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Peter J. McLeod, MD; Robyn M. Tamblyn, PhD; David Gayton, MD; Roland Grad, MD; Linda Snell, MD; Laeora Berkson, MD; Michal Abrahamowicz, PhD

JAMA. 1997;278(14):1164-1168.

Abstract
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.

Conclsion.
—Standardized patient technology provides a reliable, feasible method to assess variations in resource utilization between physicians.

Author Affiliations
From the Departments of Medicine (Drs McLeod, Tamblyn, Gayton, Snell, and Berkson), Pharmacology (Dr McLeod), Epidemiology and Biostatistics (Drs Tamblyn and Abrahamowicz), and Family Medicine (Dr Grad), McGill University, Montreal, Quebec.

Footnotes
Corresponding author: Peter J. McLeod, MD, Department of Medicine, Montreal General Hospital, 1650 Cedar Ave, Montreal, Quebec, Canada H3G 1A4.

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