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

JAMA. 1997 Oct 8;278(14):1164-8.


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.

Publication types

  • Research Support, Non-U.S. Gov't

MeSH terms

  • Diagnosis-Related Groups
  • Diagnostic Tests, Routine / economics
  • Diagnostic Tests, Routine / statistics & numerical data
  • Drug Utilization / statistics & numerical data
  • Feasibility Studies
  • Health Resources / economics
  • Health Resources / statistics & numerical data*
  • Health Services Research / methods*
  • Humans
  • Logistic Models
  • Patient Simulation*
  • Practice Patterns, Physicians' / economics
  • Practice Patterns, Physicians' / statistics & numerical data*
  • Practice Patterns, Physicians' / trends
  • Referral and Consultation / statistics & numerical data
  • Reproducibility of Results
  • United States