable estimates of total visit costs, were obtained with 4 visits per practicing physician and with 2 visits per resident. There were extreme variations in total visit costs generated by the study physicians. A small number of physicians had a major impact on this variability. CONCLUSION Standardized patient technology provides a reliable, feasible method to assess variations in resource utilization between physicians.

[1]  J. Lambert,et al.  Do female general practitioners have a distinctive type of medical practice? , 1988, CMAJ : Canadian Medical Association journal = journal de l'Association medicale canadienne.

[2]  R. Jennrich,et al.  Unbalanced repeated-measures models with structured covariance matrices. , 1986, Biometrics.

[3]  B. Leake,et al.  Differences in the numbers and costs of tests ordered by internists, family physicians, and psychiatrists. , 1984, Inquiry : a journal of medical care organization, provision and financing.

[4]  C. Woodward,et al.  Measurement of Physician Performance by Standardized Patients: Refining Techniques for Undetected Entry in Physicians' Offices , 1985, Medical care.

[5]  F. Sturmans,et al.  A method for introducing standardized (simulated) patients into general practice consultations. , 1991, The British journal of general practice : the journal of the Royal College of General Practitioners.

[6]  S. Salem-Schatz,et al.  The case for case-mix adjustment in practice profiling. When good apples look bad. , 1994 .

[7]  P. Verhaak.  Variations in the diagnosis of psychosocial disorders: a general practice observation study. , 1986, Social science & medicine.

[8]  D. Main,et al.  Practice Style Differences Between Family Physicians And Internists , 1991, The Journal of the American Board of Family Medicine.

[9]  D. Cherkin,et al.  The Use of Medical Resources by Residency-Trained Family Physicians and General Internists: Is There a Difference? , 1987, Medical care.

[10]  A. Dietrich,et al.  The Periodic Health Examination Provided to Asymptomatic Older Women: An Assessment Using Standardized Patients , 1993, Annals of Internal Medicine.

[11]  S D Nightingale.  Risk preference and admitting rates of emergency room physicians. , 1988, Medical care.

[12]  S. Rhee.  Relative importance of physicians' personal and situational characteristics for the quality of patient care. , 1977, Journal of health and social behavior.

[13]  R. Pineault.  The Effect of Prepaid Group Practice on Physicians' Utilization Behavior , 1976, Medical care.

[14]  M S Gerrity,et al.  Written case simulations: do they predict physicians' behavior? , 1990, Journal of clinical epidemiology.

[15]  R. Pineault,et al.  The Effect of Medical Training Factors on Physician Utilization Behavior , 1977, Medical care.

[16]  F Sturmans,et al.  Does competence of general practitioners predict their performance? Comparison between examination setting and actual practice. , 1991, BMJ.

[17]  D. Streiner,et al.  Health Measurement Scales: A practical guide to thier development and use , 1989 .

[18]  R. Kravitz,et al.  Differences in the mix of patients among medical specialties and systems of care. Results from the medical outcomes study. , 1992, JAMA.

[19]  W. Applegate,et al.  Comparison of Family Medicine and Internal Medicine: Charges for Continuing Ambulatory Care , 1983, Medical care.

[20]  J. Beauchemin,et al.  Practice settings and prescribing profiles: the simulation of tension headaches to general practitioners working in different practice settings in the Montreal area. , 1980, American journal of public health.

[21]  J Noren,et al.  Ambulatory medical care: a comparison of internists and family-general practitioners. , 1980, The New England journal of medicine.

[22]  M. Young,et al.  Do cardiologists have higher thresholds for recommending coronary arteriography than family physicians? , 1987, Health services research.

[23]  D. Hemenway,et al.  Testing for Physician-induced Demand With Hypothetical Cases , 1985, Medical care.

[24]  C. Woodward,et al.  Measuring physicians' performances by using simulated patients. , 1985, Journal of medical education.

[25]  K. Brandt,et al.  Therapeutic strategies distinguish community based primary care physicians from rheumatologists in the management of osteoarthritis. , 1993, The Journal of rheumatology.

[26]  J. Mckinlay,et al.  Bringing social structure back into clinical decision making. , 1991, Social science & medicine.

[27]  M. Abrahamowicz,et al.  First‐visit bias in the measurement of clinical competence with standardized patients , 1992, Academic medicine : journal of the Association of American Medical Colleges.

[28]  A. Melville.  Job satisfaction in general practice: implications for prescribing. , 1980, Social science & medicine. Medical psychology & medical sociology.

[29]  Towards a typology of general practitioners' attitudes to general practice. , 1990, Social science & medicine.

[30]  H. Barrows,et al.  Use of Standardized Patients in Clinical Assessments: Recent Developments and Measurement Findings , 1994 .

[31]  J. Eisenberg,et al.  Use of Diagnostic Services by Physicians in Community Practice , 1981, Medical care.

[32]  J. Robbins,et al.  Costs of care provided by trainees in internal medicine and family practice. , 1983, The Western journal of medicine.

[33]  A. Feinstein,et al.  Clinical Epidemiology: The Architecture of Clinical Research. , 1987 .

[34]  S. Kaplan,et al.  Ambulatory Testing for Capitation and Fee-For-Service Patients in the Same Practice Setting: Relationship to Outcomes , 1992, Medical care.

[35]  S Greenfield,et al.  Variations in resource utilization among medical specialties and systems of care. Results from the medical outcomes study. , 1992, JAMA.

[36]  R. Tamblyn,et al.  The accuracy of standardized patient presentation , 1991, Medical education.