Physician practice behavior and practice guidelines: using unannounced standardized patients to gather data

Abstract

Background: Measuring actual practice behaviors of physicians, particularly as they relate to established clinical guidelines, is challenging. Standardized patients provide one method of collecting such data.

Objective: To demonstrate the use of unannounced standardized patients in gathering data that may address adherence to guidelines in an office setting.

Design: Unannounced standardized patients (SPs) simulating an initial type 2 diabetic visit presented to community offices of 32 internists as "real" patients to record physicians' evaluation and management.

Participants: Unannounced SPs presented to the office of 32 internists as "real" patients.

Measurements: Unannounced SPs, simulating type 2 diabetics, completed a standardized assessment sheet, based on ADA guidelines to record physicians' evaluation and management following an initial visit. Patient charts were also reviewed to determine if evaluation adhered to the guidelines.

Results: Unannounced SPs recorded 56 visits with 32 community internists; all SPs remained undetected. All physicians asked SPs about medications. At least 50% of physicians asked about home blood sugar monitoring, last eye exam, smoking, edema, and told patients to stop smoking. Less than 50% of physicians asked about parasthesias, performed fundoscopy, examined feet, referred the patient to a diabetic educator or ophthalmologist, or gave patients suggestions regarding glucose monitoring or exercise. HbA1c was ordered in 78%, metabolic profiles in 86%, and urinalysis/microalbumin in 41% of patients.

Conclusions: Unannounced standardized patients can successfully collect important data regarding physician practices in community settings. This method may be helpful in assessing physician adherence to established clinical practice guidelines.