Using Standardized Patients to Measure Quality: Evidence from the Literature and a Prospective Study

Glassman, Peter; Luck, Jeff; O’Gara, Elizabeth M.; Peabody, John

doi:10.1016/s1070-3241(00)26055-0

Cited by 87 publications

(83 citation statements)

References 61 publications

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“…SPs have been used extensively to assess physician responses to a variety of scenarios in outpatient practices. [23][24][25][26][27] SP methods avoid many biases inherent in using data collected from practice patients, including selfselection, accommodation to the physician's style, and case mix. Prior research has demonstrated that SPs portray their roles consistently and that physicians can be successfully blinded to their identity.…”

Section: Standardized Patientsmentioning

confidence: 99%

“Could this Be Something Serious?”

et al. 2007

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BACKGROUND: Previous work suggests that exploration and validation of patients' concerns is associated with greater patient trust, lower health care costs, improved counseling, and more guideline-concordant care. OBJECTIVE:To describe physicians' responses to patients' worries, how their responses varied according to clinical context (straightforward versus medically unexplained symptoms [MUS]) and associations between their responses and patients' ratings of interpersonal aspects of care.DESIGN: Multimethod study. For each physician, we surveyed 50 current patients and covertly audiorecorded 2 unannounced standardized patient (SP) visits. SPs expressed worry about "something serious" in 2 scenarios: straightforward gastroesophageal reflux or poorly characterized chest pain with MUS. PARTICIPANTS:One hundred primary care physicians and 4,746 patients. MEASUREMENTS:Patient surveys measuring interpersonal aspects of care (trust, physician knowledge of the patient, satisfaction, and patient activation). Qualitative coding of 189 transcripts followed by descriptive, multivariate, and lag-sequential analyses. RESULTS:Physicians offered a mean of 3.1 responses to each of 613 SP prompts. Biomedical inquiry and explanations, action, nonspecific acknowledgment, and reassurance were common, whereas empathy, expressions of uncertainty, and exploration of psychosocial factors and emotions were uncommon. Empathy expressed during SP visits was associated with higher patient ratings of interpersonal aspects of care. After adjusting for demographics and comorbidities, the association was only statistically significant for the MUS role. Empathy was most likely to occur if expressed at the beginning of the conversational sequence.CONCLUSIONS: Empathy is associated with higher patient ratings of interpersonal care, especially when expressed in situations involving ambiguity. Empathy should be expressed early after patient expressions of worry.

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Section: Standardized Patientsmentioning

confidence: 99%

“Could this Be Something Serious?”

et al. 2007

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“…8,11,12 Unannounced standardized patients have also been used in research to rate community physicians' history taking, physical examination, medical decision making, and communication, as well as health services utilization and quality of care. [13][14][15][16][17][18] They have been regarded by some as the reference standard for assessing physician performance, 19 but their use in assessing communication is still evolving. In addition to assessing specifi c behaviors, standardized patients can also provide their subjective impression of physicians.…”

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confidence: 99%

“…Their perceptions are relatively unencumbered by prior experience with the physician, sense of indebtedness, or personal investment. They have no agendas or specifi c expectations for the visit that might affect their ratings.Others have suggested that standardized patients are a feasible and practical means for assessing physician performance, 13,19,31,34,35 although these suggestions are based on standardized patient assessment of specifi c behaviors rather than global impressions. In either case, however, their use requires considerable efforts to avoid detection by physicians, including surreptitious collaboration with offi ce staff.…”

