Alan Schwartz1, Steven Peskin2,3, Alan Spiro4, Saul J Weiner4. 1. Institute for Practice and Provider Performance Improvement, Inc., 3712 N. Broadway #460, Chicago, IL, 60613, USA. alanschwartz@i3pi.com. 2. Horizon Blue Cross Blue Shield of New Jersey, Newark, NJ, NJ, USA. 3. Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ, USA. 4. Institute for Practice and Provider Performance Improvement, Inc., 3712 N. Broadway #460, Chicago, IL, 60613, USA.
Abstract
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.
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.
Entities:
Keywords:
cost of care; directly observed care; health services research; quality improvement; unannounced standardized patients
Authors: K C Stange; S J Zyzanski; C R Jaén; E J Callahan; R B Kelly; W R Gillanders; J C Shank; J Chao; J H Medalie; W L Miller; B F Crabtree; S A Flocke; V J Gilchrist; D M Langa; M A Goodwin Journal: J Fam Pract Date: 1998-05 Impact factor: 0.493
Authors: A Taylor Kelley; Marcela C Smid; Jacob D Baylis; Elizabeth Charron; Amy E Binns-Calvey; Shayla Archer; Saul J Weiner; Lori Jo Begaye; Gerald Cochran Journal: Addict Sci Clin Pract Date: 2021-06-25