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confidence: 99%

Ratings of Physician Communication by Real and Standardized Patients

Fiscella¹,

Franks²,

Srinivasan³

et al. 2007

The Annals of Family Medicine

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PURPOSE Patient ratings of physician's patient-centered communication are used by various specialty credentialing organizations and managed care organizations as a measure of physician communication skills. We wanted to compare ratings by real patients with ratings by standardized patients of physician communication. METHODSWe assessed physician communication using a modifi ed version of the Health Care Climate Questionnaire (HCCQ) among a sample of 100 community physicians. The HCCQ measures physician autonomy support, a key dimension in patient-centered communication. For each physician, the questionnaire was completed by roughly 49 real patients and 2 unannounced standardized patients. Standardized patients portrayed 2 roles: gastroesophageal disorder refl ux symptoms and poorly characterized chest pain with multiple unexplained symptoms. We compared the distribution, reliability, and physician rank derived from using real and standardized patients after adjusting for patient, physician, and standardized patient effects.RESULTS There were real and standardized patient ratings for 96 of the 100 physicians. Compared with standardized patient scores, real-patient-derived HCCQ scores were higher (mean 22.0 vs 17.2), standard deviations were lower (3.1 vs 4.9), and ranges were similar (both 5-25). Calculated real patient reliability, given 49 ratings per physician, was 0.78 (95% confi dence interval [CI], 0.71-0.84) compared with the standardized patient reliability of 0.57 (95% CI, 0.39-0.73), given 2 ratings per physician. Spearman rank correlation between mean real patient and standardized patient scores was positive but small to moderate in magnitude, 0.28. CONCLUSION INTRODUCTIONP atient-centered care is a core dimension of health care quality, and strong communication skills are required to ensure such care.1 Yet, policy makers and researchers do not know how best to measure these physician communication skills.2 Because patient ratings of physician communication from surveys have face validity and are readily available, they are widely used by such organizations as the American Board of Internal Medicine and various managed care organizations.3 These ratings may eventually be used for specialty recredentialing and to determine physician bonus payments.Patient ratings of physicians are subject to a number of limitations, however. These limitations include potential biases from survey nonresponse, patient selection (and deselection) of the physician, patient accommodation to the physician's style with time, 4 length of relationship, different patient complaints, and ceiling effects. 5 Patients also respond in a global manner when rating their physicians, with high correlations among scales measuring Kevin Fiscella, MD Standardized patients-persons trained to portray a specifi c patient case in a standardized fashion 8 -represent a potentially more objective means for assessment of physician communication. Standardized patients can be trained to rate physician-patient communications skills reliably 9...

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“…USPs are considered a gold standard measure of physician performance because the assessment occurs in the practice setting, the clinician is unaware when they are being assessed, and the "patients" are intrinsically risk adjusted-meaning that they present an "equivalent and objective standard for comparing practicing physicians". 10,11 Our premise is that an instrument that is measuring PCC should be able to predict which interactions will conclude with a care plan that incorporates the patient's needs and circumstances into the plan of care.…”

Section: Introductionmentioning

confidence: 99%

Unannounced Standardized Patient Assessment of the Roter Interaction Analysis System: The Challenge of Measuring Patient-Centered Communication

et al. 2012

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BACKGROUND: Despite wide-spread endorsement of patient-centered communication (PCC) in health care, there has been little evidence that it leads to positive change in health outcomes. The lack of correlation may be due either to an overestimation of the value of PCC or to a measurement problem. If PCC measures do not capture elements of the interaction that determine whether the resulting care plan is patient-centered, they will confound efforts to link PCC to outcomes. OBJECTIVE: To evaluate whether one widely used measure of PCC, the Roter Interaction Analysis System (RIAS), captures patient-centered care planning. DESIGN: RIAS was employed in the coding of unannounced standardized patient (USP) encounters that were scripted so that the failure to address patient contextual factors would result in an ineffective plan of care. The design enabled an assessment of whether RIAS can differentiate between communication behavior that does and does not result in a care plan that takes into account a patient's circumstances and needs. PARTICIPANTS: Eight actors role playing four scripted cases (one African American and one Caucasian for each case) in 399 visits to 111 internal medicine attending physicians. MAIN MEASURES: RIAS measures included composites for physician utterance types and (in separate models) two different previously applied RIAS patientcenteredness summary composites. The gold standard comparison measure was whether the physician's treatment plan, as abstracted from the visit note, successfully addressed the patient's problem. Mixed effects regression models were used to evaluate the relationship between RIAS measures and USP measured performance, controlling for a variety of design features. KEY RESULTS: None of the RIAS measures of PCC differentiated encounters in which care planning was patient-centered from care planning in which it was not. CONCLUSIONS: RIAS, which codes each utterance during a visit into mutually exclusive and exhaustive categories, does not differentiate between conversations leading to and not leading to care plans that accommodate patients' circumstances and needs.

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Using Standardized Patients to Measure Quality: Evidence from the Literature and a Prospective Study

Cited by 87 publications

References 61 publications

“Could this Be Something Serious?”

“Could this Be Something Serious?”

Ratings of Physician Communication by Real and Standardized Patients

Unannounced Standardized Patient Assessment of the Roter Interaction Analysis System: The Challenge of Measuring Patient-Centered Communication

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